We ask that you arrive at least 15 minutes before your appointment to complete all the necessary paperwork. To better serve your medical needs, we ask that you provide us with as much medical information as possible.
For your convenience, you can complete your paperwork prior to your appointment.
Your options are:
- Print and complete the forms listed below
- 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.
Good Faith Estimate
If you are uninsured, you have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call our office.
Southold Family Medicine currently works with over 30 major insurance companies. Our staff is always working on accommodating our patients and their insurance providers. Please call our office at (631) 734-8742 to find out if your carrier is on our continuously expanding list of providers.
- Aetna/US Healthcare (not Flexible Five or Upfront Advantage)
- Aetna International
- Aetna Meritain Health
- Aetna Signature Administrators
- Aetna Student Health
- Aetna Workers' Comp
- Affinity Health Plan - Medicaid (not Essential)
- Affinity Medicare Passport Essentials
- Affinity Medicare Passport Essentials NYC
- Affinity Medicare Ultimate
- Affinity Medicare Solutions
- AgeWell NY
- Alicare Local 277
- Beech Street
- CenterLight Healthcare (Comprehensive Care Management)
- Champ VA
- Cigna Healthcare (Open Access)
- Emblem Affinity Medicare Solutions Plan
- Emblem Healthcare Partners Essential Plan
- Empire BC/BS
- Empire BC/BS Excellus
- Empire BC/BS Exchange (Pathway Enhanced discontinued)
- Empire BC/BS Federal
- Empire BC/BS Senior Plan (Mediblue) (not Select)
- Empire BC/BS Senior Plan (Mediblue HealthPlus HMO, HealthPlus Dual or Plus)
- Empire BC/BS Suffolk County
- Empire Blue Access (non-local plans)
- Empire Blue Healthplus (formerly Healthplus Amerigroup)
- 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
- HIP/Emblem Select Care
- HIP (Vytra VHLI/VHS/VHMS)
- HIP VIP Prime
- HIP VIP Prime Medicare (not Essential)
- Humana through GHI Network Access
- Island Group Administrators
- Oxford Freedom (UHC) (not Metro)
- Oxford Liberty (UHC) (not Metro)
- Railroad Medicare
- United Behavioral Health (Optum Health)
- United Healthcare (UHC)
- UHC Choice/UHC Choice Plus
- UHC Community Plan
- UHC Compass Exchange
- UHC Compass Rose
- UHC Options
- UHC Optum Veterans Affairs Community Care Program
- UMR United Healthcare
- United/Empire Plan (NYSHIP)
- US Family Health Plan
- Workers' Comp
Insurance plan participation may change over time. While every effort is made to ensure the accuracy of this information, we recommend that you confirm participation status with your insurance carrier or practice. Please note that insurance plan participation requirements may be waived when a patient receives medical treatment in an emergency.