New Patient Form

  • WELCOME TO THE OFFICE OF DR. DOMINICK SERVEDIO & DR. BARBARA GROSSMAN. PLEASE FEEL FREE TO 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
  • NOTICE OF PRIVACY PRACTICES- PATIENT ACKNOWLEDGEMENT

  • 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.
 

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