PATIENT INFORMATION

By providing a phone number and an email address I hereby consent to receive voicemails, phone calls and emails from NY Psychiatric Services clinics.

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  • PATIENT INFORMATION
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  • PRIMARY INSURANCE
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  • ADDITIONAL INSURANCE
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  • ASSIGNMENT AND RELEASE
  • and assign directly to N.Y. PSYCHIATRIC SERVICES, P.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for not covered services and all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
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  • NEW YORK PSYCHIATRIC SERVICES, P.C.

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  • REFFERAL LIST

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  • 1. How did you hear about us?

  • ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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  • NOTICE OF PRIVACY PRACTIVES

  • Effective date of this notice is April 14, 2003
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  • PHARMACY INFORMATION
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