New Patient Form and Office Policies

Omnicare Medical New Patient Forms

Hello, thank you for choosing Omnicare Medical. We look forward to meeting and caring for you. Please fill out our secure forms. All of the information included in these forms is securedly sent to our office,

Telephone: 973-759-6896
Email: info@omnicaremedical.com

Please check which office you made your appointment in.

Belleville

East Orange

Englewood Cliffs

West Orange

Name: First, Middle & Last

Date Of Birth

Month, Day, Year

Age

Social Security Number

Street Address

City, State

Zip Code

Email Address

Main Phone Number

How did you hear about us?

Emergency Contact

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Address

Employer Information

Employer Name

Title/Position

Employer Address

Insurance Information

Primary Insurance Carrier

Primary Insurance ID

Are you the Primary Holder of the Insurance? If "NO" please proceed to fill in information for Primary Insurance Holder

Yes No

Primary Insurance Holder Name

Primary Insurance Holder Date Of Birth

Primary Insurance Holder Address

Type "SAME" if it is your address.

Secondary Insurance

Secondary Insurance ID

Are you the Primary Holder of the Insurance? If "NO" please proceed to fill in information for Secondary Insurance Holder

Yes No

Secondary Insurance Holder Name

Secondary Insurance Holder Date Of Birth

Secondary Insurance Holder Address

Pharmacy Information

Primary Pharmacy Name

Primary Pharmacy Address

Primary Pharmacy Phone Number

Is this a Mail Order Pharmacy?

Yes No

Assignment of Medical Benefits

I hereby assign benefits payable for the eligible claims to the Provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to the Provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the Provider for any services rendered and/ or supplies provided.
I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.
I understand that this Assignment will apply to all eligible claims submitted electronically by the Provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.
If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the Provider.

Electronic Acknowledgment Of Assignment Of Benefits By Checking "Yes" you have read the above statement

YES

Release Of Medical Information

I authorize Omnicare Medical to release the medical records concerning myself/or person named as patient to any physician, hospital, or agency involved in the care of myself or said patient. By Checking "YES" I authorize the Release Of My Medical Information.

YES

HIPPA Privacy Policy

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent.

Please Check this box to Acknowledge that you understand our Privacy Policy. If you have any questions please ask our Office Staff to speak to Management.

Important Office Policies

PAYMENT POLICY:
As a courtesy, Omnicare Medical verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.
It is the policy of that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. The office manager at your location will explain this information to you prior to your first visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly.
If you are covered by health insurance, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.
Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100 percent responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment.
We highly recommend you also contact your insurance carrier and check into your coverage for (practice specialty). Do not assume that you will not owe anything if you have more than one insurance policy.

Please Check This Box to electronically acknowledge our payment policy.

CANCELLATION, LATE AND NO SHOW POLICY

Missed Appointment Policy
Our goal is to provide quality individualized medical care in a timely manner. No-shows, late shows and cancellations inconvenience those individuals who need access to medical care. We would like to remind you of our policy regarding missed appointments.
Cancellation of an Appointment
In order to be respectful of the medical needs of other patients, please be courteous and call our office promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will allow another patient access to timely medical care.
How to Cancel Your Appointment
To cancel your appointment, please call 973-759-6896. If you do not reach the receptionist, you may leave a detailed message on our voice mail or you may email us at info@omnicaremedical.com. If you would like to reschedule your appointment, please leave your name and phone number. We will return your call promptly.
Late Cancellations: A cancellation is considered to be late when the appointment is cancelled without a 24 hour advance notice.
No Show Policy: A “no-show”, is a patient who misses an appointment without cancelling it. A failure to be present at the time of a scheduled appointment will be recorded in the patient’s chart as a “no-show”. This includes arriving 15 minutes after your scheduled appointment.
The first time there is a “no-show”, late cancellation, or cancellation without a reasonable excuse there will be no charge to the patient. A 2nd occurrence will result in a fee of the visit. The 3rd occurrence will be the fee of the visit and the patient may be discharged from the practice.

Please check this box to acknowledge our cancel/late or rescheduling policy.

REFERRAL POLICY

It is the patient's responsibility to obtain a referral through your primary care physician's office if it is required by your insurance carrier. Please request the referral with our office staff and allow us 72 hours to create it for you. If you would like to email us a request for a referral please send it to info@omnicaremedical.com

Please check this box to acknowledge that you understand our referral policy.

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