New Patient Form

WELCOME TO THE OFFICE OF DR. DOMINICK SERVEDIO & DR. BARBARA GROSSMAN. PLEASE FILL OUT THIS FORM ONLINE AND SUBMIT OR PRINT AND BRING WITH YOU ON DAY OF VISIT. ANY QUESTIONS FEEL FREE TO CALL US AT 917.441.6094
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Name
Marital Status
Address
I request that the payment of authorized Medicare or other Insurance company benefits be made either to me or on my behalf to Dominick Servedio, Au.D. for any services furnished me by the audiologist. I authorize my holder of medical information about me to release to Dominick Servedio, Au.D. any information needed to determine these benefits or the benefits Payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. This includes the release of hospital information/ if item 9 of the DCFA-1500 Claim form is completed: my signature authorizes the release of the information to the insurer or agency shown. In Medicare or other insurance company assigned cases, the audiologist or supplier agrees to accept the charge determination of the Medicare or other insurance company as the full charge and the patient is responsible only for the deductible, co-insurance, and charges for non covered services/ Co-insurance and the deductible are based upon the charge determination of the Medicare or other insurance company.
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I have received this practice's Notice of Privacy written in plain language. This Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these right and the practice's legal duties with respect to my information. See bottom of page for link to HIPPA Notice of Privacy Practice in Full. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all the protected health information resident at, or controlled by, this practice, I understand I can obtain this practice's current Notice of Privacy Practices on Request.