TCM ACUPUNCTURE
504 Hamburg Tpk. Ste. 20524 Nautilus Dr. Ste 5
Wayne, NJ 07470Manahawkin, NJ 08050
Office: (973) 595-8899 Fax: (973) 595-5855 Office: (609) 661-9657
PATIENT CONFIIDENTIAL INFORMATION
Name______Home Phone______
Home Address______
Birth Date___/__/__ Age_____ Marital Status______SS No._____-___-_____
Employer______Occupation______Work #______
Employer’s Address______
Date of Accident___/__/___ Date of Surgery___/__/___ Date of Injury___/__/___
Circle One: Workers Compensation No Fault Other
CASE HISTORY
Chief Complaint______
Complaint result of:____ Auto Accident ____Injury _____Job Related ____Other
Date of Accident/Injury/Other _____/____/____
Have you seen any other doctor about this condition? ______
Doctor” Name ______Address ______
Have you had recent X-Rays? ______If Yes, when? ______Area X-Rayed ______
FOR FEMALE: Are you pregnant? _____ IF YES, HOW LONG? ______
FOR MINORS: List parents’ names and address
______
______
FINANCIAL ARRANGEMENT
How do you plan to handle your account? (check one) ___Check ___Cash ___Insurance
INSURANCE INFORMATION
Primary Insurance______ID#______
I have read the above information and certify it to be true and correct to the best of my knowledge and belief and hereby authorize this office to do whatever is necessary, in accordance with state statutes, for the care and management of this complaint.
I hereby authorize the TCM Acupuncture to submit a claim to my insurance carrier for all covered services rendered by the provider and authorize my insurance carrier to issue payment directly to the provider. I understand I am responsible for any amount not covered by insurance.
PATIENT SIGNATURE ______DATE______
(parent’s signature if patient is minor)
TCM ACUPUNCTURE
504 Hamburg Tpk. Ste. 20524 Nautilus Dr. Ste 5
Wayne, NJ 07470Manahawkin, NJ 08050
Office: (973) 595-8899 Fax: (973) 595-5855 Office: (609) 661-9657
Our Financial Policy
Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy whichrequires you read and sign prior to any treatment. All patients must complete our information and Insurance Form before being seen by the acupuncturist.
Regarding Insurance
In most cases we accept assignment of insurance benefits. However, the balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give your insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance has not paid within 90 days, you will be notified and will have the choice to pay the balance by cash or check. Please be aware that some of the services provided may be non-covered services and not considered reasonable and necessary under Medicare Program and /or other medical insurance. In the event that we believe a service may not be covered by the Medicare Program you will be informed/advised.
Regarding Insurance: Plans where we are a participating provider, all co pay and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan where we are not participating provider, refer to the above paragraph.
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary of our area. You are responsible for payment regardless of any insurance company’s arbitrary determinations of usual and customary rates.
Adult Patients
All patients are responsible for full payment of services
Minor Patients
The adult accompanying a minor and the parents(or guardian of the minor) are responsible for full payment.
Missed Appointments
Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. Please help us to serve you better by keeping scheduled appointments
Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy.
X______DATE______
Signature of Patient or Responsible Party