FOR PROSPECTIVE CLIENTS SEEKING INITIAL APPOINTMENT WITH ONE OF OUR PROVIDERS:
Kindly fill out these forms and email back at firstname.lastname@example.org. It can also be faxed at (908) 272-7502. Do not forget to include copies of your insurance card (FRONT & BACK) and driver's license. NO COPIES OF INSURANCE CARD/S, NO APPOINTMENT. The sooner we get this back from you, the sooner we can call you to set up an appointment.
FOR SCHEDULED CLIENTS ONLY
If you have been scheduled for your initial appointment, you are requested to arrive 15 minutes earlier so you will have time to fill out these forms. If for some reason that this is not possible for you, you can print these forms and bring it on your initial appointment.
CREDIT CARD/DEBIT CARD AUTH - If you wish that your credit/debit card to be kept on file to pay for your copays, coinsurances, deductibles and other patient/family responsibility.
2. AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION