New Patient Appointment

Please Complete Your Patient Information

Primary Insurance

If the insured is different than the patient, please complete below:

Additional Insurance

Emergency Contact

These are our financial policies. Please read, then type your initials next to each policy. At the end please type in your name. This will serve as your signature.

Financial Policy
Thank you for being a valued patient of Islip OB-Gyn. Please take a moment to read and sign our policies.
In order to reduce confusion and misunderstanding between our patients and our practice, we have adopted a set of financial policies.
If you have any questions about the policies, please ask to discuss them with our practice administrator or with our billing office.
We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an element of your care and treatment.
You are responsible to know your own policy and its limitations.

Insurance/ Financial Policies
*We are contracted with most insurance plans. These plans may have a co-payment (A fixed amount ($20, for example) you pay for a covered health care service), coinsurance (The percentage of costs of a covered health care service you pay (20%, for example)) or deductible (a specified amount of money that the insured must pay before an insurance company will pay a claim.).
We expect co-payment at the time of service, but deductibles and coinsurance are billed after receipt of your insurance statement.
Some services are not covered. You will know in advance if a service is not covered. An example of a non-covered service is contraception, when under a catholic health service plan or organization.
Payment plans for non-covered services can be arranged through our billing office.
*Each insurance plan is different and has its own policies on what is and is not a covered benefit.
It is your responsibility to know what is covered and which benefits fall under your plan.
We will explain these to you prior to any services as best we can.

Delinquent Accounts (For amounts that patients are responsible for)
*Account balances should be paid within 30 days of the account statement.
*Outstanding balances after 90 days will be transferred to a collection agency unless prior arrangements have been made with our billing office.

Cancellation of Appointments/ No Show
We do our best not to overbook, with the exception of same day emergencies. When and appointments are not kept, it creates an unused appointment slot that could have been used for another patient. It is very important that you call to cancel your appointment.
*If for any reason you need to cancel or reschedule an appointment, please notify our office within 24 hours to avoid a fee.
*A no show occurrence maybe subject to a $25 charge for an office and/or ultrasound visit.There may also be a $50 charge for a no show to a procedure or surgery. *If you are going to be late please contact our office. If you are more than 15 minutes late without notice you will be worked into the schedule if time allows or you can be rescheduled for another day.

Returned Check and other fees
*There will be a $25 service fee for any check returned for insufficient funds.
*After 2 returned checks we will no longer accept checks as your form of payment.
*There will a fee of $10 for any paperwork that needs to be filled out by our administrator including disability papers.

Please be mindful of cellphone use.
They should not be being used while Doctor is in the room or during triage.
I have read and understand the above policies.

Privacy Policies

These are our privacy and policies regarding protected health information. Please read and enter your name. Your name will serve as your signature.

Assignment and Release

Please carefully read and sign both statements below: It is understood that I, or we, will be responsible for all charges incurred on this account, to include all present and future services.
I understand that regardless of the insurance coverage that I may have, I am responsible for payment of all charges.
In the event of non-payment of charges for the services rendered, I agree to pay all costs of collection, including reasonable attorney’s fees.
I have read this agreement and do understand its provisions.


I hereby authorize Islip Ob-Gyn to send me newsletters, bulletins and other documents via email. Sensitive medical information will never be sent via email, since security and privacy cannot be assured. I understand that Islip Ob-Gyn will not share my email address with any other person or agencies without my express, written consent. This authorization will remain in effect until I revoke this authorization.

Identifying information

If your visit will be covered by an insurance plan, we require a current insurance card and an acceptable form of identification that matches your insurance card.
If your visit will be self-pay, and you will be paying by credit card or check, you will need acceptable form of identification that matches your credit card or check.


Notice of Privacy Practices

This notice describes how health information about you (As a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable or Personal Health Information (PHI).
This information is required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Please review this notice carefully

Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information.
In conducting our business, we will create records regarding you and the treatment and services we provide you.
We are required by law to maintain the confidentiality of health information that identifies you.
We are also required by law to provide you with this notice of our legal duties and privacy practices that we maintain in our practice concerning you PHI.
By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

Our practice must provide you with the following important information:
*How we may use and disclose your PHI
*Your privacy rights in your PHI
*Our obligations concerning the sue and disclosure of your PHI

We may use and disclose your PHI if the following ways:

*Treatment: Our practice may use your PHI to treat you by providing, coordination, or managing health care and related services by on or more health care providers. For example, we may request laboratory tests and use the results to reach a diagnosis. We might use your PHI to write a prescription and might disclose your PHI to a pharmacy and access your PHI from other pharmacies.
Payment Our practice may disclose your PHI to obtain reimbursement for services, confirming coverage, billing or collection activities and utilization review.
For example, we may contact your health insurer to certify that you are eligible for benefits and we may provide your insurer with details regarding your treatment to determine if your insurer will cover your treatment.
*Health Care Operations: Our practice may use your PHI to operate our business, such as conducting quality assessment and improvement activities auditing functions, cost management analysis and customer service.
* Appointment Reminders: Our practice may use and disclose your PHI to contact you and remind you of an appointment.
* Electronic Transmission: Our practice may display the office name, address and patient identifiable information on electronic transmission of insurance claims and statements.
* Release of Information to Family/Friends: Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you.
You have to give consent.

Use and disclosure of your PHI in certain special circumstances:
*For public health activities including reporting of certain communicable diseases.
*To authorities when we suspect abuse, neglect, or domestic violence.
*To health oversight agencies.
*For judicial and administrative processing pursuant to an administrative order.
*For law enforcement purposes.
*To advert a serious threat to your health and safety or that of others.
*For governmental purposes such as military service or for national security.
*In the even of an emergency or disaster relief.
*For Worker’s Compensation or similar programs as required by law.
*Inclusive of any other instance required by law.

Your rights regarding your PHI: * Confidential Communications: You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location.
* Requesting Restrictions: You have the right to request a restriction in our use of disclosure of your PHI treatment, payment or healthcare operations.
* Inspection of Copies: You have the right to inspect and obtain copy of the PHI that may be used to make decisions about you, including patient medical record and bill records.
* Amendment: You may ask us to amend your health information if you believe it is incorrect or incomplete and you may request an amendment for as long as the information is kept by or for our practice. To request and amendment, your request must be made in writing providing a reason that supports your request.
*Accounting of Disclosures: All patients have the right to request an “accounting of disclosures” consisting of al list of certain non-routine disclosures our Practice has made of our PHI for purposes not related to treatment, payment or operations. For example, the provider sharing information with the medical assistant or the billing department using information to file your insurance claim.
* Right to a Paper Copy of this Notice: You are entitled to receive a paper copy of our notice of privacy practices.
* Right to File a Complaint: If you believe your privacy rights have been violated, you may file a written complaint with our office, or with the Department of Health and Human Services, or the Office of Civil Rights.
* Right to Provide and Authorization for Other Uses and Disclosures: Our practice will obtain written authorization for uses and disclosures that are identified by this notice or permitted by applicable law.
Our practice is required to abide by the terms of the Notice of Privacy Practices currently in effect.
We reserve the right to change terms of our Notice of Privacy practices and to make the new provisions effective of all protected health information we maintain.

Receipt of Notice of Privacy Practices Written Acknowledgement Form

I have reviewed a copy of Islip OB-GYN’s Privacy Practices

Please use this section to show us who can receive your medical information

I give my authorization to use and disclose my protected health information to every doctor and employee at Islip Ob-Gyn.

I give my authorization to Islip Ob-Gyn to release any medical record that will help any specialist or primary care doctor with any medical care.

I give my authorization to Islip Ob-Gyn to send my test results by mail if I request them. (optional)

Family and Friends (optional)

Please name the people (friends or family members) who are authorized to receive any medical information from my chart.

Additional Patient Responsibilities

* I understand and agree that I am financially responsible for all charges for any services rendered. This includes any medical service, visit or routine examination.
* I understand that while my insurance may confirm my benefits, that confirmation of benefits does not guarantee payment and that I am responsible for any unpaid balances.
* I understand and agree that it is my responsibility to know if my insurance carries a deductible, co-payment, co-insurance, or out of network benefit limitations for the services I receive, and I agree to make payment in full.
* I agree to inform the office of any changes to my insurance coverage.
* If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full
* I understand that this office DOES NOT participate with Medicaid. This means if for any reason my coverage lapses, and I am only covered by Medicaid that any services provided will not be paid for and I will be held responsible.
* I understand that if any reason my coverage lapses, and I am only covered by Medicaid, that I will be required to make a payment arrangement prior to any services being provided.
*If I am a Medicare patient, and I have Medicaid as a secondary I understand that this office DOES NOT participate with Medicaid and that I will still be responsible for my 20% co-insurance.

Explanation of an Annual Wellness Exam

What pharmacy do you use?

An annual wellness exam is limited

At this visit your doctor will talk to you about your medical history, review your risk factors, and make a personalized plan to keep you healthy. This visit includes a pap smear, cultures for sexually transmitted diseases, as well as a referral for a routine mammogram, depending on your age.

For some insurance plans there is NO co-pay for this visit.

We will bill this visit to your insurance company as well as a wellness visit only. There will not be a co-pay if your insurance company does not require one for an annual “Wellness Visit”.

This visit does not include any discussion about any new or current medical problems, conditions or medications that you are taking or may require, based on the findings of the examination. Any visit that requires medications or discussions of medical problems that may be found, are not a part of the routine annual wellness exam. This is called a “Problem Visit”.
Some insurance plans require a co-pay for a “problem” visit. This is a requirement of your insurance plan, and all plans have different rules.

Options for “Wellness” visit that turn into “Problem” visits

You have two options to address medical or surgical problems that may be discovered or discussed during the exam:
Option 1
Your doctor will charge the usual fees for the problem visit that extends beyond the scope of the Annual Wellness Visit. You will then have the responsibility of a co-pay, if it is required by your insurance plan. If not paid at the time of the visit, you will receive a co-pay notice in the mail.
Option 2
You may schedule another visit to address those problems. At the time of that additional visit, you will be responsible for a co-pay, if it is required by your insurance company.
Please be advised that a co-pay is not “extra” money charged. It is a set amount if required by your plan that you are responsible for at every doctor appointment you go to.

Personal Medical History and Information

What is the reason for your visit today?

Annual Visit:

Problem Visit:


Do you have any chronic illnesses?

Have you had any surgeries?

Surgical and Hospitalization History not related to childbirth:

More than 3 surgeries or hospitalizations?

Please discuss during your visit

Is your period regular or irregular?

Pap smears

Are you using birth control?

What other methods have you used in the past?


Have you ever had a mammogram?

Prior Infections

Have you ever had Bacterial Vaginosis?

Do you suffer from Yeast Infections?

Have you ever had HPV(Human Papillomavirus)

Have you ever had Chlamydia?

Have you ever had Gonorrhea?

Do you have Herpes?

Do you have HIV?


Do you have Hot Flashes?

Do you have Vaginal Dryness?

Do you have Night Sweats?

Do you have problems with Memory or Concentration?

Have been getting treatment for any of the above?

Sexual Problems

Do you have decreased desire?

Do you have difficulty achieving orgasms?

Do you have pain when you have sex?

Urinary Problems

Urinary Problems

Do you use the bathroom frequently?

Do you leak urine when you cough, sneeze or laugh?

Do you wake up at night to use the bathroom?

Do you have sudden urges to use the bathroom?

Obstetrical History:

General Medical

Have you had a Flu shot this year?

Have you had a recent tetanus shot?

Are you up to date on all of your immunizations?

Have you traveled out of the country recently

What medications are you currently taking?

What supplements do you take?

Do you have any allergies?

Family and Personal History


Check all:


Check all:


Are any of them Alive?

Recent or prior personal and family medical problems

Weight loss/gain
Heart Disease
Respiratory Disease
Breast disease
Gallbladder disease
Bowel disorders
Kidney Disease
Anemia/Blood diseases
Blood transfusion
Varicose veins
Thyroid Disease
Skin Disease
Sleep Difficulty

Social History

Marital Status

Who do you live with?

Do you have pets?

How long have you lived in NY?

How is your nutrition?

How is your exercise?

Sexual Activity:


Condom use?




Others in your home:

Alcohol Use:

Illicit Drugs:

Seatbelt use?

No young Children?

If you have a young child, do you have a carseat or a booster seat?

Do you have a child or children in daycare?

Do you feel safe at home from your spouse?