Intake Forms 

Call Us:  +1.5613923557

If you prefer, you may download these forms and deliver them to the office for Dr. Homer to review.  The same policy as above applies, and there is no gaurantee that an appointment will be made.   It is usually far easier to fill out the electronic forms above.  

​​Sorry, not accepting new patients at this time. Thank you for your interest in Dr. Homer's practice.   If you feel that you would benefit from this type of practice and are directed by the office to submit intake forms, please do so.  Dr. Homer will review the forms and if he agrees that you would benefit we will call to make an appointment, or to let you know that he does not think that what is offered is the best match for you  (which would mean treatment would have to be sought elsewhere).    If you are in need of urgent services, unstable, not feeling safe, or will be running out of medicine, please seek the appropriate care with your primary care doctor, the emergency room, call 911, etc.. Thank you for your cooperation.   Sorry, not accepting new patients at this time.

GOOD FAITH ESTIMATE

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit No Surprises Act | CMS