Forms for First Visit
Before your first visit – whether in the office or via telehealth – please complete the following forms:
- Patient Information Form – by logging into our Patient Portal or you may instead print and complete this form by hand and bring it with you.
- Nutrition Intake Form – only if you have an appointment with a dietitian
- Notice of Privacy Practices
- Authorization for Assignment of Benefits
- Authorization for Assignment of Medicare Benefits
- Financial Waiver
What should you bring to your appointment?
Please prepare for your appointment by bringing with you:
- First-time visit forms (above)
- Drivers license or state issued identification card
- Primary and secondary insurance cards
- A friend or family member to take notes / help with questions (With new Covid-19 regulations we ask for you to please come in alone)
- A list of your questions / concerns / past medical history and surgeries
- Copies of reports from your previous XRAYS and CT scans
Record Release Forms
Please complete the following medical records release forms as appropriate:
- Release of Records from NYGA to request that NYGA send your medical records to another healthcare institution
- Authorization to Release Medical Information to a Designated Contact to request that NYGA provide your medical records to a family member or other individual
- Release of Records To NYGA to request that another healthcare institution release your medical records to NYGA
