We ask that you arrive at least 15 minutes before your appointment to complete all the necessary paperwork. To better serve your medical needs, we ask that you provide us with as much medical information as possible.

For your convenience, you can complete your paperwork prior to your appointment.

Your options are:

• Print and complete the forms listed below
• Using Adobe Acrobat Reader, download, fill-in and print the forms below
• Request the forms to be mailed to your home

Once completed, remember to bring your forms with you to your appointment.

Patient Forms:

• Patient Registration Packet (English)
• Patient Registration Packet (Spanish)
• Patient History Form (English)
• Patient History Form (Spanish)

Medical Records:

• Medical Record Release Form (English)
• Medical Record Release Form (Spanish)

Self Pay:

• Financial Agreement (English)
• Financial Agreement (Spanish)
   

Good Faith Estimate

If you are uninsured, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call our office.

Insurance

Farzana Ahsan, MD, FAAP currently works with over 30 major insurance companies. Our staff is always working on accommodating our patients and their insurance providers. Please call our office at (631) 281-4070 to find out if your carrier is on our continuously expanding list of providers.
 

**Disclaimer**

Insurance plan participation may change over time. While every effort is made to ensure the accuracy of this information, we recommend that you confirm participation status with your insurance carrier or practice. Please note that insurance plan participation requirements may be waived when a patient receives medical treatment in an emergency.