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Conditions We Treat
Acne (Acne vulgaris)
Acne Rosacea
ADHD/ADD
Adrenal Insufficiency
Allergy Rhinitis ( Nasal allergy, Sinus Problems)
Andropause or Hypogonadism (in Males)
Anxiety
Asthma
Atopic Dermatitis (Eczema)
Autism
Carpal Tunnel Syndrome
Celiac Disease
Chemical Sensitivity
Chronic Fatigue
Chronic Sinusitis
Constipation (Adult)
Crohn’s Disease
Depression
Diabetes Mellitus (Type 1)
Diabetes Mellitus (Type 2)
Fibromyalgia
Food Allergies
Gastroesophageal Reflux Disease (GERD)
Hay Fever
Headaches, Migraines and Cluster Headaches
Hypercholesterolemia
Hypertension
Hypertriglyceridemia
Hypopituitarism
Hypothyroidism
Insomnia
Insulin Resistance
Irritable Bowel Syndrome (IBS)
Menopause
Obesity (Adult)
Obesity (Pediatric)
Osteoporosis
Perimenopause
Premenstrual Syndrome (PMS)
Psoriasis
Tourette Syndrome
Ulcerative Colitis
Urticaria (hives)
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Insurance Information Form
Insurance Information Form
Please use this form to help determine the benefits for your insurance.
Insurance Benefits
Patient Name
*
First
Last
Phone
*
If You Want Us to Call You - Please indicate Phone
Email
*
Patien's Date of Birth
*
Do not use hyphens (example for July 29, 1967 use > 07291967)
Insurance Company Name
*
Insured Person's Name
*
First
Last
Insured Person's Identification #
*
Member Services Telephone #
Provider Service Telephone
e.g. The Telephone # of physician's office that we call
Comments / Questions
Any additional comments and or questions - please specify here.
