Patient Registration Form
EMERGENCY INFORMATION: IN CASE OF EMERGENCY, PLEASE NOTIFY:
How did you hear of Dr. Goldberg's practice?
FOR ALL PATIENTS:
It is the patient's responsibility to confirm that we accept their insurance. We do not submit claims to non-participating insurance companies.
I understand that I am responsible for all charges for services rendered to me, including the balance remaining after payment of possible insurance benefits according to my individual insurance contract.
Payment is due at the time of service unless other arrangements are made with the office manager prior to seeing the doctor. If it is agreed that these charges will be submitted to my insurance company, I agree to pay the contractual balance in full if payment is not received within 45 days from the date of service.
- If your insurance company requires that you obtain a referral in advance of your visit, it is your responsibility to make sure you bring it with you or have it sent to us prior to your visit. We regret that we can not call for you.
- If your primary care doctor’s office issues referrals electronically, it is your responsibility to obtain the confirmation/authorization number, the number of visits allowed and the duration of the referral.
- If you come without a referral, you have two choices:
- 1. Pay the minimal, discounted fee for the office visit on the day of service. We will send you a refund when payment is received from your insurance company.
- 2. Reschedule.
- We regret that we can not call your doctor’s office for you.
- Standard, fixed co-pays are due at the time of service. There are no exceptions. We can no longer bill patients for these fees. If we are forced to bill you for a co-pay, we may charge an additional “billing” service fee.
- Please remember to cancel appointments at least 24 hours in advance. If you miss a scheduled appointment, we reserve the right to charge you a penalty fee.
Please sign below to confirm that you have reviewed these practice policies and that you understand them. If you have a question please feel free to discuss it with the office manager.