New Client Forms

If you are a new patient please download and print the New Client forms below:

After reviewing its content, fill out , sign and return, before your first appointment.

For the red insurance authorization form (CMS1500) , there is no need to fill it all out.  Just sign without dating box 12 (by the client) and box 13 (by

the policy holder).

NOTE BENE:  To ensure confidentiality,   if you choose to return the  forms  via  e-mail,  make sure that you first encrypt them ,  with a pass word  before sending it .  Then , text the password  to me at 315 380 1005.  

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You may return the downloaded  forms  by:

Fax: 315 637 0605 ; or

Email: mheath1@twcny.rr.com ; or

Regular snail mail:

Rev. Michael Heath
7913 East Ridge Point Drive
Fayetteville , New York 13066