260 Middle Country Road, Suite 112,
Smithtown, NY 11787
631.724.7720
Spatique Medical Spa
260 Middle Country Rd., Suite 208
Smithtown NY 11787
631.863.3223
Marina I. Peredo, M.D., P.C.
     
FOR YOUR VISIT
     

NEW PATIENTS
 
Please arrive 10 minutes before your scheduled appointment time. This will allow time for the receptionist to complete the necessary insurance information for your visit. Please complete the new patient form and patient acknowledgements form prior to your visit. You can download the form below or you can complete the new patient form electronically by clicking the link below. If you complete the new patient form electronically, you must still download the patient acknowledgements form and bring it to your visit.

New Patient Form

If you choose to complete the Electronic New Patient Form (below), the Patient Acknowledgements form is also required.

Electronic New Patient Form
Patient Acknowledgements Form 

If you would like a copy of either the HIPAA or Patient Rights Notice, both are available in the links below.

Patient HIPAA Notice
Patient Rights Notice

 

ALL PATIENTS – ADDITIONAL INFORMATION ABOUT YOUR VISIT

Check-In Requirements
 
Arriving at your scheduled appointment time is greatly appreciated. We cannot guarantee that you can be seen before or after your scheduled appointment.


It is important to give the receptionist ALL NEW INSURANCE INFORMATION prior to your visit. This information is very important so that the physician can send any specimen or culture to the correct laboratory to avoid any unnecessary charge to you. It is also very important that we have your correct address and phone number.

TREATMENT OF MINORS

Minors cannot be treated without a guardian present.  If you are sending your child to their visit with an adult acting as their guardian, they must have a Designation of Person in Parental Relationship form filled out and signed by you.

Designation of Person in Parental Relationship Form Download


All minors must be accompanied by a parent or legal guardian. It is our office policy that the adult presenting the child for treatment is responsible for payment of all payments due at the time of service.

You must present your valid insurance card, photo ID and referral (if required by your insurance plan) at each visit. You can also call the phone number on your insurance card to verify that your primary care physician has entered a referral in the system. You will be responsible for any co-payment, deductible and/or co-insurance at the time of service. Co-payments are collected prior to service. You may also be responsible for any amount that is not covered because your insurance carrier denies the claim (not medically necessary or cosmetic in nature).

We request that all cell phones be turned off during your visit.


Payments, Balances and Billing

All payments, including account balances, must be made at the time of service. For your convenience, the office accepts cash, checks*, MasterCard, Visa, American Express and debit card.

*If you will be paying by check, we will need a valid driver's license for the person whom is the check holder.
**There will be a $25.00 fee for any check returned for non-sufficient funds.

All cosmetic procedures require a 50% deposit to secure an appointment. You are required to give 72 hours notice to cancel or reschedule your appointment or your deposit will be forfeited.

Medical Records

  If you would like to have your records transferred to us from another office, or vice versa, please complete a record release form and return to our billing    department. Please note, there is fee of .75 cents per page for medical records and a fee of $1.00 per photo, due prior to release from our office.

Record Release Form

 

In Case of Emergency

In case of an emergency, please go to the nearest emergency room. You can reach the provider on call (for emergency only) by dialing 631-741-9415. Please speak slowly and leave the patients full name and a phone number and a detailed reason for the call.
Prescription refills can only be handled during office hours. Please call the office during normal business hours and follow the prompts for a medical assistant.

 

 

 

HOURS OF OPERATION

Monday: 9:00 am - 7:00 pm
Tuesday: 9:00 am - 7:00 pm
Wednesday: 9:00 am - 7:00 pm
Thursday: 9:00 am - 7:00 pm
Friday: 9:00 am - 5:00 pm
Saturday: 9:00 am - 3:00 pm

INSURANCE PARTICIPATION

  • AARP
  • AFFINITY
  • AMERICAN MEDICAL & LIFE
  • AGEWELL
  • AMERIHEALTH
  • BEECH STREET
  • BLUE CROSS/BLUE SHIELD (NO BLUE PRIORITY OR PATHWAY)
  • CHANP VA
  • CHOICECARE HUMANA
  • CHILD HEALTH PLUS MANAGED BY EMBLEMHEALTH (ONLY DR. FASTENBERG)
  • CIGNA & CIGNA GREATWEST)
  • EMPIRE (NYS)
  • FIRST HEALTH
  • GHI
  • HEALTHNET
  • HEALTHCARE PARTNERS (NON-MEDICAID)
  • HEALTH NOW
  • HEALTHPLUS AMERIGROUP (ONLY DR. FASTENBERG)
  • HEALTH REPUBLIC
  • HIP (NON-MEDICAID)
  • ISLAND GROUP ADMININISTRATION
  • LOCAL 1199
  • MAGNACARE
  • MEDICARE
  • MEDIBLUE
  • MULTIPLAN
  • MERITAIN HEALTH
  • NSLIJ AETNA (NOT SUE CONATY)
  • NSLIJ CONNECT CARE (NOT SUE CONATY)
  • OSCAR
  • OXFORD
  • PHCS
  • RAILROAD MEDICARE
  • TRICARE
  • UNITED HEALTHCARE (NON-MEDICAID)
  • UNITED HEALTHCARE COMPASS (REFFERAL NEEDED)
  • UNITED HEALTHCARE MEDICARE ADVANTAGE
  • UMR
  • VYTRA
  • WELLCARE
  • WORLD TRADE CENTER INSURANCE (REFFERAL NEEDED)
  • QUALITY HEALTH PLANS OF NY
 
 
 
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