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Please download, print and fill out prior to your initial visit.
Please allow 20 minutes to complete. The amount of detail is up to you.

New Patient Forms - Regular Visit

Patient Intake

Signature pages


Additional form for Accident/Injury Visit

Injury / Accident Information

Patient Resources //

Frequently Asked Questions //

Do you accept my insurance or car accident/PI case?

Dr. Harasha is an Out-of-Network provider with most insurance companies. High deductibles and lack of coverage for Laser and Shockwave eliminates the benefit of using insurance.

Dr. Harasha will accept almost all personal injury or motor vehicle accidents cases. In these cases a lien is used so you can receive the care you need and payment will be made at a later date by the third party who is required to pay for your care.

What are Dr. Harasha's Fees?

Fees are based on the number of services provided at your visit and the amount of direct doctor time.

​$85   - 1 service (5-15 mins) - rarely done

$125 - 2 services (15-30 mins) - most common fee

$165 - 3 services (30-40 mins) - usually for initial visit

$220/hr - Functional Medicine and Cognitive Decline

$20 - Mobile Visit travel fee

(There is a $5 discount for cash and a 5%/$5 upcharge for credit cards)

In-Network Provider: //

  • Medicare, non-par (meaning patient pays for visit up front and gets reimbursed later)

If you are injured in an accident, please receive appropriate care immediately from Dr. Harasha, your Primary Care doctor, Urgent Care or the ER.
Dr. Harasha will most likely accept your car accident or PI case. A quick review of the case or call to your attorney will determine if his care will be of benefit to you. Please Contact us to discuss your specific case.
If you believe your own insurance or other third party should be financially responsible for your injuries, we can help by working with your insurance company or recommending an attorney.

How do you handle payments?

We collect payment at the time of service and base it on information we have available regarding copays, etc.

We accept cash, check, credit card, Care Credit and health savings accounts (HSAs).

If acceptable to you we keep your card on file and charge it as your leave your visit. This is especially important in COVID times.

We rarely send statements. This is required if your insurance did not pay what was expected and you still owe more.

Finally, we understand that your care will require several visits in a short amount of time and that can be outside your budget. In this case, we offer a 0% Loan and let you pay your bill over 6 months with auto-debit from your account.

Finally, we will create a Financial Review of Findings by your second visit to clearly illustrate what you need to pay.

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