1 E Roe Blvd, Patchogue, NY 11772 |
 
 
 
Call Us Today: 631-475-3900
 
 
 
 
 
 
 

Patchogue Medical Group Patient Forms in Patchogue, New York


Medical Patient Forms

New patients should arrive 20 minutes prior to their scheduled appointment. Please bring with you your insurance ID card and government issued proof of identity (Driver's License, state issued Non-Driver's ID, Military ID). In order to save time prior to your scheduled appointment, you can also print out the forms listed below so that you can fill them out at home and then arrive to your appointment at the scheduled time. Please be advised that your copayment will be required at the time of the visit.
 
Happy Doctor and Patient — Family Doctors in Patchogue, NY
 
 
If your insurance requires that you obtain a referral to see a specialist, please provide us with the following information*:
 
  • Name of Specialist/Doctor
  • Specialist Provider ID
 
  • Specialist/Doctor's Address
  • Specialist/Doctor's Phone Number
 
  • Specialist/Doctor's Fax Number
  • Diagnosis Code
 
*Our procedure for obtaining referrals: We require 72 hours to provide an authorization referral. If you have an HMO insurance, you will need a referral form to see a specialist. When one of our physicians recommends that you see a specialist, we request that you make the appointment with the specialist and then provide us with the information as shown above.
 

Cosmetic Patient Forms

New cosmetic patients should arrive 20 minutes prior to their scheduled appointment. If you are not a current Patchogue Medical Group patient, please bring with you your government issued proof of identity (Driver's License, state issued Non-Driver's ID, Military ID). In order to save time prior to your scheduled appointment, you can also print out the forms listed below so that you can fill them out at home and then arrive to your appointment at the scheduled time. Please be advised that any payments specified on the Cosmetics Service page will be required at the time of the visit in the form of cash or credit only.
All Patients please download the following forms:
Patients having Dysport Injections should download the following forms:
Patients having Dysport Injections should download the following forms: