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EFAX: (888) 433-4219
FAX: (302) 429-9284
Either download one of these files so you can fill it out then reupload it on this page
OR fill out the form on this page
Phone Number (required)
Date of Birth (required)
Policy Holder Name
Insurance Policy #
Do you have Dental Insurance?
What are your Health and Wellness goals?
Submit your Medical History form instead (only pdf or docx files allowed)
I hereby assign all medical and/or surgical benefits to which I am entitled including private insurance and any other health plans to Family Practice Associates. This Assignment will remain effect until revoked by me in any wrong. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure payment. I understand that I am Financially Responsible for all charges not paid by my Insurance Carrier. In an effect to continue to deliver the highest quality of care on which you have come to rely, we can wither curtail services or attempt to collect cost. We have chosen to pursue the latter option.
With that in mind, we trust we can depend on your cooperation.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Family Practice Associates or insurance company to release any information required to process my claims.
(Type your initials to agree)
Holistic comprehensive compassionate care and outreach for persons living with complex chronic medical conditions in order to improve their overall quality of life and wellbeing.
“We are committed to supporting all of your health care needs with compassion every step of the way.”
Dr. Nina / Founder
© 2024 TOVA Community Health
TEL: 302-429-5870 EXT. 120
213 Greenhill Ave., Wilmington, DE 19805
P.O. Box 9663 Wilmington, DE 19809
© 2024 TOVA Community Health of Delaware. in association with Tova Community Health. Redesign by The African Boss