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423-616-0705 08:00 AM - 08:00 PM (Mon-Sat) 08:00 AM - 06:00 PM (Sun)

Patient Information













 Male  Female



Emergency Contact Information








Visit Information




Non-Compliant

All Patients must be compliant with their treatment. If you are noncompliant then we can't provide proper treatment. Noncompliance will result in discharge form the practice. All patients that are having any issues must come in to the office to be seen so we can provide the best care.

We strive to provide the best care to all of our patients. In order to do so we ask all of our patients to work with us to provide the best care possible.

Payment Policies

We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy Is Important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask If you have any questions about our fees, our policies, or your responsibilities. It Is your responsibility to notify our office of any patient Information changes (Address, Name, Insurance, Information, etc.),


Patients are expected to present an Insurance card at each visit. All co-payments and past due balances are due at time of service. We accept cash, check or credit cards. Absolutely no post-dated checks will be accepted.


Insurance Is a contract between you and your Insurance company. In most cases, we are NOT a party of this contract. We will bill your primary Insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all Insurance Information Including primary and secondary Insurance, as well as, any change of Insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your Insurance company may pay, it is the Insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the final and customary allowance. If we are out of network for your Insurance company and your Insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.


Due to high patient demand and the limited availability of appointments, Health Services has Instituted a "NO SHOW and LATE CANCELLATION FEE" policy that will result In a 50.00 fee. If you cancel your appointment with less than 24 hours' notice or do not show-up for your appointment. Patients who cancel their appointment at least 24 hours in advance will not be charged a fee. Timely cancellation will allow this appointment time to be offered to another patient.


Patient statements will be sent out every 2 weeks. If any balances such as co-pays, deductibles due to InstaCare-PLLC go unpaid over 30 days. If no response, further action will be taken. Outstanding balances due will be sent to our attorneys with an additional 30% added to the account and the patient will be held responsible for all legal fees and court cost in order to collect this debit

Insurance Benefits

Assignment of insurance Benefits; I hereby authorize payment directly to any services provided to me,
Regulations pertaining to Medicare assignment of benefits apply, I authorize any holder of medical or other information about me to release to Social Security Administration and Health Care Financing Administration or the carriers of any other insurance company any information needed for this or a related Medicare/Other Insurance company Claim.
I understand my signature request that payments be made and authorize release o medical information necessary to pay the claim. If item 9 of the HCFA claim form is completed, my signature authorizes releasing of the information to the insurer or agency show, In Medicare/Other insurance company as the full charge (excluding non-contracted insurances and the patient is only responsible for the deductible, coinsurance, copayment or non-covered services.

Patient Acknowledgement

I have received and understand this practice's Notice of Privacy Practices written in plain language.
I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice.
If changes to the policy occur, this practice will provide me a revised Notice of Privacy Practices upon request.

Medical Authorization


To release photo copies of all medical records compiled during office visits and /or hospital admissions


The Kidney Center P.L.L.C
Dr. Mohammed Ahmed
1530 West Andrew Johnson Highway
Morristown. TN 37814
432-307-8951
(F) 844-896-2657
The purpose or need for information: To Continue medical care/treatment.
This Consent will expire (365) days after the day below or son at my election.
I place no limitations on history of illness or diagnostic and therapeutic information, including any treatment for alcohol, drug abuse, psychiatric disorder, or HIV infections,
This authorization can be revoked, but not retroactive to the release of information made in good faith.

Billing Payments

Your health care is important to us. In order to provide you with the best possible care, we occasionally send convenient text messages and emails to our patients about appointment reminders and billing payment options.
We ask to obtain consent for our practice Kidney Center to be able to send you important appointment reminders and bill paying options. We will only use the mobile device(s) or emails associated with your patient information.
You will be set to receive text messages and emails for appointment reminders, information regarding your bill and anything regarding updating your patient information but you will not receive text messages about promotions or other services we offer.
We look forward to providing better and more convenient communications with you via text messaging.