In Case of Emergency
HEALTH INSURANCE INFORMATION (PLEASE FILL OUT IF APPLICABLE)
AUTO ACCIDENT OR WORK RELATED INURY (PLEASE FILL OUT IF APPLICABLE)
Public law/rule of the State of New Jersey/Board of Medical Examiners mandates that a physician, podiatrist, and all other licensees of the Board of Medical Examiners inform patients of any significant financial interest held in a health care service. Accordingly, take notice that Kevin McElroy, D.O. does have a financial interest in the following health care service(s) to which patients are referred:
Meta Surgical Center
Meta Surgical Center does not participate with all insuance plans and may bill your services as a non-participating facility. Please ask us any questions you may have regarding their billing policy. You may, of course, seek treatment at a health care service provider of your own choice. A listing of alternative health care service providers can be found in the classified section of your telephone directory under the appropriate heading.
Accordingly, take notice that Steven Ferrer, M.D. does have a financial interest in the following health care service(s) to which patients are referred:
Surgicore Surgical Center
Surgicore Surgical Center does not participate with all insurance plans and may bill your services as a non-participating facility. Please ask us any questions you may have regarding their billing policy. You may, of course, seek treatment at a health care service provider of your own choice. A listing of alternative health care service providers can be found in the classified section of your telephone directory under the appropriate heading.
On behalf of Progressive Spine & Sports Medicine, LLC (hereinafter "health service provider" or "Progressive Spine"), kindly accept this disclosure in accordance with P.L.2018 c.32, ("Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act") as it applies to health care providers and physicians. Pursuant to this new legislation, notice is required to be provided by all physicians, including those at Progressive Spine, as follows:
Please take note that Progressive Spine is affiliated and/or refers patients to the following facilities and/or health care providers in conjunction with treatment rendered by physicians and medical personnel here at Progressive Spine. During the course of your care here at Progressive Spine, you may be referred to one of the following health care providers:
155 State Street
Hackensack, New Jersey 07601
Progressive Diagnostic Imaging
44 Route 23 North #100
Riverdale, New Jersey 07457
Radiology Associates of Ridgewood
20 Franklin Turnpike
Waldwick, New Jersey 07463
Surgicore Surgical Centers
4 locations in NJ
6 Chestnut Ridge Road
Montvale, New Jersey 07645
St. Barnabas Medical Center
94 Old Short Hills Road
Livingston, New Jersey 07039
223 North Van Dien Avenue
Ridgewood, New Jersey 07450
Please be advised that Progressive Spine makes no representations or assertions regarding whether these secondary health care providers participate in any health insurance plans nor whether these secondary health care providers accept certain kinds of health insurance. Furthermore, Progressive Spine makes no representations or assertions regarding accepted insurance and additional health care providers that may provide you services in conjuction with treatment rendered at any of the above listed health care providers. If you have further questions regarding a provider you have been referred to as a result of your care here at Progressive Spine, please contact the provider, or your health insurance provider/carrier directly for more information.
Please note that by signing this document, you acknowledge that you have reviewed this document and have received all of the required disclosures listed above and that you hereby waive any challenge to the notice requirements contained within P.L.2018, c.32, also known as "Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act".
I have read HIPAA and understand my rights contained in this notice.
By way of my signature, I provide Progressive Spine & Sports Medicine, LLC with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment, healthcare operations as outlined and described in the Privacy Notice.
Prescription Medication Agreement
This form is to help both you and your provider comply with the state and federal laws regarding controlled pharmaceuticals. Please read this form in its entirety.
I authorize my provider and my pharmacy to cooperate fully with any city, state, or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my medications. I authorize my provider to provide a copy of this agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations.
I agree to follow these guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me.
Urine Drug Screen
In an effort to continue to provide our patients with the highest quality care, Progressive Spine & Sports Medicine has instituted a universal urine drug screening policy. The purpose of providing this policy is to allow our patients to be fully informed about the reasons for and frequency of urine drug testing.
Urine toxicology, or urine drug screening, is universally recommended by the major American pain and addiction medicine societies to ensure compliance with prescribed pain treatment and to ensure the safety of patients.
Urine drug screening will be performed on ALL patients being prescribed opioid pain medications.
At a minimum, urine drug screening will be performed once every two months.
At Progressive Spine & Sports Medicine, we use "point of care" urine drug testing that provides accurate results immediately. To ensure the results we receive in the office are correct, each urine sample is also sent to a laboratory for more thorough testing.
Urine drug screening is performed to ensure that patients are both taking the medication that is being prescribed to them and not taking any non-prescribed prescription pain medications or illicit drugs that would interfere with their prescribed treatment and put them at risk for serious health consequences.
If any inconsistencies are found in office "point of care" urine drug testing, only 1 week of pain medication will be prescribed. This is to allow us to confirm the results with the laboratory run test and not subject patients to being without pain medication.
If the results of the laboratory testing confirm that a patient has been taking any non-prescribed prescription pain medications or illicit drugs, the patient is subject to any or all of the following:
If you have any questions regarding this policy, please do not hesitate to ask. By signing below, you are indicating that you have read and understand the policy.
Clinical Intake Form
Please list any surgical procedures you have had done in the past including complications and approximate dates:
Please list all current medications, including vitamins, below:
Please list all allergies and reactions including medications, food, environment, etc:
Review of Systems
Vein Screening Assessment
Please answer the following questions about how your legs and feet feel. Keep in mind how it affects your daily life.