Billing Inquiries: 516-673-4706

410 Lakeville Road, Suite 305, Lake Success, NY 11042

 

patient_profile

My Patient Profile

Patient Information

Patient Employment

Spouse/Partner

Who Referred You to Our Practice

Emergency Contact

Visit Information

Primary Insurance

Secondary Insurance

Pharmacy

Person Responsible for Billing

YOU MUST PRESENT A VALID CURRENT INSURANCE CARD & VALID PHOTO ID AT TIME OF APPOINTMENT. YOUR COPAY IS DUE AT CHECK IN.

Assignment of Benefits

Medical History

Family History