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If you're a new patient, please fill out the following forms:

NEW PATIENT INFORMATION

First Name

Last Name

Date of birth

Address

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Postal code

Phone *

Email *

Emergency Contact Name

Emergency Contact Relation

Emergency Contact Phone

Summarize your beauty/physical goals or concerns:

Gender

Summarize anything specific you'd like us to discuss

Possible Referrals

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INSURANCE AUTHORIZATION

I request that payment of Authorized Medicare benefits and or Private insurance companies be made on my behalf to Passaic Sleep Medicine and Neurological Services (Neuro Wellness), Dr Fawad Mian, MD for any services furnished to me. I authorize the release of ALL medical information pertaining to myself, be released to the insurance companies and its agents along with any information necessary to determine these benefits or benefits payable for related services. I understand that I am responsible for any balance not covered by my insurance company (this includes co-insurances, deductibles).

Full Name

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Date

ASSIGNMENT OF BENEFITS/ FINANCIAL AGREEMENT

I hereby give authorization for payment of insurance benefits be made directly to Passaic Sleep Medicine and Neurological Service (Neuro Wellness), Fawad Mian, MD for services rendered. I understand that I am financially responsible for all charges regardless of insurance coverage. Accounts 20 days past due will be considered in default and it may become necessary to refer my account to an attorney for collections. If my account is referred to an attorney for collections, I agree to be responsible to pay all amounts, including attorney's fees in the amount of 30% of the default amount placed for collections. The attorney's fees in the above amount shall become due and owing at the time the account is placed for collections and I understand that it will be assessed and added to the balance at that time. I also agree to pay simple interest at the rate of 1.5% per month on any balance in default. I authorize my medical records to be released as necessary to secure payment of benefits. I also agree that a photocopy of this agreement shall be as valid as the original.

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