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Demographics BERGEN WEST PEDIATRIC CENTER P A INSURANCE DEMOGRAPHIC INFORMATION FORM

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Demographics BERGEN WEST PEDIATRIC CENTER P A INSURANCE DEMOGRAPHIC INFORMATION FORM Powered By Docstoc
					 BERGEN WEST PEDIATRIC CENTER, P.A. INSURANCE/DEMOGRAPHIC INFORMATION FORM

Patient’s Last Name: _________________________ First Name/DOB: _____________________ M/F
Sibling’s Name(s) & Birthdate(s):
1.________________________________________ 2.__________________________________M/F

3.________________________________________ 4.__________________________________M/F

5.________________________________________ 6.__________________________________M/F

Street Address: _______________________________________________________________________
City/Town_________________________________________________State:_________Zip:_________
Home Phone: ________________________________________________________________________

Mother: __________________________________          Father: __________________________________
Biological Adoptive Step-Parent Legal Guardian      Biological Adoptive Step-Parent Legal Guardian
Home Phone: _____________________________          Home Phone: ______________________________
Cell Phone: _______________________________         Cell Phone: ________________________________
Email: ___________________________________         Email: ____________________________________
Street Address: ____________________________       Street Address: _____________________________
City__________________ State_____ Zip _______      City__________________ State_____ Zip ________
Occupation:_______________________________         Occupation:________________________________
Name of Employer: _________________________        Name of Employer: __________________________
Business Phone: ____________________________       Business Phone: _____________________________

Please list any additional guardians, step-parents, etc. on reverse side. Remember to sign consent form if you give
permission for any non-legal guardians to have access to the patient’s medical information.

INSURANCE INFORMATION
Insurance Co. and Plan Type________________________________________________________________
Address: __________________________________________________Phone:_________________________
Subscriber Name: _________________________________________Relation to Patient_________________
DOB: ___________________________________________ Social Security #:_________________________
ID Number: ______________________________________ Group #:________________________________

Secondary Insurance Co. and Plan Type: _______________________________________________________
Address: __________________________________________________Phone:_________________________
Subscriber Name: ________________________________________ Relation to Patient_________________
DOB: ___________________________________________ Social Security #:_________________________
ID Number: ______________________________________ Group #:________________________________

Preferred Pharmacy/Address: _______________________________________________________________
How did you hear about us? ________________________________________________________________

Check box and initial if we may leave voice messages on your answering machine or voicemail ________________
                                                                                                    Initials
Please indicate if you would prefer to receive appointment confirmations by:    PHONE or EMAIL
I hereby fully authorize Bergen West Pediatric Center, P.A. and/or their agent to bill, receive, release, and
exchange information with my insurance carrier.

Patient or parent/legal guardian signature: ________________________________Date: _____________
Print patient or parent/legal guardian name:__________________________________________________
Dear Bergen West Patients:

According to the HIPAA privacy guidelines effective, April 2003, it is required by law that you read our office’s
Notice of Privacy Practices and sign below indicating that you have reviewed a copy of this policy. A copy of
our policy can be given to you upon request. Also, a complete copy can also be found on our website at
www.bergenwestpediatriccenter.com for your convenience.

Your cooperation is appreciated. Thank you very much.

Bergen West Pediatric Center, PA
541 Cedar Hill Avenue
Wyckoff, NJ 07481
201-652-0300



I have read the Notice of Privacy Practices at Bergen West Pediatric Center, PA




_________________________________                            Date________________
Patient/Guardian Signature
                 POLICY FOR NON-PARTICIPATING PROVIDER INSURANCE OR SELF INSURED


The following is a statement of our financial policy, which we require you to read and sign prior to treatment.

All patients much complete one Patient Information and Insurance Form before seeing the doctor.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE.

WE ACCEPT CASH, CHECKS and CREDIT CARDS, (Mastercard, Visa, Discover and American Express).

If Bergen West Pediatric Center, P.A. is NOT a participating provider with your insurance plan, you are
responsible for payment in full at the time services are rendered.

Your insurance policy is a contract between you and your insurance company. You, as a member are
responsible for understanding your benefit coverage. We cannot tell you what your particular plan will or will
not cover.

We will provide you with a receipt with which you can attach to your insurance form for submission. You are
responsible for the claim submission to your carrier.

USUAL and CUSTOMARY RATES: Our practice is committed to providing the best treatment for our patients
and we charge what is usual and customary for our area. You are responsible for payment regardless of any
insurance company’s arbitration determination of usual and customary rates.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.

I have read, understand and agree to this Financial Policy.


___________________________________
Patient/Parent or Guardian Please Print




Patient/Parent or Guardian Signature                          Date
                                            POLICY & INFORMATION

Insurance Policy:
It is the policy of Bergen West Pediatric Center, P.A. to obtain insurance information at the time of visit. It is
your responsibility to provide any and all updated insurance information to the front desk at the time of visit.

If you fail to provide current insurance information at the time of visit you will be held responsible for all open
claims during that time period. If you provide us with insurance coverage AFTER the date of service, we can
only submit insurance claims within a 60 day period from date of service. After that time, you will be
responsible for the payment and submission of your claim.

No Show Charges:
As a courtesy, Bergen West Pediatric Center contacts all patients in advance to remind you of your Well Care
appointments. Please be advised that our policy is a charge of $25.00 No Show fee for appointments
cancelled in less than 24 hours.

Bill Fee:
You are contracted with your insurance to pay a co-pay at time of visit. If the co-pay is not met at time of visit,
a charge of $20.00 will be applied to your account in addition to your original co-payment amount.

Interest/Returned Checks:

Interest is accrued on all balances that are over 30 days past due. There is a charge on all returned checks of
$25.00.

School/Camp/Etc Forms:

There is a charge of $5.00 per form per child a calendar year, not to exceed $10.00 per child.




__________________________________                                  __________________________
Patient and/or Parent or Guardian                            Date

				
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