Patient Forms

The new patient registration form is the first of the City Prime Care patient forms you will see. It opens your chart with us, so we can reach you, schedule follow-ups and send results to the right place. Having your ID and contact details on hand makes it quick to complete.

The registration form asks for:

• Your full legal name, date of birth and preferred name or pronouns
• Home address, phone number and the best way to contact you
• Preferred language, so we can plan for English, Spanish or Chinese support
• An emergency contact and their relationship to you
• Your pharmacy and any doctors or specialists you already see

Paper copies are available at the front desk when you check in. If you would rather complete it at home, call Elmhurst at (718) 555-0175 or Chinatown at (212) 555-0180 before your visit and ask for a set. Downloadable versions are being prepared and will be posted on this page. The new patient guide explains what else to expect at a first appointment.

The medical history form gives your provider a clear picture of your health before the conversation in the exam room begins. Accurate answers help us spot risks early, avoid medication conflicts and recommend the screenings that fit your age and history. If you are not sure of a date or a dose, write down what you remember and bring the bottles or a list; we can fill in the gaps together.

Expect questions about:

• Current medications, vitamins and supplements, with doses if you know them
• Allergies to medications, foods or latex, and what reaction you had
• Past illnesses, surgeries and hospital stays
• Conditions that run in your family, such as heart disease, diabetes or cancer
• Vaccination history and recent screenings
• Lifestyle habits like smoking, alcohol use, sleep and exercise

Like the other forms, it is available at check-in or by phone request ahead of your visit, with a downloadable version on the way.

The HIPAA consent form confirms that you have received our Notice of Privacy Practices and explains how your health information may be used for treatment, billing and routine clinic operations. HIPAA is the federal law that protects the privacy of your medical records, and signing this acknowledgment does not give up any of your rights under it.

The form also lets you tell us who, if anyone, may receive information about your care. Many patients list a spouse, adult child or caregiver who helps with appointments or prescriptions. You can also note whether we may leave detailed voicemails or only ask you to call back. You can change these choices at any time by asking the front desk for an updated form.

You may ask for a copy of our full privacy notice at either clinic. As with the other paperwork, the consent form is handed out at check-in and can be requested by phone before your visit so you can read it at home without feeling rushed. A downloadable version is being prepared.

The insurance section of your City Prime Care forms lets our billing team check your coverage before your visit and submit claims correctly afterward. Small mistakes, like a missing group number or a policyholder name that does not match the card, are the most common reasons a claim is delayed.

Have these ready when you fill it in:

• Your insurance card, front and back, and a photo ID
• The policyholder's name and date of birth if the plan is through a spouse or parent
• Any secondary insurance, including Medicare or Medicaid
• A referral from your plan, if your plan requires one

We accept most major insurance plans, including Medicaid and Medicare, but coverage varies, so call to confirm your plan before you come in. Our insurance page has more detail on coverage and what to ask your plan. Please bring your cards to every visit, even if nothing has changed, so we can keep your file current.

Right now there are two ways to turn in your completed forms, and both keep your information in our hands only.

• Bring them to your visit. If you filled them in at home, hand the pages to the front desk when you check in. Arriving a few minutes early leaves time to review anything that is unclear.
• Complete them at the front desk. If you did not get a set in advance, arrive about 15 minutes early and our staff will give you the forms and answer questions as you go.

Please do not email forms that contain health information. Regular email is not a secure way to send medical details, insurance numbers or signatures, so we cannot accept completed forms that way. We do not have an online form system yet; when a secure option is ready, we will explain it here.

Once your paperwork is in order, book an appointment online or call the clinic nearest you. Staff at both locations can help in English and Spanish, and our Chinatown team also speaks Chinese.