Intake Form

HIPAA Form

We have given the above named patient a copy of our Notice of Privacy Practices. We have answered any questions that they have regarding this form.

Please list any any individuals that you would like to have access to your medical records.

Your Signature (HIPAA)

Permanent Signature Authorization

I authorize the releaase of medical information to my insurance carrier and its agents as required to process claims for benefits on my behalf

I request that payment of authorized benefits be made to Noah Zinkin, MD

I acknowledge that if I am seen without necessary insurance referrals/authorizations, I will be responsible for any balance not covered by my insurance carrier. I understand that if my insurance coverage changes, it is necessary to notify Dr. Zinkin's office prior to my appointment. I acknowledge that all copayments are payable at the time of my visit.

Your Signature (Permanent Signature Authorization)

Thanks for submitting!

Advanced Gastrointestinal and Liver Disease

Call 631.923.1420

Intake Form

We have given the above named patient a copy of our Notice of Privacy Practices. We have answered any questions that they have regarding this form.

Please list any any individuals that you would like to have access to your medical records.