Personal Information:

Date

Name (required)

Preferred Name

Date of Birth

Social Security Number

Sex (required) ---MaleFemaleOther

Address (required)

Email (required)

Home Phone

Cell Phone (required)

Work Phone

Race
---American Indian/ Alaska NativeAsianNative Hawaiian/Other PacificBlack or AfricanAmericanCaucasianHispanicOtherDo not wish to answer

Ethnicity
---Hispanic or LatinoNot Hispanic

Primary Language

Employment Information:

Employer
---Full TimePart TimeRetiredStudentNone

Occupation

Address

Phone #

Physician/ Pharmacy Information:

Primary Care Physician

Phone #

Address

Referring Physician

Phone # of Referring Physician

Address of Referring Physician

Preferred Pharmacy

Phone # of Pharmacy

Address of Pharmacy

Responsible Billing Party:

Name

Date

Address

Social Security Number

Phone #

Relationship to patient
---SelfSpousePartnerOther

The Undersigned patient or individual acting on behalf of the patient agrees that the above facts are correct

Patient or Representative of Patient (required)

ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY

I hereby give permission to NJ Gastroenterology Health and Wellness to bill my insurance company for professional medical services rendered. I agree to pay all charges due or that become due to NJ Gastroenterology Health and Wellness for the care and treatment provided to me by NJ Gastroenterology Health and Wellness.

I understand that insurance benefit verification and authorization is not a guarantee of payment and if the charges are denied, the medical charges will become my responsibility and obligation. I am responsible to pay all copayments, coinsurance and deductible applied to my account after the insurance payment is made and/or the claim is processed.

In addition, any charges denied by the insurance company because they do not meet the criteria for medical necessity would be my responsibility.

And it I do not or did provide NJ Gastroenterology Health and Wellness with accurate and current information regarding my insurer, I will be personally responsible for the cost of the care rendered.

I agree that all bills are to be paid when presented or in advance of treatment, itself pay. And if I fail to pay my bill, I realize that my account with be forwarded to the collection agency and attorney and court fees will be added to my due balance.

Signature of Patient or Legally Authorized Representative Date (required)

ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of NJ Gastroenterology Health and Wellness' Notice of Privacy Practices. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

If you have any question regarding NJ Gastroenterology Health and Wellness ' Notice of Privacy Practices, please contact out Privacy Office at 1-609-382-0111.
I acknowledge receipt of NJ Gastroenterology Health and Wellness Notice of privacy practices.

Signature of Patient or Legally Authorized Representative Date (required)

FOR OFFICE USE ONLY

Attempts have been made to obtain written acknowledgement of receipt of Pulmonary Health Consultants' Notice of Privacy Practices, but acknowledgement could not be obtained because:
• Individual refused to sign
• Barrier(s) to communication prohibited obtaining the acknowledgement
• An emergency situation prevented us from obtaining the acknowledgement

Other(Please Specify)
Signature of Provider Representative Date (required)

CONSENT FORM FOR THE AUTHORIZATION OF TREATMENT & RELEASE OF INFORMATION

Name

Date

Date of Birth

MRN#

Consent for Medical/Surgical/ Urgent Cart

I hereby authorize NJ Gastroenterology Health and Wellness to provide initial and ongoing medical/surgical treatment that is necessary and reasonable as based on acceptable standards of care for my wellness and the treatment of my physical condition.

I consent to examination, blood tests, (including blood tests for communicable disease such as Hepatitis and HIV/AIDS when healthcare personnel have been exposed to my blood and/or body fluids), laboratory procedures, medications, infusions, nursing care and other services or treatments rendered by my physician, consulting physician, and their associate and assistants, or rendered by facility personnel under the instructions, orders and direction of such physician(s).

Authorization to Release Medical Information

I hereby authorize NJ Gastroenterology Health and Wellness to release information obtained in the course of my medical/surgical/urgent care to my insurance carries and other providers of health care and healthcare organizations involved in my care. in the event of an employee blood or body fluid exposure, I authorize NJ Health and Wellness to release pertinent testing for the treatment of the employee. I also authorize NJ Gastroenterology Health and Wellness to receive my medication history.

Assignment of Benefits

I hereby assign all medical/ surgical/ urgent care benefits to which I am entitled, including major benefits, Medicare, private insurance and any other health plans, to NJ Gastroenterology Health and Wellness. A photocopy of this assignment is to be considered as valid as the original.
I understand that I am financially responsible for all costs not covered by my insurance plan (s). This includes but not limited to co-pays, coinsurances, deductibles, and non-covered procedures and/or diagnoses. I understand that if my insurance requires a referral for me to receive treatment here that is my responsibility to obtain that referral from my primary care physician. I also understand that I am expected to make payment for previous balances or balances sent o collections prior to my office visit. If I am unable to pay my balance in full, I understand that I can speak to the office manager to setup a payment plan.
I understand that NJ Gastroenterology Health and Wellness reserves the right to impose a fee for un-cancelled (failure to show) appointments.

Consent to Call. Teak or Email

I consent to receiving the following automated communications from NJ Gastroenterology Health and Wellness
Health Notifications [ ] Email [ ] Phone [ ] Text Message
Appointments [ ] Email [ ] Phone [ ] Text Message
Announcements [ ] Email [ ] Phone [ ] Text Message
Billing [ ] Email [ ] Phone [ ] Text Message
If email was chosen as a communication preference above, please provide your email address:

I authorize the release of information including the diagnosis, records and examinations rendered to me as well as claims information, to the persons listed below:

Name
Relationship
Phone Number
Name
Relationship
Phone Number
Date
Relationship to Patient

REQUEST FOR RELEASE OF HEALTHCARE INFORMATION

Patient Name:
Today's Date
Last 4 digits of SSN
Date of birth
I hereby authorize:
Phone Number
Fax:

To release, use, and disclose health information about me as described below to:

This request and authorization applies to :
[ ] All Healthcare information

Patient Signature (required)

TREATMENT CONSENT FORM

• Billing & Payments
• Treatment Fees
• Client Bill of Rights
• Out Of Network Practice Status
• Sessions
• Referrals
• Medications / Receiving medication history
• Legal Fees / Professional Services
• Summary of Medicare Acceptance
• Contacting Us
• Insurance Reimbursements
• COVID- 19 Informed consent
• Confidentiality
• Client Grievances
• Privacy Practices
• Introduction / Psychotherapy
• Cancellation / No-Show Policy
• No Harm Contract / Video Surveillance
• Injections / Testosterone Replacement
• Consent to receive appointment reminders (voice/text)
• Professional Records
• Assignment & Release of Benefits
• Tele-medicine
• Minor Child Treatment Consent

Your signature below indicates you have read the treatment consent and are aware you can receive a copy if requested, which contains information on clinical services, professional fees, cancellation and no show policies, billing and payments, insurance reimbursement, authorization and release of benefits, contacting us, professional records, no harm contract, client bill of rights, client grievances, policies, confidentiality, Medicare acceptance, appointment reminders, out of network status, video surveillance, referrals, minor child consent, and medications/testosterone replacement / injections, and you agree to abide by its terms during our professional relationship. For minor children, please initial the line below in addition to signing this form.

Name of Patient (printed):
Date
Signature of Patient (or legal guardian) (required)

ASSIGNMENT AND RELEASE OF INSURANCE BENEFITS

I certify that I, and/or my dependents, have insurance coverage with and assign directly to New Jersey Gastroenterology Health and Wellness all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature or the signature of my dependents on all submissions.I , the undersigned, hereafter referred to as the patient' do hereby assign all of my rights and interest to New Jersey Gastroenterology Health and Wellness, hereafter referred to as the medical provider to pursue and obtain payment from the above-named Insurance carrier. I, assign to the medical provider, all my rights and benefits under the Insurance contract for payment for services rendered to me. I, the patient, do hereby understand and acknowledge that if I refuse to comply with reasonable requests of the Insurance carrier, any denied claims I will be held responsible for same. I, the patient, do hereby direct my health insurance carrier and/or other insurance carrier to issue payment on my behalf directly to the medical provider. The check should be made payable to the medical provider. Further, in the event that the health carrier and/or other Insurance carrier fails to forward the check to the medical provider, I will endorse and sign the check to the medical provider within (5) five days of the receipt of same. I, the patient, do hereby acknowledge that I will not file suit and/or arbitration for the payment of the above provider's medical bills. I understand that the above referenced medical provider has an attorney and will collect payment on my behalf from the insurance carrier or from me if I fail to pay. To prevent the Insurance carrier and/or the vendor designed by the Insurance carrier from refusing to accept my Assignment or submitting challenge to my Assignment as being Invalid, I execute this Special Power of Attorney to appoint and authorize the medical provider and counsel on behalf of the medical provider to file suit and/or arbitration directly against the insurance carrier in my name. This Assignment serves as a limited retained agreement between me and the chosen attorney by the medical provider for the sole purpose of representing me on a claim for outstanding treatment. The above-named Care Center/Physician(s) may use my health information and may disclose such information to the above-named Insurance Company (companies) and their agents for the purpose of obtaining payment for related services.

I also acknowledge that if I do not provide benefit checks received by me within 30 days of the confirmation of checks being sent to me m credit / debit card provided on intake will automatically be charged for the visit.

Patient Name
Signature of Patient (or legal guardian) (required)

CREDIT OR DEBIT CARD TO KEEP ON FILE

Please be advised that a credit/debit card is required regardless of insurance coverage/method of preferred payment due to the office's late cancellation / no show policy.

Patient's Name
Date of Birth
Type of Card ---VISAMCAMEXDISCOVEROTHER
Name on Card
Card Numbers
Expiration Date
Security Code
Zip Code
How would you like your receipt? ---TextEmail
Cell Phone
Email Address
Signature (required)

Acknowledgement of Procedure for Scheduling and Medication Refills

Please read each statement and sign below.
I am responsible for calling the office to schedule my follow-up appointments. X

I am responsible for giving a 24-hour notice to cancel/reschedule my appointment. If I do not cancel in advance or if I do not show for my appointment, I agree to pay a fee of $100.00-$180.00. X

I understand that my medications will not be refilled without speaking to my provider during my scheduled appointment. X

I understand that I am responsible for informing the office staff of any changes to my insurance and/or payment information prior to scheduling an appointment. X

I understand (if applicable) that my medicinal marijuana script will only be renewed during my scheduled appointment with Brian Berberian, MD X

I understand and agree to the terms listed above.

Name of Patient:

Signature of patient (required)

Date:

Failure to comply with these procedures may result with discharge from the practice and liability for all balances owed.

( Kindly click the submit button again, if it is not submitted for the first time )