New Patient Registration Forms

Complete Foot & Ankle Care

Please correct the errors described below.

ERIC ROCKMORE, D.P.M., STEPHANIE HORLING, D.P.M., MARC KAMENITZ, D.P.M.

1230 Whitehorse Mercerville Rd, Suite C, Hamilton, NJ 08619, Phone 609-585-0500

11 Overlook Road Suite B110, Summit, NJ 07901, Phone 908-273-0056

www.fasnj.com

To Our Patients:

Due to changes in the Health Insurance Industry, it is possible that a portion of the services you receive MAY be your responsibility. For example, some insurance plans have a deductible where the patient is responsible for the allowed amount. Other insurance plans have a co-insurance which means that they pay a fixed percentage of the charges and the patient is required to pay the remainder. If you have a plan like this, we ask that you help us maintain an efficient medical facility by providing your credit card information (or health savings card or flex spending card) to be retained, securely encrypted, on file (just like at hotel check-in) to cover the anticipated balance owed after your insurance has been processed.

More importantly, if the reason for your visit is Morton's Neuroma, Plantar fasciitis, Heel Spurs, Achilles, or other foot pain, our doctors may recommend special imaging at our office using ultrasound. These imaging studies give important and rapid information about your condition and may be an important part of your consultation with your doctor. Some insurance companies may not cover this service. If it is determined that your insurance plan will not cover this service, we will notify you at the time of your check-in.

In addition, computer-assisted gait (walking) analysis may be suggested to determine the intricate way you are moving. This diagnostic test may also help in decision making for custom foot orthotics. Some insurance companies may not cover this service, however, this may be an important part of your consultation with your doctor. If it is determined that your insurance plan will not cover this service, we will notify you at the time of your check-in.

-

werwer

-

Insurance Information

-

-

Medical History

Surgery

werwer

Social History

-

Please Check Response for each Item Below

CONSTITUTIONAL SYSTEMS

HEMATOLOGICAL/LYMPHATIC

EYES

INTEGUMENTARY (skin, breast)

CARDIOVASCULAR

NEUROLOGICAL

MUSCULOSKELETAL

RESPIRATORY

PSYCHIATRIC

ENDOCRINE

-

Medicare Benefits

I request that payment of authorized Medicare benefits be made on my behalf to Foot and Ankle Specialists of NY & NJ LLC for any services furnished me by that physician or supplier. I authorize any holder of medical information about me to release to Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services.

-

Privacy Notice

Our practice is committed to securing the privacy of your health information. Accordingly, we have a copy of our practice's Notice of Privacy in the reception area. You are not required to read this Notice. However, we would like your acknowledgement that you have been notified that the practice has such a Notice of Privacy Practices.

** We reserve the right that any requests for medical records must be in writing **

I authorize Foot and Ankle Specialists of NY & NJ LLC to release information regarding my medical condition to the following:

-

Financial Policy

We would like to thank you for choosing Foot and Ankle Specialists of NY & NJ, LLC as part of your health care team. It is our sincerest desire to provide you with the most excellent personalized care. You can expect that we will spend the time needed to hear all of your concerns and collaborate with you to develop a care plan to address any and all issues that fall under our specialty. To that end, the following financial policy is in place to ensure that we can continue to be of service to you. We require your signature to document that you have read and understand these policies to agree to abide by them.

Cancelled Appointments and No Shows:

If you are unable to keep your scheduled appointment, please call our office 24 hours before your appointment to reschedule. This will allow time to provide that slot to another patient. The first missed appointment will be forgiven. The Practice reserves the right to charge $50.00 for appointments that are not cancelled at least 24 hours in advance. After three missed appointments the practice reserves the right to discharge the patient.

Insurance:

It is the patient's responsibility to provide us with current insurance information and to present an active insurance card at each visit. If false, expired, or incorrect insurance information is presented to us, you will be solely responsible for the fees incurred, and payment will be required in full.

Referrals:

It is the patient's responsibility to provide a written referral for "specialist care" at the time of service. If the claim is denied due to lack of referral - the bill will be sent directly to you and payment to us will be immediately owed in full. It will then be the patient's responsibility to seek reimbursement from his or her insurance carrier.

Co-Payments:

Required insurance co-payments will be collected at the time of service. The Practice accepts cash, personal checks, and credit cards. There is a service charge of $35.00 for returned checks. There is a $5.00 rebilling fee if the copay is not paid at the time of service.

Surgical Procedures:

In the event that a patient elects to have a surgical procedure that has been recommended by the Practice, an ESTIMATE of the required patient's co-pay or deductible for the surgeon's fee will be given to the patient prior to scheduling the procedure. Surgical procedures will not be scheduled until the ESTIMATED co-pay is paid in full. The Practice cannot ensure the accuracy of, the ESTIMATE nor is it bound by the ESTIMATE. Insurance companies vary in covered costs. Because it is an ESTIMATE the Practice may have to issue the patient a refund or credit for future care, or if the ESTIMATE was too low, the patient shall promptly pay any additional amount owed once the insurance company has paid its portion of the bill. Please note that anesthesia and the operating facility will bill separately.

Outstanding Balances:

Patients with an outstanding balance are expected to pay their balance in full at or before their next appointment. If a patient does not pay their outstanding balance within 30 days from the date of service, the Practice reserves the right to transfer the account balance to an outside collection agency or attorney or to take such other steps as we deem necessary to collect your bill. If your account is referred to collections, you agree to pay our actual collection costs, including reasonable attorney's fees. Accounts with unpaid balances greater than 30 days are subject to a rebilling fee of $15.00 each month. Any unpaid balance the Practice reserves the right to discharge the patient from the Practice.

Please call if you have a question about your bill. Most problems can be settled quickly and easily, and your call will prevent any misunderstandings.

Signature Sheet

I HAVE CAREFULLY READ THIS ENTIRE FINANCIAL POLICY AND UNDERSTAND IT COMPLETELY. I AGREE TO THIS FINANCIAL POLICY OF FOOT AND ANKLE SPECIALISTS OF NY & NJ, LLC AND I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYING THE BILL FOR THE PRACTICE'S WORK, AS SET OUT ABOVE.

-

Your message will be encrypted.