Quality Since 1970

Brian P. Wilson DO, FACOG

Patrick J. Slattery MD, FACS

Brian F. Luepke MD

Tom D. Thockmorton MD

Jeffrey J. Dietzenbach MD

Jeffre D. Helmink MD, FACS

Please print our registration form and fill out completely.  Mail or bring with you to your appointment. 

Registration Form

• Medicare
• Iowa Medicaid
• Wellmark Blue Cross Blue Shield
• Midlands Choice
• Interplan Health Group
• United Health
• Coventry
• Sanford Health
• Avera Health Plans

Please print form, sign and date after reading Privacy Practices.  Mail or bring to your appointment.

Privacy Rights Acknowledgment

Please read our Privacy Rights then print off the acknowledgment and sign and date where indicated.  Bring the signed acknowlegement to your appointment.

Privacy Rights

Please read through our Financial Policy to understand your payment options and how we bill your charges.

Financial Policy

Please print the form and fill out required information. Be sure to sign and date the form.  Mail or hand carry to our office.

Requst For Release of Medical Information

If you would like us to share your information with another person please print and fill out this form.  Be sure to sign and date the form then mail or hand carry to our office.

Authorization of Use/Disclosure of Protected Health Information