Fee Negotiation Information Form

*

Office Name in first name Docter's Name in last name

First Name

Last Name

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Plan(s) *

Please select your current Insurance Plan(s) If your insurance plan(s) is or are not listed please list them in the additional information box!

United Health Care

Delta Dental

Humana

Cigna

Ameritas

Envolve

Hoosier Health Wise

HIP (Healthy Indiana Plan)

Other