Pre-Registration

Agency Name

Type

Patient Demographics

First Name

Last Name

Birth Date

Sex

Male Female Prefer not to say

Phone

Social Security #:

Emergency Contact (Name & Phone)

Address Information

Address Line 1

Address Line 2

City

State/Province

Zip/Postal

Insurance Information

Insurance Name

Member ID#

File Upload

Please take a photo of the front of your insurance card.

Please take a photo of the back of your insurance card.

Please take a photo of the front of your driver's license.

Notice of Privacy Practices

I acknowledge that I have received (or have been offered) a copy of this office’s Notice of Privacy Practices.

Use of Health Information

I consent to the use and disclosure of my personal health information for treatment, payment, and healthcare operations, as permitted by law.

Consent for Care

I consent to any examinations, diagnostic tests, and/or care deemed necessary and appropriate by the provider.

Insurance / Laboratory Tests

If I present insurance information for laboratory tests or blood work, I authorize the release of necessary information to process claims and accept financial responsibility for any non-covered services.

Date

By submitting this form, I authorize NY Best Medical to contact me using automated technology, including calls and text messages, at the phone number I have provided. I understand that my consent is voluntary and not a condition of receiving services or making a purchase. I also acknowledge that I have read and agree to the Privacy Policy and Terms & Conditions.