The following details are needed to register as a new patient:
[1] Registration package.
[2] Copy or picture of the front and back of insurance benefit cards.
[3] Copy or picture of your photo ID
[4] $50 refundable new-patient fee
[1] New Patient Registration Package:
Please download the form to your computer first. Then open the saved document on your computer. You can fill out the saved form directly from your computer.
If you fill out the form on line, you won't be able to save it afterward; however, you can still print it.
You can signed the form electronically by typing your name in the signature fields. Please save the registration form and email it back to the office at HungTranMDNew@Gmail.com. Please use this email only for sending in your registration forms, as all other emails will be filtered out and will not be seen.
[2] and [3] Pictures of insurance and photo ID:
Please send us a copy or picture of the front and back of your insurance benefit cards and your photo ID for verification of your insurance coverages and for your identification. You can email it to HungTranMDNew@Gmail.com.
[4] $50 refundable new-patient fee:
A deposit of $50 new-patient fee is required to set up an appointment time for all new patients. The new-patient fee is fully refundable if the appointment is canceled at least 24 hours in advance, not counting Saturday, Sunday, or holidays. The new-patient fee will be applied to your co-pays at the time of service. If the appointment is not kept, the deposit will be applied to the missed-appointment fee charge, which is $50.
Download and save to your computer first before completing: Other information/forms:
[1] Registration package.
[2] Copy or picture of the front and back of insurance benefit cards.
[3] Copy or picture of your photo ID
[4] $50 refundable new-patient fee
[1] New Patient Registration Package:
Please download the form to your computer first. Then open the saved document on your computer. You can fill out the saved form directly from your computer.
If you fill out the form on line, you won't be able to save it afterward; however, you can still print it.
You can signed the form electronically by typing your name in the signature fields. Please save the registration form and email it back to the office at HungTranMDNew@Gmail.com. Please use this email only for sending in your registration forms, as all other emails will be filtered out and will not be seen.
[2] and [3] Pictures of insurance and photo ID:
Please send us a copy or picture of the front and back of your insurance benefit cards and your photo ID for verification of your insurance coverages and for your identification. You can email it to HungTranMDNew@Gmail.com.
[4] $50 refundable new-patient fee:
A deposit of $50 new-patient fee is required to set up an appointment time for all new patients. The new-patient fee is fully refundable if the appointment is canceled at least 24 hours in advance, not counting Saturday, Sunday, or holidays. The new-patient fee will be applied to your co-pays at the time of service. If the appointment is not kept, the deposit will be applied to the missed-appointment fee charge, which is $50.
Download and save to your computer first before completing: Other information/forms:
