New Patient Form Call 201-639-2656 Fax 201-345-4405 106 Prospect Street. 3rd Floor Ridgewood, NJ 07450, USA New Patient New Patient Form for Intake. Step 1 of 4 25% Date(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Name(Required) First Last SexMaleFemalePrefer Not to AnswerDate of Birth(Required) Month Day Year Age(Required)Email(Required) Home #(Required)Cell #(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child Social Security Number(Required) Ethnicity Parents Names(Required) Referred by: Family members treated by Dr. Joffe / Dr. Pehlivan: PEDIATRICIAN INFORMATIONPediatrician's Full Name(Required) Pediatrician's Phone Number(Required)Pediatrician’s Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Reason for today's visit:(Required) Please Choose(Required)RightLeftBothSpineOther:Date problem began:(Required) MM slash DD slash YYYY How did this occur?(Required) Please select one of the following if applicable School Accident Chronic Condition Motor Vehicle Sport Injury Noticed at Birth Was the patient seen in the Emergency Room / Urgent Care?(Required) Yes No Patient InformationHeight(Required) Weight(Required) Age of first Menstruation Last Menstrual Period (date) Please list any allergies:(Required) Are you pregnant or is there any chance of pregnancy? Yes No Medical History (Please check all that apply): Asthma Autism Fractures Seasonal Allergies Developmental Delays Sprains Cerebral Palsy Epilepsy / Seizures Arthritis ADHD Bone / Joint Infections Dislocations Emotional or Psychiatric Disorder Scoliosis Other: Select AllList(Required)MedicationDose / How OftenReason Add RemoveCOVID Vaccine (Date)(Required) Yes No Past COVID Diagnosis(Required) Yes No Does the patient smoke?(Required) Yes No Do any family members smoke?(Required) Yes No Please document any unlisted medical problem: Please document any surgeries: Birth History Birth Weight Please select delivery presentation type: Head First Breech Twin/Multiples C-Section In ICU after Delivery?(Required) Yes No Please list any perinatal complications YOUR INSURANCE COMPANY(Required)In the past few years, the number of different health insurance plans has increased. Even within one company, there may be several plans with varying benefits and requirements. It is your responsibility to ensure that proper authorization and referrals for the services provided from PPOS are covered. - Some plans require REFERRALS from your Primary HealthCare Physician (The referral must be received before the appointment) - Some plans require a specific facility to be used for your MRI, CT scans, Ultrasounds, Blood Work and Surgical procedures. I agree to the insurance company policy.OUT OF NETWORK COVERAGE(Required)You should be aware that in the event an out of network insurance plan covers all or part of your treatment, payment for some may be mailed directly to you. If an insurance company sends you payment, they are meant to be sent to PPOS. It is your responsibility to send immediately with all the associated paperwork from the insurance company. As a courtesy to our patients, we file insurance; however, we will not become involved in disputes between you and your insurance companies regarding deductibles, co-payments, covered charges, secondary insurance, or other matters regarding payment. I agree to the out of network coverage policy.Appeals(Required)I hereby authorize Preferred Pediatric Orthopedic Surgery to appeal any denial or fair compensation for coverage by my health care provider for services rendered by Preferred Pediatric Orthopedic Surgery to my child. I further understand and acknowledge that any payment issued by my insurance carrier for services rendered by Preferred Pediatric Orthopedic Surgery as a result of this appeal must be remitted to Preferred Pediatric Orthopedic Surgery. In the instance my appeal is denied, I remain responsible for all payments due and owing Preferred Pediatric Orthopedic Surgery for services rendered. I agree to the appeals policy.RECORDS(Required)You, the patient, are entitled to any and all records that pertain to your medical condition. For medical/legal reason we never release the original records. Records are only released to the patient or someone that the patient specifically designates. Copies of the office assessments, outside test results, and x-rays are available. If you would like to view your records or obtain copies of your records the office will comply with your request within 30 days after a written release is received. Please note that there is a fee for copying records and x-rays. I agree to the records policy.NO SHOW POLICY(Required)Effective May 1, 2021 any established patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours’ notice will be considered a No Show and charged a $25.00 fee. Any established patient who fails to show or cancels/reschedules an appointment with no 24 hours’ notice a second time will be charged a $50.00 fee. If a third No Show or cancellation/reschedule with no 24-hour notice should occur the patient may be dismissed from PPOS. Any new patient who fails to show for their initial visit will not be rescheduled. The fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit. I agree to the no show policy.PATIENT PRIVACY(Required)In order to protect your privacy and in accordance with Federal Law, we do not leave confidential medical information on answering machines or with anyone other than the patient or patient’s legal guardian without prior authorization. Please read and sign below acknowledging receipt of the policy. I agree to the patient privacy policy.Please indicate below your preference:(Required) We may leave detailed messages on this answering machine # Do not leave detailed messages on any answering machine Permission to fax medical instructions to my child's school *If over the age of 18 please list who we can speak to other than yourself regarding medical information:NameRelationship Add Remove Primary Insurance InformationPrimary Insurance Company Name:(Required) Subscriber ID Number(Required) Group Number:(Required) Ins. Co. Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Person Responsible for Account (Guarantor):(Required) First Last Phone(Required)Relationship to Patient(Required) Guarantor’s Birth Date:(Required) MM slash DD slash YYYY Guarantor's SS #:(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer(Required) Work Phone#(Required)Occupation(Required) Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Insurance InformationSecondary Insurance(Required)NoYesSecondary Insurance Company Name:(Required) Subscriber ID Number(Required) Group Number:(Required) Ins. Co. Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Person Responsible for Account (Guarantor):(Required) First Last Phone(Required)Relationship to Patient(Required) Guarantor’s Birth Date:(Required) MM slash DD slash YYYY Guarantor's SS #:(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer(Required) Work Phone#(Required)Occupation(Required) Business Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Assignment and ReleaseConsent(Required)I hereby authorize payment directly to PPOS, all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance, for all services rendered on my behalf or my dependents. I authorize the above noted doctor and/or provider or supplier of services in this office to release any information required to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I agree to the assignment and release policy.NameThis field is for validation purposes and should be left unchanged.