Patient pre-registration

Pre-Registration

Complete your registration ahead of your visit. Your information is transmitted securely and stored confidentially. Fields marked * are required.

Please fill out this form in English.

Agency

Agency Name

Visit Type

Patient Demographics

First Name *

Last Name *

Date of Birth *

Gender *

Phone *

Email *

Social Security #

Stored encrypted. Never shown after submission.

Emergency Contact

Address

Address Line 1 *

Start typing and pick your address. City, State and ZIP fill in automatically.

Address Line 2

City *

State *

ZIP *

Insurance

Insurance Name

Member ID #

Insurance Card (front) *

Insurance Card (back)

Consents & Authorizations

I acknowledge that I have received and reviewed the Notice of Privacy Practices. *

I authorize NY Best Medical to use and disclose my health information for treatment, payment, and healthcare operations. *

I consent to medical care, testing, and treatment provided by NY Best Medical and its affiliated providers. *

I authorize the release of my medical and insurance information to my insurance carrier and affiliated laboratories, and assign benefits to NY Best Medical. *

Signature

Signature *

Sign here

Draw your signature using your mouse or finger.

I have read and agree to the Privacy Policy and Terms of Use. *

I agree to receive SMS notifications about my registration from NY Best Medical. Message and data rates may apply. Reply STOP to cancel.