Manhattan Family Practice Intake

ALBERT LEVY, MD
Manhattan Family Practice

911 Park Avenue, New York, NY 10075
office@manhattanfamilypractice.com
+1 (212)-288-7193

Dr. Albert Levy Intake Form

Patient Information Form

Please submit the Patient Sign-in Information form ahead of your scheduled appointment. Completing this form in advance will help us streamline your check-in process and ensure that your visit proceeds smoothly and efficiently. Your cooperation is greatly appreciated.

Personal Information

First Name

Last Name

Social Security # - last 3 digits

Date of Birth

Sex

Marital Status

Contact Details

Address

Street Address

City

State

Zip Code

Home Phone

Mobile Phone

Work Phone

Emergency Contact

First Name

Last Name

Phone

Relationship to patient

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

We will not disclose your medical records to others without your consent or unless the law authorizes or compels us to do so. Our Notice of Privacy Practices describes in greater detail how your health information may be used and disclosed. (Copies are available at the reception.) I understand that I am financially responsible for the payment of medical services received. I may be responsible for any balance not covered by my insurance and I hereby authorize Manhattan Family Practice to furnish any necessary medical or incidental information concerning my medical care and treatment to my insurance carriers.

I consent to have this website store my submitted information and pass it to the Manhattan Family Practice office, so Dr. Levy's team can respond to my inquiry.

ALBERT LEVY, MDManhattan Family Practice