New Patient Registration | THE MED STATION

Patient Registration Form

Full Name (Last Name, First Name, MI)

Complete Home Address

Date of Birth, Sex & Social Security Number

e-mail Address

Cell Phone and Home Phone Number

If patient is a minor (below 18 years old), please enter the same information as above for the parent or guardian of the minor patient.

Employment Information: Employer/Company Name Complete Address Phone Number Fax Number

Insurance Information (Insurance Name, Member ID, Group Number & Insurance Address)

Please indicate the name of persons you give authorization for The Med Station to share any of your medical information/records and communication in your behalf. If you do not authorize us to share to anyone in your behalf, please eneter NONE.

Please indicate how you heard about us (for example, referred by doctor (name), friend, family member, work (where), online (Google,Facebook, Instagram, Website,etc), business group (chamber of commerce), advertisement (where) and etc. Thank you!

Please send a picture or scan both sides of your insurance card and government-issued Identification (drivers license, state ID, passport) to our e-mail or fax:

516-759-5537

Then call our office to check-in and the front desk receptionist will assist you with setting up the Telemedicine video visit for you in preparation for seeing the doctor. Call us at 516-759-5406.

By clicking the submit button below you agree:

You have electronically signed this form and is responsible for the full accuracy of the information entered on the date this is submitted.
You authorize payment of medical benefits to The Med Station for services rendered by your insurance. You also authorize the release of any information necessary to process a claim with your insurance.
You will be financially responsible for the services rendered by The Med Station in the event your insurance does not cover a certain service, requires you to pay a copay for each service, the deductible after the claim has been processed with your insurance and if you have a gap in insurance coverage or have no insurance coverage.
In cases that your insurance requires The Med Station to be your primary care provider (PCP) in order for the insurance to financially cover your care, you may be required to change us as your PCP at least temporarily before we can provide care. We will try to assist you in this transition. Some insurances have us a primary care only or and urgent care only. PCP change should be listed under Debbie Feliciano M.D.
In compliance with HIPAA privacy laws, grant permission to share your information with the indicated individuals you have entered and with all pertinent health care providers for your care.

Please send a picture or scan both sides of your insurance card and government-issued Identification (drivers license, state ID, passport) to our e-mail or fax:

516-759-5537

Then call our office to check-in and the front desk receptionist will assist you with setting up the Telemedicine video visit for you in preparation for seeing the doctor. Call us at 516-759-5406.

By clicking the submit button you agreed:

You have electronically signed this form and is responsible for the full accuracy of the information entered on the date this is submitted
You authorize payment of medical benefits to The Med Station for services rendered by your insurance. You also authorize the release of any information necessary to process a claim with your insurance.
You will be financially responsible for the services rendered by The Med Station in the event your insurance does not cover a certain service, requires you to pay a copay for each service, the deductible after the claim has been processed with your insurance and if you have a gap in insurance coverage or have no insurance coverage.
In cases that your insurance requires The Med Station to be your primary care provider (PCP) in order for the insurance to financially cover your care, you may be required to change us as your PCP at least temporarily before we can provide care. We will try to assist you in this transition. Some insurances have us a primary care only or and urgent care only. PCP change should be listed under Debbie Feliciano M.D.
In compliance with HIPAA privacy laws, grant permission to share your information with the indicated individuals you have entered and with all pertinent health care providers for your care.

Fax: (516) 759-5537

GLEN HEAD LOCUST VALLEY

Patient Registration Form

Please fill out each box in order to submit properly