Maryam Eskandari, M.D.
Psychiatry, Psycho-Oncology & Psychotherapy

-Forms-

Here are the 6 new patient registration forms that I will give you to fill out in the waiting room 15-30 minutes before your first appointment ~ if you wish, you can feel free to instead print them out & complete them at home prior to your first appointment:

Patient Registration.pdf

(1) Patient Registration Form

Consent to Treatment.pdf

(2) Consent to Treatment Form

HIPAA Advisement.pdf

(3) HIPAA Notification Form

HIPAA Acknowledgement.pdf

(4) HIPAA Acknowledgement Form

Consent to Release Info.pdf

(5) Consent To Release Information Form 

*this form is optional*

Good Faith Estimate.pdf

(6) Good Faith Estimate Form

I am an out-of-network provider.  If your insurance provides out-of-network benefits, you may be able to receive partial reimbursement from your insurance company for the fees you pay me for your treatment.  I have created this form (see below) to outline the most important questions you should ask your insurance company to better learn about your out-of-network benefits.  You may wish to call your insurance prior to your first appointment with me to verify your out-of-network insurance coverage.

Insurance Benefits Verification.pdf

Insurance Benefits Verification Form