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.
You may return the downloaded forms by:
Fax: 315 637 0605 ; or
Email: email@example.com ; or
Regular snail mail:
Rev. Michael Heath
7913 East Ridge Point Drive
Fayetteville , New York 13066