Patient Information

We ask that you arrive at least 15 minutes before your appointment to complete all the necessary paperwork.  For us to best serve your medical needs, you must provide us with as much medical information as possible.

For your convenience, you can complete your paperwork in advance of your appointment. Your options are:

  • Print and complete the forms listed beow
  • Using Adobe Acrobat Reader, download, fill-in and print the forms below
  • Request the forms to be mailed to your home

Once completed, remember to bring your forms with you to your appointment.

 

Patient Forms:

Additional Forms:

Self Pay:


Dr. Gottlieb with nursing staff

Patient Portal

Register a patient, access your child's immunizations, locate visit information, prescription history, request forms, request referrals and more.


Insurance

Southampton Pediatric Associates currently works with over 30 major insurance companies. Our staff is always working on accommodating our patients and their insurance providers. Please call our Southampton office at  (631) 283-7733 or our Hampton Bays office at (631) 728-5300 to find out if your carrier is on our continuously expanding list of providers.

  • Aetna/US Healthcare
  • Aetna International
  • Aetna Maritain Health
  • Aetna Signature Administrators
  • Aetna Student Health
  • Affinity Medicaid (not Essential)
  • Alicare Local 277
  • Beech Street
  • CenterLight Healthcare (Comprehensive Care Management)
  • Champ VA
  • Cigna Healthcare (Open Access)
  • Emblem Healthcare Partners Essential Plan
  • Empire BC/BS
  • Empire BC/BS Excellus
  • Empire BC/BS Federal
  • Empire BC/BS Senior Plan (Mediblue)
  • Empire BC/BS Suffolk County
  • Fidelis Medicaid (not Essential)
  • GHI CBP
  • GHI HMO
  • GHI Medicare
  • Great West Healthcare (Cigna)
  • Healthfirst (including HNP and SHP) (not Essential)
  • HealthNet Federal Services (Tricare)
  • HIP Medicaid
  • HIP (Healthcare Partners)
  • HIP/Emblem Essential Plan
  • HIP/Emblem Select Care
  • HIP VIP Prime
  • HIP VIP Prime Medicare (not Essential)
  • Humana through GHI Network Access
  • Island Group Administrators
  • Magnacare
  • Medicare
  • Medicaid
  • Multiplan/PHCS
  • Oxford Freedom (UHC) (not Metro)
  • Oxford Liberty (UHC) (not Metro)
  • Railroad Medicare
  • Tricare
  • United Behavioral Health (Optum Health)
  • United Healthcare (UHC)
  • UHC Choice/UHC Choice Plus
  • UHC Community Plan (not Essential)
  • UHC Compass Exchange
  • UHC Compass Rose
  • UHC Options
  • UMR United Healthcare
  • United/Empire Plan (NYSHIP)
  • US Family Health Plan
  • Workers' Comp