--- ------------------

NEW JERSEY Jules M. Geh::zeiler, M.D., ,FJ\~C.S.· Y. SJ.mucl Litvin. MD.•Fe·

IT<I G. Keselmm, M.D, FAU.' lIan Waldman, MD.'UROLOGIC Betsy A. B. Greenkaf, D.O., FAC. ,0.G.t

INSTITUTE ·(""plrtm,lt o' hr \ TIl n f:\ 1.,Jr l j r '1\1l!

n.-r L tlheJ rrnul 1~1v,~ h'~rt 11[" II' I, '0 UU 1\ ,I ~cr

N.J.U.I ID#: _

Last Name: First Name: MI: _

Street Address: _

It

S. S. #: E-mail:

Driver's License# _

Primary #: Secondary #: Other Tel. #: (Cell # Preferred)

Sex: M / F DOB: Age: Marital Status: S / M / CU / D / W

Referred By: Primary Care Physician: _

Ref. By Tel. #: _ PCP Tel. # ----------------- ­

INSURANCE INFORMATION: Primary Carrier Secondary Carrier

Insurance Company Name:

Name of Subscriber:

Relationship to Patient:

Subscriber's D.O,B.:

Subscriber's SS#:

Insured's I.D.#:

Group #:

Pharmacy: Mail Order Pharmacy:

Address: Address: City: City: Tel. #: Tel. #:

Fax #: Fax #:

Ethnicity: Race: Language of Preference: _

1 Industrial Way East, Suite 101, aLOnLOwn, NJ 07724 I Tclephone: 732.963.9091 Fax: 732.963.9092 25 Kilmer Drive, Building 3, Suite 214, Morganville, NJ 0775 I I Telephon ; 732.536.8880

OI'llJlll . inl/ate Stale oft},f! Art Care

------------------ ------

-----------------------------------------

NEW JERSEY Jules M. Geltzeiler, M.D" FAC5.· Y. Samuel Litvin, M.D.,FAC.s •

Ira G. Kl'Sclman, M.D., FAC.s.' l1an Wald=. M.D.'UROLOGIC Betsy A. B. Grecnle.lf, DO., F.A.C.O.O.Gt

INSTITUTE

Patient Name: N.J.U.1. 10#:

Medicare Lifetime Signature on File:

I authorize payment of Medicare benefits to the New Jersey Urologic Institute, P.A. for services rendered to me. I

understand that I am financially responsible for balances cont covered by insurances. I authorize release of medical

information about me to the Centers for Medicare and Medicaid Services and to my insurance company to determine

benefits.

PLEASE NOTE: URINE CULTURES, CYTOLOGIES & PATHOLOGY STUDIES MAY BE SUBJECT TO ADDITIONAL TESTING BY

OUTSIDE LABORATORIES. YOUR INSURANCE COMPANY WILL BE BILLED SEPARATELY BY THESE OUTSIDE LABS.

x _ Sign Date

All Other Insurance Signature on File:

I authorize payment of any insurance benefits to the New Jersey Urologic Institute, P.A. for services rendered to me or

my dependent. I understand that New Jersey Urologic Institute will submit claims to my insurance company and that I am responsible for all co-pays, deductibles and charges for service no covered by my insurance company. I authorize the

release of medical information to my insurance company in order to evaluate and pay medical claims.

PLEASE NOTE: URINE CULTURES, CYTOLOGIES & PATHOLOGY STUDIES MAY BE SUBJECT TO ADDITIONAL TESTING BY

OUTSIDE LABORATORIES. YOUR INSURANCE COMPANY WILL BE BILLED SEPARATELY BY THESE OUTSIDE LABS.

x _ Sign Date

Employer Name Occupation _

Address:

Employer Tel. #: Contact Name: _ ( '. I

Emergency Contact Name Tel. # _

10 Industrial Way Easr. Suite 101, EaLOnlOWTl, NJ 07724 I Telephone: 732963.9091 Fa.x: 732.963.9092 25 Kilmer Dnve, Building 3, Suite 214, Morganville, NJ 0775 I Telephone: 732.536.8880

COInpassionutc Stoic afthe Art Care

NEW JER EY Jules M. Geltzciler, M.D., F.I\.C.S.· Y. Samuel Litvin. M.D. FAC.s.· Ira G. Keselman, MD. F ..5.' Ibn Waldm.m. M.D" UROLOGIC

Betsy A. B. Greenleaf, D.O., F .C.O.O.G.tINSTITUTE

Patient Name: N.J.U.1. IQ#: _

Your care and our records for your care are considered confidential. If you wish us to release information to your spouse, child, parent, or friend, please list these name(s) below and sign your name.

I authorize New Jersey Urologic Institute, P.A. to release records and information on my care to the following people:

x _ I) II.'

NO SHOW FEES:

I'm aware a NO SHOW fee will be charge to may account if I fail to cancel any appointment prior to 24 hours. I understand that the NO SHOW fees are $250 for initial office visit, $5fi for follow-up office visits exists and $25!l for an in office procedure.

"Failure to sign this acknowledgment will not prevent this policy from becoming effective."

x _ I It:

Patient Liability Agreement

I understand that I am financially responsible for all bills incurred while under the care of the New Jersey Urologic Institute, P.A. In the event that my account is not paid in full, I shall be liable for any and all cost of collection, including, but not limited to a 35% fee of the outstanding balance ifmy account is forwarded to a collection agency for collection; and if my account is forwarded to an attorney for legal proceedings I agree to be liable for an additional attorney fee making a total collection and attorney fee of 50% of the outstand ing balance.

x _ ,\

10 Industrial Way Easl, Suite 101, Eatontown, NJ 07724 I Telephone: 732.963.9091 Fax: 732.963.9092 2S Kilmer Drive, Building 3, Suite 214, Morganville. NJ 07751 I Telephone: 732.536.8880

\\ w'-\.njuwlo '!cUJm nmpassiOl/lI/C .-tllt a/the Art Care