Aetna/Coventry-Medicare/HMO/Non-HMO
Alliant Health
Ambetter by Peach State
BCBS HMO/POS/PPO
BCBS Medicare
Cigna Medicare/Healthspring/Bravo Health
Coventry HMO/POS/PPO
DOL/Workers Compensation
First Health PPO (Coventry Product)
Medical School
GHI PPO (Emblem Health)
Humana Commercial
Medicaid-GA
Medicare (Railroad)
Medicare Original (Enrolled as Par Status)
Meritain Health
Multiplan/PHCS/NCCPO/Beech Street
NovaNet
Peach State Healthcare (PHCS)
Peachstate-GA Managed Medicaid
Tricare South-Prime (HMO)
Tricare South-Standard (PPO)
UMR
United Healthcare-Commercial/Medicare
Wellcare-Managed Medicare
Dekalb Medical Center
*Please bring this form, as complete as possible, with you to your appointment and DO NOT email this to us as it contains Private health information.
We are currently accepting new patients into our practice. Thank you for considering us. To become a new patient:
Call us at 770.492.8665
When you come to our office for the first time as a new patient, we'll ask you to complete some initial forms, including an Authorization and Consent for Treatment Form, so please download this form and complete it in advance of your appointment. Bring this form with you and present the form at the Reception Window for faster processing.
To make sure there are no delays in care during your first visit experience, please arrive 15 minutes prior to your scheduled appointment to ensure your registration is complete before meeting with your new provider.
Remember to bring:
In an effort to respect the time of all of patients, our staff strives to stay on schedule so that other patients do not have to wait.
For patients who are delayed and arrive late for appointment, every effort will be made to see them the same day. However, wait times may apply, or appointments may need to be rescheduled.
Authorization for release of Patient Information Form- Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
Midha Medical Clinic Authorization and Consent for Treatment Form- All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
Midha Medical Clinic Preferred Contacts Form- Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.
Financial Policy Form- This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Midha Medical Clinic Notice of Privacy Practices Form- All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.