Please complete the form below to capture the New York State required COVID information as well as our patient registration form.

Please complete the form below to capture the New York State required COVID information as well as our patient registration form.

I authorize payment of insurance benefits directly to East Northport Medical Care. I authorize the release of any necessary medical information to all my insurance companies.I understand that I will be held liable for payment of all services rendered to me by East Northport Medical Care if I have provided incorrect insurance information which results in non-payment on any date of service.I understand that I am responsible for any unpaid portions of my deductible and/or coinsurances.It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations.This information is furnished by your insurance carrier and every patient’s policy is different. Our relationship is with you and not your insurance company but we will gladly provide you with any information you need for you to contact your insurance company to inquire about non covered services.A $10.00 billing processing fee will be added to any copayments not paid on the day services are provided.There will be a $35.00 fee for any check dishonored by any Financial Institution.I permit a copy of this authorization to be used in place of the original.I authorize the doctor to act as my agent in helping me obtain payment from my insurance company.I acknowledge receiving a copy of ENMC privacy act. I acknowledge receipt of the Joint Notice of Privacy Practices from Beacon CHSLI.