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Garden City
(516) 794-0404
Plainview
(516) 433-3232
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Tele-Medicine Enrollment Forms

Steps to complete these applications:

  1. Call the Garden City Office to Setup Telemedicine
  2. Download all the forms below
  3. Fill out the forms and fax them with relevant documents to: 516.794.0332
* Tele-Medicine Agreement * Patient Registration Form
* Acknowledgement of Receipt of Notice of Privacy Practices * Policy Regarding Scent-Free Environment
* Statement of Financial Responsibility * Patient Consent Form
* Notice of Privacy Policies for C.C. Medical Services