This form helps prospective patients connect with us more efficiently and explore whether the requested relationship will be a good fit.

If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911 or go to your closest emergency room.

This request is not an emergency or urgent matter. I wish to proceed
Is patient is an adult (18+ years old) or a minor (under age 18)
Are you taking Xanax daily or expect to take xanax daily?
Dr. Tariq doesn't prescribe Xanax to be taken on a daily basis. Are you willing to decrease your use of Xanax?
Are you making this appointment to get a disability or leave of absence form filled out? ( Please understand that Dr. Tariq doesn't fill out disability forms, or leave of absence forms.)

Unfortunately, it seems like our practice will not be a good match for your needs. It would be best if you seek care from a different provider. It will help prevent any hard feelings down the road.

Are you the patient, or you are filling out the form for someone else (child, sibling, spouse)? *
How do you plan to pay for your treatment *
I have called the behavioral health phone number on the back of my insurance card and made sure that Dr. Mudassar Tariq (NPI 1588895825, Tax ID: 81-3989390) is in network *
If you have out of network benefits, do you want to see Dr. Mudassar Tariq, MD using your out of network benefits?
My Plan type is
Do you have a deductible for mental health (A certain dollar amount (e.g $1500) that you will have to pay first before insurance starts paying.)) *
Who is the main subscriber on insurance (Primary insured)? *

In some HMO plans, the mental health is contracted out to third party insurance. You might not even be aware of the name of that insurance. Few examples are Magellan, compsych, Beacon, optum etc.  We are in network with Magellan and Compsych but not with Beacon and Optum. So we just want you to be aware, that if it is a third party carve out, even if your card says Blue Cross Blue Sheild, we might not be in network and you might be billed for full fee. If you are not sure, just google the behavioral/mental health phone number on the back of your insurance card, or you can call that number and ask them this question.