Hudson Valley Gastroenterology

PRE-REGISTRATION FORM

To save you time processing information in the office on your first visit, please feel free to use this form to submit to us before you come in. You may also print this out to mail in to us at Hudson Valley Gastroenterology, 26 Pearl Street, Kingston, NY, 12401.

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Street Address:

Mailing Address, if different:

Email:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Fax:
Describe Symptoms:

Sex
Male   Female
Date of Birth:
Marital Status:
Social Security #:
Occupation:
Employer:
Employer Address:
Employer Telephone:
Spouse, Parent, or Next of Kin:
Referring Doctor:

INSURANCE INFORMATION

Primary Insurance:
Insurance ID#:
Subscriber, if other than patient:
Group # Co-Pay:
Secondary Insurance:
Secondary Insurance ID#:
Subscriber, if other than patient:
Group # Co-Pay:

INSURANCE AUTHORIZATION & ASSIGNMENT

"I hereby authorize Dr. Michael L. Steckman/Dr. Kevin K. Dodd or Hudson Valley Gastroenterology, P.C. to furnish information to insurance carriers concerning my illness and treatment and I hereby assign to the physician all payment for medical services to myself or my dependent. I understand that I am responsible for any amount not covered by insurance.

Date:
Your Name:
(We will require your signature in the office.)

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