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We now have forms that you can fill out on your computer at home, print out and bring with you to an appointment or email to the
appropriate department. Instructions
You need to have Adobe Reader
installed on your computer. Right click any of the links below and choose "Save Link As". After the file has downloaded, click to open it and fill in the required information. When complete, you can click the "Print" button in the upper right corner and bring the completed form with you to an appointment. If you prefer, you can save the form to your hard drive and then attach it to an email to the appropriate department.
Patient Intake Forms For each visit you need to
fill out three forms: Either the Physical Form - if you are haing a complete physical, or the Short Visit form, if you are seeing a PA. You also need to fill out the Privacy Acknowlegement Form and the Demographics
Form.When seeing a Doctor or PA: For an Annual Physical, this is the standard form that you need to fill out. You can do so in advance at your convenience, print it, and bring it with you.
If you are seeing a PA for a short visit, you should fill-out the Patient Short Visit Form.ALSO, for each visit, you need to fill out the
Privacy Policy Acknowlegement Form and the
Demographics Form. You can also do these now at your convencience, print them and bring them with you. Referral To See A Specialist To see a specialist, your insurance may require you to make a
request through our office. This form is an information sheet designed for internal office use ONLY! It is a REQUEST for a referral, not an actual referral to be given to a specialist. Please complete the form with
as much information as you can, then either print it out and bring it with you to your appointment and leave it in the basket on the referral counter, or you can email the completed form to one of these email
addresses:
If the first letter of your last name is A-H email: yralim@yafferuden.com If your last name begins with Letters I-O email: yrajones@yafferuden.com or if your last name begins with Letters P-Z email:
yralane@yafferuden.com. Referral Form Medical Records Release Use this form to give us permission to send/receive your medical records
to/from doctors outside YaffeRuden. Once you have filled out the necessary information, we'll take care of the exchange of records. Print this form and bring it with you or mail to: Referral Department, Yaffe Ruden & Associates, 201 E. 65th Street, New York, NY 10065
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