BROOKLYN OFFICE

Telephone: 718.833.2300
Address: 7715 4th Avenue, Brooklyn NY

STATEN ISLAND OFFICE

Telephone: 718.982.6800
Address: 1779 Richmond Avenue, Staten Island NY

BILL PAY
PATIENT PORTAL
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Forms

Feel free to download, print, and fill out the following forms prior to your child’s visit. Just bring a printed copy at the time of your appointment to save some time. 

Patient Registration Form

Patient Insurance Information Form

Initial History Questionnaire

Authorization for Medical Treatment

Credit Card Authorization Form

Records Release Authorization Form

Records Release Authorization Form – Outgoing

Over 18 Authorization

GPM Photo Authorization

NYU HIE Consent Form

Financial Policy

Notice of Privacy (for review purposes only – you do not need to bring this form with you)

For general questions only (NO medically related or appointment issues), please contact us at info@gpmpediatrics.com.

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7715 4th Avenue Brooklyn, New York 11209 • phone: 718.833.2300 • fax: 718.836.2305
1779 Richmond Avenue Staten Island, New York 10314 • phone: 718.982.6800 • fax: 718.982.6830

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