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Patient Information
OFFICE POLICIES:
Please review our office policies. If you have any questions please call during normal office hours which are Monday through Thursday from 8:00 a.m. until 5:00 p.m. 

Office visits are by appointment only and vary according to each practitioner’s schedule.

CANCELLATION POLICY:
Because the appointment time has been reserved for you, you will be charged for cancellations with less than 24-hours notice, or for a no show A fee of $75.00 will be charged for appointments cancelled with less than 24 hours. These charges are not covered by your insurance and are due and payable prior to any further appointments. In the event you must cancel and cannot reach the office personnel, please leave a message on the office voice mail system. Our answering machine will date and time your call. 

TELEHEALTH:
It is YOUR RESPONSIBILITY to make sure you are able to perform a 2 way video and audio communication throughout your appointment. If you are unsure how to perform a TELEHEATTH visit please brings your device to our office and we will show you.
If you do not hear from our office after an hour past your appointment time please call our office @ 716-691-0639 option 0.
You will be asked to pay your copay and or co-insurance at the visit via credit card. IF you are unable to make a payment at that time of visit It is YOUR RESPONSIBILITY make a payment by calling our office at 716-691-0639 or our billing company 716-389-3307 or by mailing a check to our office. ALL Payment must be made prior to your next scheduled appointment or your
appointment maybe cancelled until payment is received.


PATIENT RECORD FEES:
There is a fee of $10.00 for NYS disability forms, as well as for other disability forms that are 1 page or less. More complex forms will be charged up to $25.00, depending on the length and time involved to complete the form. Your records, if copied, will cost $0.75 per copied page. Records requested by other physicians or health professionals rendering active treatment are free of charge. Dictated reports by your clinician will incur a charge based on the amount of time spent on producing the document. Court appearances are charged by the half day and will differ from clinician to clinician. Form completion will take between 10-14 days.

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Privacy Policy
Medical History FormTo save time please print, then complete form and bring to your 1st appointment
Patient Release of Records FormAll new patients must provide a release of records form prior to their 1st appointment. Please complete the form and mail or fax to Jaffri Medical or previous healthcare provider.
Office Policies
Patient Registration FormTo save time please print, then complete form and bring to your 1st appointment