New Patient Form

    Patient Information
















    Your Preferred Pharmacy







    Your Insurance






    MEDICARE: No providers at Fritz Clinic provide Medicare services or Disability Medicare services. I understand that I cannot be treated under my Medicare at Fritz Clinic.

    I understand that any prescription I receive from a physician at Fritz Clinic will not be covered under Medicare.

    BLUE CROSS BLUE SHIELD: I understand that Fritz Clinic is a cash-only practice and is out of network with BC/BS. I understand that I may file my visit for reimbursement with BC/BS. However, all services provided by Fritz Clinic (in all locations) are out of network.



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