Patient Forms

Patient Forms & Information

Please print out the following forms and bring them filled out to your initial consultation appointment with a member of our team.

New Patient (Vascular / General)

• New Patient Registration Form
• Notice of Privacy Practices Acknowledgement HIPAA (requires your signature)

New Patient (Bariatrics)

• New Patient Registration/Medical History
• Psychological Questionnaire
• DIET Inventory
• Dietary Assessment
• Notice of Privacy Practices Acknowledgement HIPAA (requires your signature)

Insurance & Billing Information

Please always call your insurance company to ensure that you are able to see one of our providers. Please note that co-payments in the form of cash or check are required at the time of your appointment. In most instances, Highland Surgical Associates is able to accept the following health insurances:

Aetna	Medicaid
Blue Cross Blue Shield	Medicare
Cigna	Neighborhood Health Plan
Fallon	Tricare
Harvard Pilgrim	Tufts

Depending on your health insurance provider or managed health care plan, you might need a pre-authorization or referral before seeing a physician or specialist at Highland Surgical Associates. Contact your health insurance provider if you have questions about the specifics of your health care coverage.

If your health insurance provider requires a managed care referral, please contact your Primary Care Physician before your appointment and have them fax the necessary referral to us at (617) 696-6655

If you have any billing concerns or if your insurance is not listed above, please contact our billing company, DBI, at (781) 749-9071 and they will be happy to assist you