COVID-19 Patient Registration

COVID-19 Patient Registration

Please complete the form below to capture the New YorkState required COVID information as well as our patient registration form.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Mobile)*
Please enter a valid phone number.
Phone Number (Other)
Please enter a valid phone number.
Email*
example@example.com
Social Security Number
Birth Date*

MonthDayYear
Date
Martial Status*

SingleMarried
Sex*

FemaleMale
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Desired Testing Date (Closed Saturday & Sunday)*

MonthDayYear
Date

Secondary Insurance Information (if applicable)

Please complete the form below to provide your up to-date insurance information.
Insurance Company Name
Secondary Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance ID/Policy #
Secondary Insurance Group #
Secondary Insurance Policy Holders Name

First NameLast Name

How did you find us?*
Any comment to share?
IMPORTANT NOTE FOR INTERNATIONAL TRAVELERS:
- You must bring a copy of your passport to your COVID testing appointment so that we may document it on your report.
- This is very important and may put your travel plans at risk without it.
Terms & Assignment of Benefits

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.
Do you agree to our terms listed above?

YesNo
Today's Date

MonthDayYear
Date
Should be Empty:

COVID-19 Patient Registration

Covid & Symptomatic Questionaire

Primary Insurance Information

Secondary Insurance Information (if applicable)

IMPORTANT NOTE FOR INTERNATIONAL TRAVELERS: