Patient Forms

If you are a new patient or it has been more than three years since you have last visited Dr. Peairs, please bring the following completed form with you to your office visit.

These forms are fillable PDF’s you may also print the forms and fill it in by hand, if you prefer.

Patient Form Printable
Patient Form Fillable

Please note: You will not be able to save your responses to this form; you must print it out. Be sure to print a copy of the form for Dr. Peairs, and you may want to print a copy for your own records.

Policies and Procedures

We are committed to providing you the best possible care. If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy.

Payment for services is due at the time services are rendered.
New patients are required to pay in full for the first visit, after which we will be glad to submit your charges to your insurance company. We accept cash, checks, Mastercard or Visa. We will be happy to help you process your insurance claim form for your reimbursement. In special instances, we may accept assignment of insurance benefits.

YOU must realize, however, that:

  1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.
  2. Our fees are generally considered to fall within the acceptable range by most companies, and, therefore, are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (such as 50%, or 80%) of the Usual, Customary, and Reasonable fees for this region. Thus, our fees are considered usual, customary, and reasonable by most companies. This statement does not apply to companies who reimburse based on an arbitrary “schedule” of fees, which bears no relationship to the current standard and cost of care in the area.
  3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

A fee will be charged for returned checks. Charges may also be made for broken appointments and appointments canceled without 24 hours advance notice. Billing charges will apply for an unpaid balance over (30) thirty days. After (60) sixty days, accounts will be placed with a collection agency. Any additional charges incurred by turning an account over to a collection agency will be the responsibility of the patient.

We must emphasize that as healthcare providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that a temporary financial problem may affect timely payment of your account. If a problem does arise, we encourage you to contact us promptly for assistance in the management of your account.

If you have any questions about the above information, or any uncertainty regarding insurance coverage, PLEASE do not hesitate to ask us. We are here to help you.

If you would like to make an appointment or need details on our phone, location, and hours, please follow this link: Make an appointment with Dr. Peairs

For other questions, please contact our office: Arizona Arthroscopy and Sports Medicine.

We accept worker's compensation and over 15 different types of insurance, including:
  • Aetna
  • Blue Cross/Blue Shield
  • CIGNA
  • Humana
  • Great West
  • State of Arizona
  • Healthsmart
  • Medicare
  • Motorola Health Advantage
  • Mutual of Omaha
  • Pacificare
  • United Healthcare

Please visit our Insurance Accepted page to see all of the plans we accept.