Note: If you prefer to print the form and bring it to your appointment, please arrive ten minutes early to allow for processing of the form and prevent delays.
Important tips for filling out the form: Dates must be entered in MM/DD/YYYY format. When including insurance information, please include the ‘Provider Services’ or ‘Member Services’ telephone number as this may help expedite your visit to our office. Please also remember to bring the physical insurance cards to your appointment as we may need additional information from them. You can see more information about your First Visit here.
While we prefer to have a credit card physically on-site, we understand that some patients, such as students or those travelling away from home, may not have the card available. Please use the below credit card authorization form to give us all the information we need to process your credit card for payment while adhering to legal standards that protect both you and our practice. We must have all of the information requested on the form in order to process the payment. This form is NOT required unless you will not have your credit card with you on the day of your visit. Please read more about our financial policy here.
Credit Card Authorization Form
For your convenience, we have made our Medicare Private Contract available online in case you would like to review it well in advance of your appointment. This contract is not valid unless both the patient/POA and Dr. Levine have signed and dated it.
Medicare Private Contract
You need Adobe Acrobat Reader to view our forms. Please download the free Acrobat Reader from Adobe’s web site if it is not already installed on your system.