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Patient Forms

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Financial Policy Forms

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  Brooklyn Office
  
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  Long Island Office
  
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  New Jersey Office
  

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  HIPAA Authorization Form
  
• Medical History Initial Visit Form
• Patient Information Form
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  New York State Assignment of Benefits Form
  
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  INA Assignment of Benefits Form
  

• Designation of Authorized Representative Forms

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  Generic here
  
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  For persons with United Healthcare plans
  
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  For persons with Cigna plans
  
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  For persons with Aetna plans
  
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  For persons with Anthem Blue Cross plans
  
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  For persons with Horizon plans
  
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  For persons with 1199 plans
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  For persons with Emblemhealth plans
  
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  For persons with Empire plans
  
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  For persons with National Association of Letter Carriers
  
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  State of New Jersey Consent to Representation in Appeals of Utilization Management Determinations and Authorizations for Release of Medical Records in UM Appeals and Independent Arbitration of Clams
  

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  Standard Notice and Consent Documents Under the No Surprises Act
  

• Insurance Appeal Authorization Form