Michael H. Rieber, M.D. Orthopaedics Unlimited Patient lnformation Form rel: 973 322 7 40O Fax'. 97 3 322 7 4Ol First Name Add ress Middle Name 200 So Orange Ave Suite 230 Livingston, NJ 07039 266-272 Chestnut Street Newark, NJ 07105 Last Name State _ Zip Code City Home Telephone # Email: Ce ll Fax # Date of Birth 5ex Age _ SocialSecurity # Referring Physician ls this visit of a work or motor vehicle accident? Yes Name of lnsurance Company MaritalStatus Other No lf yes provide Date of lnjury Claim # Address Name of Adjuster lnsurance lnformation Phone # Fax # Name of Company Phone # Add ress tD # Group # Relationship to Patient Name of lnsured 55# Secondary lnsurance tD# Group # Address Policy Holder Phone # Pharmacy Name Phone # Address
Transcript
Michael H. Rieber, M.D.Orthopaedics UnlimitedPatient lnformation Formrel: 973 322 7 40OFax'. 97 3 322 7 4Ol
First Name
Add ress
Middle Name
200 So Orange Ave Suite 230Livingston, NJ 07039
266-272 Chestnut StreetNewark, NJ 07105
Last Name
State _ Zip CodeCity
Home Telephone #
Email:
Ce ll
Fax #
Date of Birth 5ex
Age _ SocialSecurity #
Referring Physician
ls this visit of a work or motor vehicle accident? Yes
Name of lnsurance Company
MaritalStatus
Other
No
lf yes provide Date of lnjury
Claim # Address
Name of Adjuster
lnsurance lnformation
Phone # Fax #
Name of Company
Phone #
Add ress
tD #
Group #
Relationship to Patient
Name of lnsured
55#
Secondary lnsurance tD#
Group #
Address
Policy Holder
Phone #
Pharmacy NamePhone #
Address
Patient HistoryPrevious Surgeries:
Date:
Current Medications:
Allergies to Medication:
Other Allergies:
Are you PreBnant?
Do you Smoke?
Do you Drink Alcohol?
Have you ever had any of the following conditions?
Yes
Yes
Yes
No
No
No
How Much?
How Much?
Asthma
Stroke
Arthrltis
Cancer
Diabetes
Glaucoma
Hepatitis
Herpes
Depression
Anemia
Family History:
Cancer
Diabetes
Stroke
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Hypertension
Hypotension
Heart Surgery
Heart Disease
Liver Disease
Artificial Joints
Emphysema
Shingles
Hrv/ ArDs
Alcohol/ Drug Abuse
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
No
No
No
No
No
No
NoYes
No
No
No
Heart Disease
Arthritis
Addiction
Yes
YesNo No
Michael H. Rieber, M.D.Orthopaedics UnlimitedPatient lnformation Formf el: 973 3?2 7 4OOFax:973 322 74Ot
200 So Orange Ave Suite 230Livingston, NJ 07039
266-272 Chestnut StreetNewark, NJ 07105
I certify that the information I have provided is accurate. I authorize the release of medical orother information required to process this claim. I understand I am responsible for any unpaidbalances. I understand it is my responsibility to obtain any necessary referrals required by myinsurance plan orior to being treated by Orthopaedics Unlimited. All Co Pavments are requiredat time ofvisit. There is a 525.00 fee for Return Checks.
SiBnatu re: Date:
My lnsurance Carrier is . (l have been informed thatOrthopaedics Unlimited is Non-Participating Provider with BCBS). All unpaid deductibleamounts are required prior to treatment. A billwill be submitted to your insurance CO. on yourbehalf. Asthe patient, and a "covered person" under mvhealth insurance policv. ldirectmvinsurance carrier that all checks in pavment for medical services provided bv OrthopaedicsUnlimited. shall be made oavable to the practice onlv, and that such oavment checks shall notalso be made pavable to Michael H. Rieber, M.D."
Signature: Date:
Assitnment of Benefits:I irrevocably assign to Othopaedics Unlimited all my rights and benefits under any insurancecontracts for payment of services rendered to me by Orthopaedics Unlimited. I irrevocablyauthorize all information regarding my benefits under any insurance policy relating to any
claims by Orthopaedics Unlimited to be released to Orthopaedics Unlimited. I irrevocablyauthorize Orthopaedics Unlimited to file insurance claims on my behalf for services rendered tome. I irrevocablv direct that all pavments are made out to and so to Orthopaedics Unlimitedgq!y. I irrevocably authorized Orthopaedics Unlimited to act on my behalf and report any
suspected violations or improper claims practices to the proper regulatory authorities. This
assignment of benefits has been explained to my full satisfaction and I understand its natureand effect.Signatu re: Date:
I have read and understood the privacy policy ofOrthopaedics Unlimited, I DO / I DO NOT
Grant permission to release my medical information. Name of person Authorized to receiveyour medical information SiSnatu re:
Patient History Date:
Credit Card Billing Authorization Form
As of March 77,2Of4, a new office policy has been set in place. All patients are required tosecure a credit card on file. We will be collecting your credit card at time of visit and storing itin a secure encrypted file with Key Bank. Nothingwill be charged to this card at the time of visitunless instructed by the patient.
Your insurance will be billed as it always has been and you will receive an Explanation ofBenefits letter that will explain your visit to the office. The letter will explain what procedurewas billed, what the insurance paid, and what the patient owes, the office should there be a
balance owed. For example; if there is a deductible or co-insurance on the insurance plan. Wesimply have to treat all patients the same. The amount owed is what will be charged to thecredit card on file. You will be given a 2-3 week grace period to review your Explanation ofBenefits letter and act on it accordingly. Should you choose not to pay your balance with thecredit card on file, Kindly contact the office upon receipt of your Explanation of Benefits letterand simply inform the office that you wish to use a different form of payment (cash, check, orother credit card) Yes, we do accept assignment and only bill what the insurance instructs us tobill the patient.
Print Name:Person Authorizing:Credit Card Type: Visa c MasterCard n Discover r Amex rCredit Card Number:Expiration Date:
The undersigned agrees that all information provided to the applicable financial institution is
accurate and complete. Deductible, Co-Pays, and Co-lnsurance are due in full at the time ofservice.
By completing and signing this form, you authorize Orhtopaedics Unlimited LLC to charge thepatient responsibility that is set forth on the Explanation of Benefits from your insurancecompany that is not paid by your insurance company (the "Patient Responsibility"). TheExplanation of Benefits from your insurance company determines the Patient Responsibility.
I have read this Credit Card Billing Authorization Form and a8ree to the terms and conditionsset forth above. I hereby consent to medical care and treatment as deemed necessary andproper by the medical staff of Orthopaedics Unlimited. Furthermore, lagreeto sign all healthinsurance benefits directly to Orthopaedics Unlimited, and understand that I am responsible forany costs of Patient Responsibility not covered by my health insurance which shall be chargedto the credit card as set forth above.
