New Patient Forms
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We want to help you a soon as possible. The process moves more quickly if all required information is submitted at the same time. See checklist below:
If you are having difficulty obtaining forms or have any questions, call
636-777-2937
Wed or Thurs 8:30 a.m. - 4:00 p.m.
for a customer service specialist, or
FEEL FREE TO LEAVE A VOICEMAIL 24/7
(messages will be returned the next business day)
WE ARE HERE TO HELP
TOGETHER WE WIN!
Once forms are completed, they can be submitted by:
FAX: 636-777-2161
MAIL: 611 N. Central, Eureka, MO 63025
IN PERSON: During business hours above
ALL "New Patient Packet" FORMS ARE COMPLETED
TAX FORMS: For patient and spouse/significant other
- Taxes filed with IRS: need current, signed, unaltered copy
- Taxes self-filed with IRS: need IRS "Letter of Acceptance"/receipt
- No taxes filed last year: need IRS "Letter of Non-Filing" form
(see "New Patient Packet" for details about how to obtain form)
CURRENT DRIVERS LICENSE or Legal Picture ID (i.e. passport)