635 Madison Avenue & 59th St Floor 12
New York , NY 10022
T: 212 - 486 - 7447 | F: 212 - 486 - 3557
Confidential Patient Registeration & Authorization
Welcome to Our Office
Fields in RED are required
Section1 - Patient Contact Information
Section 2 - Insurance Information
Section 3 - Primary Care Physician
Section 4 - How did you hear about us
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Accent on Health Ob/Gyn, P.C. to release any medical or incidental information that may be necessary, to my insurance carrier, for either medical care or in processing applications for financial benefit.
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of surgical/medical benefits to Accent on Health Ob/Gyn, P.C. for the services rendered. I understand that I am financially responsible for any balance not covered by my insurance and authorize Accent on Health Obgyn, P.C. to charge my credit card on file after notifying me in writing of the not covered balance.