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Should future correspondence be sent to the Practice/Billing Manager? Please Select Yes No
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Billing State -- AL AK AR AZ CA CO CT DC DE FL GA HI ID IA IL IN KS KY LA MA MD ME MI MO MN MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
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May Provider Serve as PCP? Please Select Yes No
Providers's Primary Specialty Please Select One Allergy & Immunology Anesthesiology Bariatric Surgery Breast Surgery Cardiology Cardiothoracic Surgery Cardiovascular Disease Chiropractor Clinical Neurophysiology Clinical Social Worker Colorectal Surgery Critical Care Medicine Dentistry Dermatology Dietetics-Nutrition Electrophysiology Emergency Medicine Endocrinology ENT Family Practice Gastroenterology General Practice General Surgery Geriatrics Gynecologic Oncology Gynecology (only) Hand Surgery Head & Neck Surgery Hematology Hematology/Oncology Hepatology Infectious Disease Internal Medicine Infertility Licensed Clinical Social Worker Licensed Master Social Worker Maternal/Fetal Medicine Medical Genetics Medicine Midwifery Neonatology Nephrology Neuro Psychology Neurology Neurosurgery Nuclear Medicine Obstetrics Gynecology Occupational Therapy Oncology Ophthalmology Optometry Oral & Maxillofacial Surgery Orthopaedic Surgery Pain Management Pathology Peds -- General Peds -- Surgery Peds -- Urology Peds --Allergy & Immunology Peds --Cardiology Peds --Critical Care Peds --Emergency Medicine Peds --Endocrinology Peds --Gastroenterology Peds --Genetics Peds --Hematology/Oncology Peds --Infectious Disease Peds --Neonatal/Perinatal Medicine Peds --Nephrology Peds --Neurology Peds --Neurosurgery Peds --Ophthalmology Peds --Opthalmology Peds --Pulmonary Medicine Peds --Radiology Peds --Rheumatology Physical Medicine & Rehabilitation Physical Therapy Plastic Surgery Podiatry Psychiatric Neurology Psychiatry Psychologist Pulmonary Medicine Radiation Oncology Radiology Rheumatology Social Worker Sports Medicine Surgical Critical Care Surgical Oncology Thoracic Surgery Urogynecology Urology Vascular Surgery
Providers's Secondary Specialty Please Select One Allergy & Immunology Anesthesiology Bariatric Surgery Breast Surgery Cardiology Cardiothoracic Surgery Cardiovascular Disease Chiropractor Clinical Neurophysiology Clinical Social Worker Colorectal Surgery Critical Care Medicine Dentistry Dermatology Dietetics-Nutrition Electrophysiology Emergency Medicine Endocrinology ENT Family Practice Gastroenterology General Practice General Surgery Geriatrics Gynecologic Oncology Gynecology (only) Hand Surgery Head & Neck Surgery Hematology Hematology/Oncology Hepatology Infectious Disease Internal Medicine Infertility Licensed Clinical Social Worker Licensed Master Social Worker Maternal/Fetal Medicine Medical Genetics Medicine Midwifery Neonatology Nephrology Neuro Psychology Neurology Neurosurgery Nuclear Medicine Obstetrics Gynecology Occupational Therapy Oncology Ophthalmology Optometry Oral & Maxillofacial Surgery Orthopaedic Surgery Pain Management Pathology Peds -- General Peds -- Surgery Peds -- Urology Peds --Allergy & Immunology Peds --Cardiology Peds --Critical Care Peds --Emergency Medicine Peds --Endocrinology Peds --Gastroenterology Peds --Genetics Peds --Hematology/Oncology Peds --Infectious Disease Peds --Neonatal/Perinatal Medicine Peds --Nephrology Peds --Neurology Peds --Neurosurgery Peds --Ophthalmology Peds --Opthalmology Peds --Pulmonary Medicine Peds --Radiology Peds --Rheumatology Physical Medicine & Rehabilitation Physical Therapy Plastic Surgery Podiatry Psychiatric Neurology Psychiatry Psychologist Pulmonary Medicine Radiation Oncology Radiology Rheumatology Social Worker Sports Medicine Surgical Critical Care Surgical Oncology Thoracic Surgery Urogynecology Urology Vascular Surgery
Hospital Where Privileged* Please Select One Forest Hills Hospital Franklin Hospital Glen Cove Hospital Huntington Hospital Long Island Jewish Medical Center Maimonides Medical Center Nassau University Medical Center NSUH-Manhasset Plainview Hospital Schneider Children's Hospital Southside Hospital Staten Island University Hospital Syosset Hospital The Zucker Hillside Hospital Not Applicable*
Additional Hospital Where Privileged Please Select One Forest Hills Hospital Franklin Hospital Glen Cove Hospital Huntington Hospital Long Island Jewish Medical Center Maimonides Medical Center Nassau University Medical Center NSUH-Manhasset Plainview Hospital Schneider Children's Hospital Southside Hospital Staten Island University Hospital Syosset Hospital The Zucker Hillside Hospital
Provide the reason if not applicable*
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