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Patient Forms

We appreciate and value your time, so we’ve created downloadable forms in order to expedite your visit with us. Download and print the forms below.  Complete the forms and bring them to your visit with our office.  This will save you time on the day of your visit!

All forms are in PDF format, which you can print out and complete.

Release Form to Talk with Family Members About Your Care
This release allows us to talk with family members you designate about your care, if they contact our office on your behalf.  

Financial Policy Form
This form contains our financial policy and our billing and payment agreement.

Consent to Release Medical Information
This release allows us to disclose information from patient medical records to a designated person or entity.  Please note:  electronic signatures will not be accepted.  If you complete the form online you will need to print it out and sign it.

Patient Non-Discrimination and Language Assistance, Notice of Privacy Practices, No Surprises Act Notice, Good Faith Estimate Notice and Notice Regarding No Audio or Video Recording

Non-Discrimination and Language Assistance

Notice of Privacy Practices

No Surprises Act Notice

Good Faith Estimate Notice

Video or Audio Recording of Any Type is Prohibited on Surgical Associates of Neenah, S.C.’s Premises, including Waiting Areas, Exam Rooms, Procedure Rooms, Conference Rooms and Hallways.

Payment Information

Just as we are committed to providing quality care, we are concerned with keeping your medical costs as low as possible.

Insurance payments:

We accept most insurance plans and, as a courtesy to our patients, we will submit claims for services on behalf of our patients.  Because insurance is a contract between the patient and insurance company, the patient is ultimately responsible for payment.  We accept assignment which means we will be paid directly by the insurance company; however, the patient remains responsible for any deductibles, co-pays and any bills not covered by insurance. Co-payments are due at the time of the visit.

Insurance Forms:

Please bring any special insurance forms and your insurance card at the time of each visit. If you are seeing us for a worker’s compensation issue, please be prepared to provide us with the name of the insurance company, the insurance company’s address, date of injury and claim number.


As a courtesy to our valued senior patients, we accept assignment of Medicare.


We are a participating provider in most area health plans.

Medical Assistance:

We are a participating provider in Wisconsin’s ForwardHealth plan.

Your Referrals:

Our greatest compliment is to be asked to care for one of your friends or family members. We encourage patient referrals and would be happy to care for someone you know.