New Patient Form

Name: CNY Mental Health
Address: 892 E Brighton Ave, Syracuse`, NY, 13205, US
Telephone: (315) 475-3178

Please complete all information

Name:*
First Middle Last
Gender:*
- Male
- Female
Address:*
Street Address City State ZIP Code
Date of Birth:*
MM slash DD slash YYYY
Home Phone:*
Cell Phone:*
Email:*
Employer
Name:*
Phone:*
Primary Care Physician
Name:*
Phone:*
Therapist / Counselor
Name:
Phone:
Pharmacy
Name:*
Phone:*
Fax:*
Address:*
Street Address City State ZIP Code
Spouse / Parent or Guardian Information
Name:*
First Last
Relationship:*
- Spouse
- Parent
- Guardian
Phone:*
Employer:*
Date of Birth:*
MM slash DD slash YYYY
Address (if different):*
Street Address City State ZIP Code
Insurance Information
Primary Insurance:*
Policy Holder:*
Member / Policy #*
Claims Address:*
Street Address City State ZIP Code
Secondary Insurance Information
Secondary Insurance:
Policy Holder:
Member / Policy #:
Claims Address:
Street Address City State ZIP Code
Signature
Authorized Person's Signature:*
- I authorize the release of any medical information necessary to process my claims.
Payment to Provider:*
- I authorize payment of my medical benefits directly to Dr. Riaz Syed. I understand and agree that by accepting services, I am financially responsible to Dr. Riaz Syed for payment of any of my charges that are not reimbursed by other means and agree that I am responsible for any legal or collection fees that my be incurred should my account require these services. I further understand that three cancelled or missed appointments within a year can result in termination of care, also if I do not cancel my scheduled appointment 24 hours in advance, I will be charged for the missed appointment.
Guarantor's Signature:*
Date:*
MM slash DD slash YYYY

New Patient Form

Employer

Primary Care Physician

Therapist / Counselor

Pharmacy

Spouse / Parent or Guardian Information

Insurance Information

Secondary Insurance Information

Signature