New Patient Registration Forms

You can save time by printing and filling out new patient registration forms prior to your appointment. Please take time to familiarize yourself with our Patient Privacy Policy. When you arrive, just hand over the completed forms to the receptionist to be scanned into your secure electronic medical record.

📋

New Patient Intake Form

Complete medical history, current medications, and health information.

Download PDF
✍️

Consent Form

Authorization for treatment and consent to receive care.

Download PDF
🔒

HIPAA Release Form

Authorization to release medical records to another provider.

Download PDF
📄

Privacy Notice

Our Notice of Privacy Practices under HIPAA.

Download PDF

Additional Forms

💊

Controlled Substance Agreement

Required for patients prescribed controlled medications.

Download PDF

Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost. Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items and services.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Questions?

If you have any questions about these forms or need assistance completing them, please contact our office:

Phone: (631) 517-9170
Email: modernfamilymed@gmail.com