Forms

There is a standard service charge of $15 for any form completion ($50 for expedited service – same/next business day if the physician is in the office). This amount is due at the time the forms are submitted to our office. Please allow 5-7 business days for processing. The forms will be sent to you in a password protected PDF with a six digit numerical code (no slashes). For example- if your child’s date of birth is January 15, 2003 the code will be 012003.

Please download any of the following forms as needed:

Registration Form and Insurance Information

HIPAA/Prescription CONSENT FORM

Assignment of Benefits Form

Office Policy on Insurances and Payments

Lab Fee

Late/Missed/Cancelled Appointment Policy  

Delegation of Consent

HIPAA/Prescription Consent Form

Assignment of Benefits Form

Credit Card Form

*** IMPORTANT NOTICE ***

IRVING PLACE LOCATION TO CLOSE

Our 67 Irving Place location will be closing on March 30th and all patients can be seen at the Chelsea location 420 W 23rd St, New York, NY 10011

TELEHEALTH

Due to the Coronavirus pandemic, we are converting the majority of our visits to telehealth. Please dowload and read the Healow Quick Start Guide for instructions on how to use our service.

This will enable us to provide our families with care, while limiting visits to the office and following social distancing guidelines.

IN OFFICE AND HOME VACCINE VISITS

In order to vaccinate our patients on schedule during the COVID-19 pandemic, we have two options, in person visits or NEW home vaccine visits… Learn More

Forms

HIPAA/Prescription Consent Form

Assignment of Benefits Form

Credit Card Form

MAKE AN APPOINTMENT

LOCATIONS

In Gramercy Park

In Chelsea

SHARE

*** IMPORTANT NOTICE ***

IRVING PLACE LOCATION TO CLOSE

TELEHEALTH

IN OFFICE AND HOME VACCINE VISITS

* IMPORTANT NOTICE *