New Patient Enrollment Form

Name*

First Name Last Name
Date of Birth*

Month Day Year
Gender*
Race
Age
Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Home Phone Number*
Cell Phone Number
Please enter a valid phone number.
Social Security Number
E-mail*

Confirmation Email example@example.com
Marital Status
Preferred Language
How were you referred to this office?

DoctorPatientFriendInternetOther
Name of referring physician, if applicable:
In Case of Emergency
Emergency Contact:

First Name Last Name
Relationship
Contact Number
Primary Care Physician
Primary Care Physician Phone Number
Please enter a valid phone number.
Pharmacy Name*
Pharmacy Address*
Pharmacy Phone Number*
Please enter a valid phone number.
HEALTH INSURANCE INFORMATION (PLEASE FILL OUT IF APPLICABLE)
Name of Insured

First Name Last Name
Insured's Date of Birth

Month Day Year
Primary Insurance Name
Member ID
Secondary Insurance Name
Member ID
Relationship to Insured
EMPLOYER INFORMATION
Name
Occupation
Address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
AUTO ACCIDENT OR WORK RELATED INURY (PLEASE FILL OUT IF APPLICABLE)
Insurance Carrier (Auto or Employer)
Policy Number
Claim Number
Date of Injury

Month Day Year
Adjuster's Name
Adjuster's Phone Number
Please enter a valid phone number.
Attorney's Name
Attorney's Phone Number
Please enter a valid phone number.
Signature*

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Surgical Centers

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.
Signature*

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Affiliated Providers

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:

Affinity Radiology

155 State Street

Hackensack, New Jersey 07601

(201) 968-5544

Progressive Diagnostic Imaging

44 Route 23 North #100

Riverdale, New Jersey 07457

(973) 839-5004

Radiology Associates of Ridgewood

20 Franklin Turnpike

Waldwick, New Jersey 07463

(201) 445-8822

Surgicore Surgical Centers

4 locations in NJ

www.surgicoreasc.com

Meta Surgical Center

6 Chestnut Ridge Road

Montvale, New Jersey 07645

(201) 484-8222

St. Barnabas Medical Center

94 Old Short Hills Road

Livingston, New Jersey 07039

(973) 322-5000

Valley Hospital

223 North Van Dien Avenue

Ridgewood, New Jersey 07450

(201) 447-8000

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".

Signature*

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Privacy Policy

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.
This notice is effective as of: (Today's Date)*

Month Day Year
Signature*

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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.
Patient Name*

First Name Last Name
Patient DOB*

Month Day Year
The purpose of this agreement is to prevent misunderstandings about certain medicines that you will be taking for:*

Pain ManagementOther
- I understand that this agreement is essential to maintain the trust and confidence necessary for a successful provider/patient relationship.
- I understand that if I deviate from the terms of this agreement, my provider will stop prescribing medications for me. However, if appropriate, I understand that he/she will taper the medication and that a drug dependence treatment program may be recommended. My provider may refer me to another physician in order to continue care.
- I will communicate fully with my provider about the character and intensity of my symptoms, the effect of them on my daily life, and how well the medication is helping to relieve them.
- I will use my medication as prescribed and not adjust the dosage on my own.
- I will not use illegal controlled substances, including marijuana, cocaine, etc.
- I will not share, sell, or trade my medication with anyone and understand that this is illegal.
- I will not attempt to obtain any controlled medications, including opioid pain medications or controlled stimulants from any other provider.
- I understand that it is a felony to obtain these types of medications by fraudulent means.
- I will safeguard my medications from loss and theft. I understand that lost or stolen medications will not be replaced. I should notify the police if my medications are stolen.
- I agree that refills of my prescriptions will be made only at the time of an office visit with my provider during regular office hours. No refills will be made available during off-hours.
- I agree to submit to urine drug tests if requested by my provider to determine my compliance with my medication program.
- I will bring all unused medications to office visits at the request of my provider.
I agree to use the following pharmacy for filling prescriptions for the medications addressed in this agreement:*
Pharmacy Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
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.
This agreement is valid as of today's date:*

Month Day Year
Signature*

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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:
- Referral to a pain psychologist to determine the appropriateness of continued treatment with opioid pain medication
- No longer being prescribed opioid pain medication
- Discharge from the practice
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.
Signature*

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	Alive (Age)	Deceased (Age)	Cause of Death	Health Issues
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