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Online Request Forms: Referral || Medication Refill || Medical Records || Appointment Cancellation
Online request forms can not be faxed. All requests must be through website.

New Patient Appointments

Dear Patients,

We thank you for selecting one of our partners as your primary care physician. We know your time is valuable and want to make it fast and easy for you to schedule your initial visit. As long you do not require immediate medical attention, our staff can set your account up and confirm your insurance without having to leave you on hold while they do this. Just click on the link below, complete all of the information and someone will call you within 24 hours to schedule your appointment. Please keep in mind that our standard hours of operation are Monday thru Thursday 8:00am - 4:00pm and Friday 8:00am - 2:00pm. This website is not monitored during the weekend or on holidays. You may submit your information, but the 24-hour timeframe for a return call will not apply.

We look forward to meeting you.

Thank you,
Associates in Internal Medicine, P.C.

MAKE APPOINTMENT WITH WHICH PHYSICIAN?

PATIENTS' LEGAL FIRST AND LAST NAME:

DATE OF BIRTH:

HOME ADDRESS:

***APARTMENT NUMBER AND/OR FLOOR:

CITY:

STATE:

ZIP CODE:

DAY TIME TELEPHONE #:

EXT #:

SECONDARY TELEPHONE #:

SOCIAL SECURITY #:

IF YOU ARE NOT A US CITIZEN COMPLETE BOTTOM OF SHEET


WE ACCEPT OXFORD, HEALTHNET, UNITED HEALTHCARE, MEDICARE AND MAGNACARE.

NAME OF INSURANCE PLAN (ONLY IF WE ACCEPT):

INSURANCE ID #:

GROUP #:

POLICY HOLDER:


ONLY COMPLETE THE FOLLOWING SECTION IF YOU ARE " NOT " THE POLICY HOLDER OF INSURANCE PLAN

NAME OF POLICY HOLDER:

DATE OF BIRTH OF THE POLICY HOLDER:

SOCIAL SECURITY # OF THE POLICY HOLDER:

TELEPHONE # OF THE POLICY HOLDER:


IF YOU ARE NOT A US CITIZEN WE REQUIRE ONE OF THE FOLLOWING DOCUMENTS ID#'S AND THE DOCUMENT MUST BE PRESENTED PRIOR TO SEEING THE PHYSICIAN ON THE DAY OF YOUR APPOINTMENT.

(AMERICAN) DRIVERS LICENSE ID #:

GREENCARD ID #:

PASSPORT ID #:


AFTER WE CONFIRM YOUR INSURANCE AND SET UP YOUR ACCOUNT WE WILL CALL YOU TO SCHEDULE YOUR APPOINTMENT.
PLEASE PROVIDE THE DAY TIME TELEPHONE NUMBER ABOVE THAT YOU WISH TO BE CONTACTED AT BETWEEN 8:00AM AND 4PM. THANK YOU.