Language
  • English (US)
  •  /  /
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  /  /
    Pick a Date
  •  /  /
    Pick a Date
  •  
  •  
  •  
  •  /  /
    Pick a Date
  •  
  • Registration: PLEASE FILL OUT ENTIRE FORM Dr. Nilesh Patel

  • If you do not have a cellphone please enter house phone that you can be contacted on and choose Phone for preferred method of appointment message reminders

  • (Email will be used to register for Patient Portal, to access visits

  •  /  /
    Pick a Date
  • Patient’s or Authorized Person’s Signature

    I the undersigned give my authorization to treat and assign directly to Nilesh Patel MD, all medical benefits, If any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered charges whether or not . I hereby authorize the doctor to release all information

    paid by insurance this includes deductibles, co-insurance and copayments

    necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. I understand that payment is expected at the time of service and diagnostic testing is a separate charge from the office visit.

  • Clear
  •  /  /
    Pick a Date
  • ACKNOWLEDGMENT AND CONSENT

  • By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the medical group listed at the beginning of this notice, and how I may obtain access to and control of this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protection that apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information from my Health Care Provider. Finally, by signing below, I consent to the use and disclosure of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of the medical group, its staff, and its business associates. (Please ask the front desk for the copy of the notice.)

  • Clear
  •  -  -
    Pick a Date
  •  

    Healthix Consent Form

    I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow Nilesh Patel, MD, PC. to obtain access to my medical records through the health information exchange organization called Healthix. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Healthix is a not-for-profit organization that shares information about people’s health electronically to improve the quality of healthcare and meets the privacy and security standards of HIPAA, the requirements of the federal confidentiality laws, 42 CFR Part2, and New York State Law. To learn more visit Healthix’s website at www.healthix.org.

    The choice I make in this form will NOT affect my ability to get medical care. The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.

  • Clear
  •  /  /
    Pick a Date
  •  
  • Should be Empty: