New Patient Registration
Please Note: Our office is currently not accepting new patients.

Once we begin accepting new patients, we will be unable to accept all insurance carriers.

Primarily your visits will be with our Certified Nurse Practitioner. Before submitting this form please determine if this is acceptable to you. Please note that not all insurance carriers cover nurse practitioners. Courtenay Simmons, CRNP, has been treating patients in the Tennessee Valley for several years and we are very glad that she joined us in providing excellent care to the patients of our practice.

By completing this form, you are authorizing Kara Wallace MD, PC, access to insurance information to verify benefits.  
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Previous primary care physician:
Patient Full Name *
Patient Date of Birth *
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What is your home address:
Daytime Phone Number *
CONSENT TO TEXT NOTIFICATIONS: I hereby consent to provide my wireless telephone number(s), so that representatives from Kara Wallace, MD, PC, its successors or assigns can contact me via text message regarding any matter, including but not limited to my medical treatment, prescriptions, insurance eligibility, insurance coverage, scheduling, billing or collection matters. I understand that I will be able to change my preference at any time. I understand that I may be charged for such calls by my wireless carrier and that such calls may be generated by and automated dialing system. *
CONSENT TO CALL: I hereby consent to provide my telephone number(s), including my wireless telephone number(s), so that representatives from Kara Wallace, MD, PC, can contact me in any manner including but not limited to by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded voice. I understand that I will be able to change my preference at any time. I understand that I may be charged for such calls by my wireless carrier and that such calls may be generated by an automated dialing system. *
Email Address: Please provide an email address so that we may communicate with you through our secure portal. *
What is your preferred pharmacy?
Name & Location:
 *
Language Preference(s) *
Required
Barriers to Communication *
Required
Insurance Information
The following is to help us distinguish whether we do/can work with your insurance provider so that we can proceed with registration as a new patient. In providing this information it is understood that , you are authorizing Kara Wallace MD, PC, access to insurance information to verify benefits.

Please note we are not accepting New patients with United HealthCare, Humana, Cigna, Medicare Replacement plans and a few others. If you are unsure if we are accepting new patients with your insurance please call our office.
Name of Insurance Carrier *
Insurance Contract ID Number *
What is the name of the Policyholder? (Person in whose name the insurance policy is held) *
Policyholder's date of birth: *
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DD
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Copay/Co-Insurance  Amount
Insurance Deductible Amount - If no standard office visit Copayment
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