New Patient Forms

If you are a first time patient visiting NYU Comprehensive Epilepsy Center, please fill out the new patient forms below. All new patients are required to bring their insurance card(s) to the initial visit.

Welcome to the Epilepsy Unit

A booklet to help answer your questions about us. Click here to read more.

Required Forms

New Patient Registration Form
Includes patient demographic and contact information, insurance information, and primary care providers and (if applicable) referring physician’s contact information.

Electronic Health Record Consent Form
Acknowledgement of NYU Langone Medical Center’s use of an electronic medical record system for patient care. All patients seen must have this form completed and on file prior to seeing a doctor.

Patient Responsibility Form
Patients are mandated to initial ALL sections; Release of Information to patient’s treating physician(s), verifying Assignment of Insurance, Financial Liability for patient’s insurance, Medicare Signature and number (if applicable), Ancillary Services terms and conditions, and Cancellation/ No-Show policy. Please retain a copy of the Financial Policies Form for your personal records.

HIPAA Health Insurance Portability and Accountability Act
Patient privacy practice acknowledgement. (Please note a copy of HIPAA is available upon arrival to initial visit)

Pharmacy Information
The NYU Comprehensive Epilepsy Center uses an electronic medical record, and in order to comply with federal mandates and patient safety, all patients are required to provide their pharmacy's information to electronically fill medications.

Optional Form

Medical Record Release Form
Authorizes NYU Comprehensive Epilepsy Center to release the patient’s medical records to a designated recipient, such as an outside physician or the patient him/herself.