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Request an Appointment

We are here to help you make an appointment. To begin your request, please fill out the form below. We will contact you within 24 hours with information. If you submit your request on a holiday or Friday afternoon through Sunday, we will respond by the end of the next business day. If you do not hear from us within this timeframe, have questions, or prefer to make an appointment by phone, please call Hudson Valley Urology, P.C. at 845.437.5000 and we would be happy to assist you.

* Indicates a required field

Patient Information

* Patient's Name
* Street Address
* City
* Date of Birth (MM-DD-YYYY)
* Gender	Female Male
* Health Insurance Provider (HIP)	Select Insurance Coverage Admar Corporation-PPO Aetna (Transplant Only) Anthem-HMO Anthem-PPO BCE EMERGIS-PPO Beech Street (Capp Care)-PPO Benefit Administrative System (BAS)-PPO Benefit Panel Service (BPS)-PPO Benefit Systems and Services Inc. (BSSI)-PPO Beyond Benefits-PPO Blue Cross and Blue Shield-HMO Blue Cross and Blue Shield-PPO Blue Cross and Blue Shield-POS Blue Cross and Blue Shield-Transplant Caterpillar-PPO Caterpillar-Transplant CCN Group Health-PPO CCN Group Health-Transplant Champus Tricare-PPO Chickering Student Health Plan-PPO Cigna-HMO Cigna-PPO Cigna-POS Cigna-Transplant Community Health Alliance-PPO Community Healthcare System (Munster Hospital Employees)-PPO Community Partners Health Plan-PPO CorVel-PPO Coventry (CCN, First Health, Personal Care)-HMO Coventry (CCN, First Health, Personal Care)-PPO Definity (Sara Lee Employees)-PPO Encore Health Network (The Healthcare Group, LLC)-PPO First Health-PPO First Health-Transplant Focus Healthcare Management Associates-PPO ForMost-PPO ForMost-Transplant Galaxy (Managed Care Inc. Excludes American Coalition)-PPO General Electric-Transplant Great West (Formerly One Health Plan of IL)-HMO Great West (Formerly One Health Plan of IL)-PPO Great West (Formerly One Health Plan of IL)-POS Group Insurance Administration (GIA)-PPO Health Dynamics-PPO Health Dynamics-Transplant Health Network-PPO Health South-PPO HealthStar-PPO HFN-PPO HFN-EPO HFN-Medicare HMO Illinois Humana-HMO Humana-PPO Humana-POS Humana-EPO Humana-Medicare Humana-Transplant ICON Identity Solutions-PPO Indiana Health Network-PPO Intergroup Health Plan (Preferred Plan, Inc./Pro America)-PPO Interlink (Transplant Only) ISPAT Inland Steel (Mittal Steel USA)-PPO JBC Gold and Platinum-Medicare Kaiser Permanente-Transplant Lettuce Entertain You Employees-PPO Medicaid Medicare Mittal Steel USA (Formerly ISPAT Inland Steel)-PPO MultiPlan-PPO Mutual of Omaha-Transplant One Health Plan of IL (Great West)-HMO One Health Plan of IL (Great West)-PPO One Health Plan of IL (Great West)-POS PBA-PPO Personal Care-HMO Personal Care-PPO ppoNEXT-PPO Preferred Health Network (PHN)-PPO Preferred Network Access (PNA)-PPO Preferred Plan, Inc./Pro America (Intergroup Health Plan)-PPO Pro America-PPO Purdue University Employees-Employer Group-PPO Sagamore Health Network-PPO Select Health Network-HMO Select Health Network-PPO State of Illinois-PPO State of Illinois-Transplant Three Rivers Network-PPO Unicare-HMO Unicare-PPO Unicare-POS Unicare-EPO Unicare-Transplant Union Health Services, Inc-PPO United Healthcare-HMO United Healthcare-PPO United Healthcare-POS United Healthcare-EPO United Resources Network (Transplant Only)-HMO United Resources Network (Transplant Only)-PPO United Resources Network (Transplant Only)-POS United Resources Network (Transplant Only)-EPO United Resources Network (Transplant Only)-Transplant Up & Up-PPO USA Networks (Transplant Only)-HMO USA Networks (Transplant Only)-PPO USA Networks (Transplant Only)-POS USA Networks (Transplant Only)-EPO USA Networks (Transplant Only)-Transplant
	If your provider is not listed, please call Hudson Valley Urology, P.C. at 845.437.5000
* Do you have a physician referral?	Yes No
HIP Phone Number
HIP Address
Insured's Name

Contact Information

Name (if different from patient name)
* Email Address
* Daytime Phone	Ext.
Evening Phone	Ext.

Appointment Information

Referring Physician (if applicable)
Referring Physician Phone
Referring Physician Address
Requested Physician
Have you seen this physician before?	Yes No
Have you been a Hudson Valley Urology, P.C. patient in the past?	Yes No
* Please describe your medical condition and what type of appointment you are requesting.
* How did you hear about us?	Select Type Hudson Valley Urology, P.C. Other Doctor Nurse or Hospital Employee Internet Friend or Relative Magazine Newspaper Radio Television Flyer or Poster Other

By submitting this form you acknowledge the risk of sending this information by email and agree not to hold Hudson Valley Urology, P.C. liable for any damages you may incur as a result of the transfer or use of this information. The use or transmittal of this form does not create a physician-patient relationship. More information regarding the confidentiality of this request can be found in our Privacy Notice.