Contact Us to Schedule

Insurance Information

• Insurance Company and Plan
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• Please call the provider’s office at 516-294-5440, so we can discuss your insurance coverage or payment options and help you schedule an appointment.
  Kent Chan, MD does not accept this insurance plan. To schedule an appointment, call the office at 516-294-5440 or continue filling out this form and we’ll contact you within one business day.
  Kent Chan, MD does not accept this insurance plan. To schedule an appointment, call the office at 516-294-5440 or continue filling out this form and we’ll contact you within one business day.
  Kent Chan, MD accepts this insurance.
• Insurance Member ID
• Insurance Group Number (Optional)

Personal Information

• First Name
• Last Name
Date of Birth
Month (MM)
Day (DD)
Year (YYYY)
• Legal Sex Why do we ask for this?
  We are committed to making sure all patients feel safe and respected. We understand that not everyone’s legal sex is the same as their gender identity. We ask about legal sex because it is necessary for insurance billing, and assists us in linking this visit to prior visits. Please select the sex listed on your State ID and/or Insurance Card. You will have the opportunity to provide more detailed information on your Gender Identity and Pronouns later in the registration process.
  Female Male X
• Street Address
City
State
Zip Code
Phone Number
Phone Type
Mobile Home Work
• Email
• Confirm Email

Visit Information

• Reason for Visit (Symptoms, Diagnosis, Test Results, or Other Information) 0/500
• Referring Doctor (Optional)
• Preferred Date and Time Of Appointment (Optional)

By providing my contact information, I consent and authorize NYU Langone to contact me about my healthcare by email, text message, or phone call. I understand that I can change my communications preferences or opt out of communications at any time in my NYU Langone Health MyChart account or by talking to my doctor’s office. Read more about how we may communicate with you.