New Patient Registration Forms

 

If you are a new patient at the Medical Clinic NYC and wish to accelerate your check-in process, you can do so by downloading, completing, and bringing the following THREE (demographics, HIPAA, and ABN) forms with you the day of your initial visit. These forms must be printed and completed by hand and cannot be submitted electronically.

• New Self-Pay patients should fill ONLY the first form.
• Signing the HIPAA form will offer protection to an individual with preexisting medical conditions, sets standards for the release of medical records, and prevents loss of medical coverage during specific circumstances.
• Our office requires an insured patient to leave a credit card on file in the event your insurance doesn’t cover for all or partial services received at the medical clinic due to co-insurances or deductibles. Your privacy is our concern; therefore your credit card and all other personal information will be stored in your personal electronic chart in our medical database. If you incur a balance, we will contact you and explain in detail what was not covered by your insurance, why, and how much you are responsible for, then ask for permission to charge the card left on file.

  Registration Forms

 

 

 

Insurance

 

At the Medical Clinic of New York City, we accept the following health insurances for all of our health services; with the exception of travel office visits. We do not participate with health insurances for travel consultations/immunizations because these are not covered services, as they are not considered a medical necessity.

1199	Great-West
Aetna	Guardian
Atlantis	HealthNet
Blue Cross/Blue Shield (all states)	MagnaCare
Beech Street	Multiplan
CIGNA	MVP
Coventry Health	Oxford
Emblem	PHCS
First Health	POMCO
GHi	United Healthcare

 

• If you do not see your insurance, please contact our office to verify our clinic’s participation with your insurance plan.
• If you do not have an insurance card yet but have coverage, please contact your insurer or HR department and obtain your member ID number (also known as subscriber number) and the medical claims mailing address.

 

Note: If you have an HMO plan, please select our doctor before your visit to speed up the check-in process. Electing our doctor will not change your benefits and doing so will prevent you from being responsible for the services rendered in our medical clinic. You can select or switch primary care physicians several times and you do not have to keep our doctor as your listed PCP if you do not wish to.

 

Use the following information when making the selection:
Doctor: Slava Fuzayloff
National Provider Identifier: 1235173261
Tax ID: 205831125

 

 

 

Uninsured Patients

In the event that you are uninsured, our health services will carry the following fees:

• Regular office visits (sickness, medication refill, x-ray scripts, treatment of  minor cuts/burns, etc.) - $98
• Physical Examinations (annual, pre-employment, school, for foreign visas, or commercial drivers permits- DOT/CDL)- $150 (blood/urine tests and immunization vaccines NOT included)
• STD testing consultation - $98 (test price NOt included)
• Hemorrhoid consultation- $150 (1st treatment- $350, 2nd treatment $500, 3rd treatment is FREE)
• Travel immunization consultation- $65 plus the vaccine (s) cost

 

 

 

Payment Policy

All health services and procedures obtained at the Medical Clinic NYC must be paid in full at the time of visit. Copayments are to be paid before each visit and under no circumstances will be billed.

We accept the following payment options:

• Cash
• Debit Cards
• All major credit cards (VISA, MasterCard, Discover, and American Express)