Patient Forms

New Patient Forms

• Instructions for New Patient Forms- November 2023

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• New Patient Form- Nov. 2024

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• Healthix Consent Form- November 2020

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• Consent for Participation in Citywide Immunization Registry

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Existing Patient Forms

• Instructions for Existing Patient Forms- November 2023

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• Existing Patient Update Form- June 2024

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• Healthix Consent Form- November 2020

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• Consent for Participation in Citywide Immunization Registry

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Other Patient Forms

• Authorization for Release of Health Information- November 2020

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• Medicare Wellness Physical Form

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• GHI $30 Copay Letter- 12/2021

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• House Call Criteria Form- December 2020

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• Notice of Privacy Practices Acknowledgement Form- November 2020

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• Notice of Privacy Practices- November 2020

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No Fault Claim Forms

• No Fault Form- August 2024

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• NY DMV Assignment of Benefits Form- August 2024

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NYC Line of Duty Injury Forms

• NYC Line of Duty Information Sheet- Feb. 2022

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