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
Injury / Accident Information
Patient Resources //
Additional form for Accident/Injury Visit
Frequently Asked Questions //
Do you accept my insurance or car accident/PI case?
Dr. Harasha is an In-Network provider with the insurance companies listed below. Being in one of these plan will give you benefits like reduced fee schedules and lower co-pays.
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?
We keep fees simple. If you are In-Network with one of the companies below your insurance dictates your fees.
For patients paying out of pocket or with high deductibles fees are as follows:
$120 for Initial Visit
$60 for each follow-up visit
You can add another type of service for $30 extra
In-Network Provider: //
United Health Care
Anthem (Blue Cross)
Ambetter (Home State Health)
American Specialty Health (ASHN)
Medicaid (MO Heathnet)
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.
We rarely send statements. This is required if your insurance did not pay what was expected and you still owe some.
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 6-10 months with auto-debit from your account.