Forms used by Dr. Afshar in her Practice:
Below are some forms for you to download, read and complete. Please bring the completed and/or signed forms with you to your first visit with Dr. Afshar.
The HIPPA Privacy Notice Form informs you of your privacy rights; please keep it for your records only.
The Electronic Communication Policy Form is also for you to review and keep for your records only.
If you wish to use your BCBS PPO insurance benefits, please make note to read and sign The Authorization to Release to Insurance Form and bring it and the completed/signed New Intake/Registration Form, Patient and Provider Agreement Form, and Credit Card Authorization Form with you to your first session. If we are meeting remotely, please also read and sign the Telehealth Consent Form.
Please complete the The Authorization to Release to Third Party Form only if you wish for Dr. Afshar to speak with another provider, significant other, medical doctor, school professional or other contact.
| HIPPA Notice of Privacy Form |
| Intake/Registration Form |
| Patient and Provider Agreement Form |
| Authorization to Release to Insurance Form |
| Authorization to Release to Third Party Form |
| Credit Card Authorization Form |
| Telehealth Consent Form |
| Electronic Communication Policy |
For more Information, a Complimentary Phone Consultation, or to Schedule an Appointment, Contact Dr. Afshar's office at: 773.991.4417 or via E-mail at: [email protected]
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1-business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, please visit www.cms.gov/nosurprises or call 1-877-696-6775