We strive to provide the “Best Health Care Experience

Hackensack Meridian Pediatric Surgical Associates

(As a safeguard for your privacy, DO NOT e-mail these forms back to us. However, you may fax them back to us to our secure fax #732-935-0757, if this is convenient for you.)

The following is the "patient information" forms that we require. Please fill out these forms in their entirety and bring them with you for your appointment along with your insurance card(s). All parents/guardians must have a photo ID. If you are not the biological parent, please bring proof of legal guardianship. We cannot treat your child without it. If your child is 18 years of age or older, please make sure they also bring their ID.

Please fill in both "legal" parents information on the attached forms. Without it, we cannot release any health information to them.

Please be aware, we also need a script from your child's pediatrician requesting the consultation with our doctor(s). It must state the reason for the consultation. If your insurance company mandates the use of a referral form, that form will be sufficient.

Due to the nature of Dr. Staab's specialty as a pediatric surgeon, we may experience the need to insert emergency appointments during our regularly-scheduled appointment times. We do not anticipate a long wait, but in order for the doctor to give each patient the time and attention required, you might experience a longer wait time. We do our best to avoid this from occurring and would greatly appreciate your patience and understanding if this should occur. Our goal is to have your child seen within 1 hour of their scheduled appointment time.

We strive to provide the

"Best Health Care Experience"

Please let us know how we are doing. After your visit with our doctor, you may receive a survey. Please take

the time to complete all sides of the form and mail it back in the envelope provided or check your email for online survey.

Thank you. -- The Staff at Hackensack Meridian Pediatric Surgical Associates

Updated 10/10/2017

Hackensack Meridian Pediatric Surgical Associates

Patient's Name:

PEDIATRIC PATIENT REGISTRATION- PERSONAL INFORMATION

1. _____________________________________________ DOB ___________________Sex: Male Female (Circle One) 2. _____________________________________________ DOB ___________________Sex: Male Female (Circle One)

Name of Pediatrician: _________________________________Town: _______________________ Tel#________________ Did they refer you to us? ________________________ If not, who did? _________________________________________

Language spoken at home: ______________________ Pharmacy name & phone: ____________________________________

Race:

American Indian/Alaska Native Native Hawaiian /Other Pacific Islander

Asian White

Black/African American Choose not to answer

Ethnicity: Hispanic/Latino

Not Hispanic/Latino

Choose not to answer

Parent/Guardian: _____________________________DOB: ___________Relationship to patient(s): ___________________

Home Address: (Street) _____________________________________ (City/State) _______________________ (Zip) ________

Preferred phone: ______________________ Cell or Home Alternate Phone: ______________________ Cell or Home

Preferred Method of Contact (please circle): Phone

US mail

Email via secure portal

Email Address: _____________________________________ Employer: __________________________________________

Parent/Guardian: ___________________________DOB: ___________Relationship to patient(s): _____________________ Home Address: (Street) ______________________________________ (City/State) ______________________ (Zip)________ Preferred phone: ______________________ Cell or Home Alternate Phone: ______________________ Cell or Home Email Address: _____________________________________ Employer: __________________________________________

Emergency Contact: ____________________________Phone:_____________________Relationship:____________________ INSURANCE INFORMATION

Primary Insurance Co. Information: (name, address and phone # of person responsible for payment) Insurance Company Name: _____________________________________________Phone: ___________________________ Policy/ID Number: ____________________________Group #: __________________ Effective Date: __________________ Subscriber's Name: _____________________________________ Relationship to Patient____________________________ Subscriber's DOB: _______________ Ins. Address: __________________________________________________________________________________________ Secondary Insurance Co. Information: (name, address and phone # of person responsible for payment) Insurance Company Name: ______________________________________________ Phone: ___________________________ Policy/ID Number: _____________________________ Group #: ________________ Effective Date: ____________________ Subscriber's Name: _______________________________________ Relationship to Patient____________________________ Subscriber's DOB: ____________________ Ins. Address: ___________________________________________________________________________________________

Signature: _______________________________________________________________ Date: ______________________

Updated 10/10/2017

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES Victoriya Staab, M.D.

Christine M. Williams, PA- C 4 Industrial Way West Suite 100, Eatontown, NJ 07724

Phone: 732-935-0407 Fax: 732-935-0757

BARRIER TO CARE:

State of New Jersey mandates that every physician documents any barrier to care including cultural and linguistic needs in the medical record. Factors affecting care are visual or auditory factors which may impede your ability to comprehend medical discussion and language, cultural and/or religious customs, which may impact the provider's ability to provide medical care. Addressing these needs will improve patient satisfaction and also decrease health care disparities.

Do you have any Impairment ? (i.e. Visual, hearing, speech, learning, physical and language/cultural barrier) ___________________________________________________

What language do you speak, read or write? ____________________________________

Do you have any religious or culture customs that the doctor should know about?

Yes

No ________________________________________________

________________________________________________________________________

Patient's Name: _____________________________________ DOB: __________________ Legal Guardian's Signature: __________________________________________________ Relationship________________________________________________________________ Date:______________________________________________________________________

Updated 10/10/2017

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES Victoriya Staab, M.D.

Christine M. Williams, PA- C 4 Industrial Way West Suite 100, Eatontown, NJ 07724

Phone: 732-935-0407 Fax: 732-935-0757

PERMISSION TO RECEIVE PRERECORDED MESSAGES AND/OR TEXT MESSAGES As a service to our patients, we provide courtesy appointment reminder calls and when we can text messages. We also may place other important calls and send text messages using a prerecorded or automated message. In order to authorize receiving the calls and messages, please fill out the information below and provide the phone number where you wish to receive these messages. Important note: By providing your cell phone number below, you consent to receiving appointment reminder calls, important calls and/or text messages on your cell phone. If you would like us to utilize a different number--please provide that number below instead of your cell phone number. This authorization permits us to leave messages, call or text you on the phone number that you provide below. If you provide your cell phone number, you will receive automated or prerecorded messages on your cell phone. We are required by law to advise you of this. You do not need to sign this authorization; however, - if you do not sign this authorization, we will not be able to provide you with courtesy reminder calls, text messages or other important calls.

Patient Name __________________________________ Patient date of birth:______________ Legal Guardian if a minor: __________________________________Relationship: ______________ Signature of Parent or Legal Guardian _______________________________ (if patient is a minor) Phone number authorized by Patient to receive calls and message as set forth above: Cell Phone Number: __________________________ Telephone Number: __________________________

Date_____________________

Updated 10/10/2017

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES Victoriya Staab, M.D.

Christine M. Williams, PA- C 4 Industrial Way West Suite 100, Eatontown, NJ 07724

Phone: 732-935-0407 Fax: 732-935-0757

Patient's Name: _______________________________________ Date of Birth: _____________

Payment Policy

We are committed to providing you with quality and affordable health care. Some of our patients have questions regarding patient and insurance responsibility for services rendered, so we've developed this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.

1. Insurance. If you are not insured by a plan we do business with, payment in full is expected at each visit or with-in 14 days of the billing statement. If you are insured by a plan we do business with, but don't have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage or with-in 14 days of the billing statement. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

3. Non-covered services. Please be aware that some ? and perhaps all ? of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services at time of service or with-in 14 days of billing statement.

4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 60 days, the balance will automatically be billed to you.

Updated 10/10/2017

Initial ______________

7. Nonpayment. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency authorized to credit report all outstanding debts to the four major National Credit Agencies, litigate in a court of law (other legal fees my apply) and charge a service fee of 30% of the outstanding balance in the event that we incur additional pre-collection and collection fees to reach a final resolution of any outstanding balance for which you owe the practice.

8. Additional Cost of Collection Services. Invoices shall be deemed to be accepted by you unless Meridian Pediatric Surgical Associates, PC is notified in writing within 14 days of the invoice being issued that you dispute the amount of the invoice.

In the event of non-payment, Hackensack Meridian Pediatric Surgical Associates, PC may in addition to the invoice amount charge:

(i.) Interest on any outstanding amounts from the due date calculated at the statutory penalty rate of 16%. (ii) Legal and debt collection fees incurred by Hackensack Meridian Pediatric Surgical Associates, PC in relation to recovery of outstanding amounts.

Where any part of your medical account with Hackensack Meridian Pediatric Surgical Associates, PC has fallen into arrears then the totality of that account whether or not in arrears shall become immediately due and payable.

9. Missed appointments. Our policy is to charge for missed appointments not canceled within a reasonable amount of time. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment or call 24 hours prior to cancel-scheduled appointment.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.

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

I have read and understand the payment policy and agree to abide by its guidelines:

_____________________________________________ Signature of patient or responsible party

______________________ Date

Patient's Name: _______________________________________ Date of Birth: _____________

Updated 10/10/2017

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES Victoriya Staab, M.D.

Christine M. Williams, PA- C 4 Industrial Way West Suite 100, Eatontown, NJ 07724

Phone: 732-935-0407 Fax: 732-935-0757

CONSENT FOR TREATMENT: I acknowledge that I have elected on my own behalf or on behalf of my dependent to receive medical services that may or may not be covered by my health plan or any number of reasons.

I understand and acknowledge that I am financially responsible for, and therefore shall pay for, all services rendered to me or my dependent that are not paid or contractually adjusted by my insurance, in whole or in part, by my health plan for any reason whatsoever.

RELEASE OF INFORMATION: I authorize the release of all information necessary to process my insurance claims and pertinent to my medical care. This release will remain in effect until revoked by me in writing. A photocopy of this release is to be considered as valid as the original.

ASSIGNMENT OF BENEFITS: I assign all medical and/or surgical benefits including major medical benefits to which I am entitled, including Medicare, BCBS, HMO plans, and commercial insurance to (insert practice name) This assignment will remain in effect until revoked by me in writing. I hereby authorize the above to release information to secure payment on my behalf.

I understand that I am financially responsible for all charges. I have read this information and understand it.

Patient Name: _______________________________ DOB: _________________________

Signature: ___________________________________________________________________

Signature of Parent or Guardian: _______________________________________________

(If patient is a minor.)

Date:___________________________________

Updated 10/10/2017

HACKENSACK MERIDIAN PEDIATRIC SURGICAL ASSOCIATES

Patient Name: ____________________________________ Date of Birth: __________ Age: ___________ Sex: Male Female Weight at birth? _________ Hospital: __________Country? ________ Full term? Yes / No born @______gestation Vaginal/ C-Section Is child a multiple? Yes No , If Yes, (twin) (triplet) (quadruplet) Birth Order: ___ Conceived by In-Vitro Fertilization? Yes No

Apnea Monitor: Currently being used or was it used?

If yes, When? ___________ When was it stopped? ________________

Male Patient: Circumcised: Y N -If yes, Date: _____________________ Hospital: ________________________________

Female patient: Menstruating: Y N Onset _________________________ Last ____________________________________

Medication

Current Medications:

Condition Being Treated

Does your child have any ALLERGIES:

Type of Allergy: (Circle Answer)

Please Answer Each Question (Circle Answer)

Reaction Type

Shellfish Latex Anesthesia Surgical Adhesive Environmental Any Allergy to Medications

*** If so please list: Other Allergies (please list):

Yes No Yes No Yes No Yes No Yes No Yes No

Has ANY biological family member had a problem with anesthesia?

Yes-Relationship __________________________________ No

Does your child have any IMPORTANT MEDICAL CONDITIONS: Please Answer Each Question

(Circle Answer)

Does your child have or had:

If yes, list type of condition

Name of treating physician

Any blood conditions

Yes No

Asthma

Yes No Last episode:

Heart Problems/Murmur

Yes No

Diabetes

Yes No Insulin Dependent? Yes No

Neurological

Yes No

Has your child had any OPERATIONS/HOSPITALIZATIONS?

Procedure / Reason for Hospitalizations

Date

Hospital/ Doctor

_______________________________

SIGNATURE

_________________

DATE

__________________

___________S_ig_n_a_t_ure

TIME

______________________________

Signature

Updated 10/10/2017

__________

Review Date

______________ Review Date

For updating use only

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