Patient Forms

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“I'm up and running,
pain free.”

-Jamie L.

Save time at your appointment or before surgery by filling out your patient paperwork ahead of your visit. Click on the links listed below to view and print applicable patient forms. Be sure to fill them out and bring them with you on the day of your visit.

If you have questions about which forms need to be filled out, please call our office at 212‑434‑4920 so we can assist you.

 

Patient Forms

Demographics Form

No Fault Assignment of Benefits

Worker’s Compensation Information

 

Surgery Forms

Lenox Hill Hospital & Lenox Hill Annex (Manhattan Eye, Ear and Throat Hospital)

Patient Forms A-C

Consent Form

Health Care Proxy Guide

Lenox Hill Hospital Surgical Information Checklist

Lenox Hill Annex (Manhattan Eye, Ear and Throat Hospital) Surgical Information Checklist

 

SurgiCare of Manhattan

Patient Health Questionnaire

Patient Medication List

Consent Form

Surgical Information Checklist

 

Health Insurance Portability and Accountability Act (H.I.P.A.A.)

Notice of Privacy Practices

Patient Records Access Request Form

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