ON-LINE FORMS
NEW PATIENT REGISTRATION PACKET (3 Pages)
This packet of 3 forms includes the information you will be required to fill out and sign at the time of your first visit to our office. It includes the New Patient Registration Form, our Financial Agreement Form and our HIPPA Privacy Notice form. The First sheet needs to be filled out completely and the 2nd and 3rd pages should be reviewed carefully and then require your signature. These forms may be printed out and filled out ahead of time or you can fax them to us ahead of your first schduled appointment at (201) 391-3039.
CAR ACCIDENT / WORKER'S COMPENSATION REGISTRATION FORM (1 Page)
If you are being seen in the office as a result of a car accident or work-related injury then you must also fill out the pertinent portions of this form in addition to the standard New Patient Registration form.
OFFICE FINANCIAL POLICY (1 Page)
This form is included in the New Patient Registration Packet. We include it here on its own for you to review at any time. The information contained in this policy are very important and we urge you to review the policies carefully.
NOTICE TO BLUE CROSS / BLUE SHIELD PATIENTS (1 Page)
This form is for patients with Horizon or Empire Blue Cross/Blue Shield Insurance. They frequently mail physician reimbursement checks directly to you at your home. This notice instructs you on how to handle these payments. This notice will not matter after Jan. 1, 2011, as the State of New Jersey made it illegal for insurance companies to do this any longer.
NOTICE OF PRIVACY PRACTICES (2 Pages)
Our privacy practices form. This is available for your review in the office or you may click on it here to review as needed.
HUDSON CROSSING SURGERY CENTER DISCLOSURE (1 Page)
Dr. Betsy holds a financial interest in The Hudson Crossing Surgery Center and is required to disclose this to patients. This notice is posted in the office as well, located at the exit from the hallway, by the check-out counter.