New Patient Form

New Patient Form

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.

Medical Disclaimer

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

Medicare Prescription Disclaimer

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.

BC/BS Disclaimer

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