New Patient Forms
New Patient Intake Form: Please complete this ONLINE form prior to your appointment. It will take approximately 15 minutes.
24 Hour History Form: Please complete this form the day before your appointment. You will be asked to complete this form again prior to each follow up appointment.
CHILD Tongue Tie Intake Form: Intake form for children over 1 year of age ONLY.
In-Network Insurance
We are in-network with:
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AETNA (most private plans, *excludes Aetna Better Health / Aetna Medicaid)
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MERITAIN (managed by Aetna)
👉 In-network claims are submitted directly for you. If you have Aetna coverage, your visit may be subject to copays, coinsurance, or deductible requirements based on your plan.
Important:
Both Breastfeeding Medicine Consultations and Tongue Tie Consultations involve both parent and baby. Insurance requires separate claims for each.
If the parent and baby have different insurance policies, please let us know in advance so that your claims are processed correctly.
If only the baby is covered in-network with Aetna, there will be a separate fee for the parent. We'll provide a separate claim you can submit for reimbursement.
Payment at Time of Service
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We collect payment for any expected member responsibility (copay, coinsurance, deductible) at the time of your visit. We do not offer payment plans.
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We accept credit cards, debit cards, HSA, and FSA. We do not accept American Express.
Self-Pay/ Prompt Pay Discounts
For out of network visits, we offer a prompt pay discounts when paid in full at the visit:
✅ Frenotomy Appointments (Tongue/Lip/Oral Ties) - includes consultation, all releases, and feeding support immediately after the procedure: $665
✅ Tie Consultation Only (no procedure performed and NO lactation support): $220
✅ Breastfeeding Medicine Consultation (lactation and feeding support, no procedures): $420
If you're out-of-network, you'll get a detailed claim (superbill) to submit to your insurance for possible reimbursement.
Check out of network coverage ahead of time.
Here are the billing codes you can give your insurer:
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Diagnosis Codes: P92.5, Q38.1
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Procedure Code: 41010 (Frenotomy)
If you need help, just ask—we’re happy to explain.
Referrals
If your insurance requires referrals, you’ll need separate referrals for both parent and baby before the visit
No Show & Late Cancel Fee
New patient appointments missed or cancelled with less than 24 hours’ notice will incur a $75 fee.
