received a copy of the Patients Rights Form and Notice of Privacy

Transcripción

1111 Paulison Ave • Clifton, New Jersey 07015 • (973) 253-2900
This is to acknowledge that I,______________________________, received a copy of
the Patients Rights Form and Notice of Privacy Practices from Medical Imaging
Center of North Jersey.
Esto debera reconocer que Yo, ________________________recibi una copia de los
Derechos de Paciente y la Nota de Practicas de Privacidad de Medical Imaging Center
of North Jersey.
_______________________________
Patient’s Name (Print)
(Nombre del Paciente )
___________________________________
Signature (Patient, Legal Guardian or Parent)
(Firma del Paciente/ o Tutor , Padre)
_________________
Date
(Fecha)
Please complete the following registration form and return it to the receptionist. Also please have your ID and insurance
card(s) ready so that we may take a copy for our records.
Porfavor complete el formulario siguiente de matricula y lo de vuelve al (a) recepcionista. Tambien tenga listo porfavor su tarjeta de
indentification y seguro para que le tomenos una copia para nuestro registros.
PATIENT INFORMATION -----PLEASE PRINT
(INFORMACION DEL PACIENTE) POR FAVOR ESCRIBA EN MOLDE
Name:Last:_________________________________________First:________________________________M.I.______
(Nombre) Apellido
Nombre
I.D.
Address:__________________________________________________________________________________________
(Direccion)
City:________________________________________________State________________Zip Code_________________
(Ciudad)
(Estado)
Social Security Number:________-________-________
(Numbero de Social Security)
(Codigo Postal)
Date of Birth______/______/______
(Fecha de Nacimiento)
Primay phone # (C) (H) (W)_____________________________________ Weight:____________ Age:____________
(Telefono primary)
(Peso )
( Edad)
Secondary Phone #(C)(H) (W)________________________________________________________________________
(Telefono Secundario)
Emergency Contact Name_____________________________________Phone#:_______________________________
(Nombre de Contacto de Emergencia)
(Telefono)
Sex: Male Female
Marital Status: Single Married Divorced Widowed Separated
(Sexo) Maculino/Femenino
Estado Marital
soltero/a
casado/a Divorciado/a
Viudo/a
Separado/a
Referring Dr.Name:__________________________________Ref Dr. Phone#_________________________________
(Nombre del Dr)
(#Telefono)
Have you ever been a patient in this facility?______No_____Yes, If yesWhen?______Same Ins/or Accident _______
(Usted hacido paciente de esta Clinica)
_____No_____Si , Si es Si
Cuando?
(Mismo seguro/Mismo Accidente)
IF RELATED TO AN ACCIDENT ……………Please (Circle one)
(Circule one)
(ES RELACIONADO CON UN ACCIDENTE)
MVA
Accidente de carro
Worker’s Comp
Accidente de Trabajo
Slip & Fall
Resbalo & Caida
Date of Accident:_________________
Fechad del Accidente
Primary Insurance Information:
(If is related to an accident write down the primary Insurance that is covering for the accident )
(Informacion del Seguro Primario): (Si es relacionado a un accidente escriba el seguro primario que esta cubriendo el accidente)
Insurance Carrier Name:____________________________________________________________________________
(Nombre del Seguro)
Insured’s Name:___________________________Insured’s Address_________________________________________
(Nombre del Asegurado)
(Direccion del Asegurado)
Telephone #:_____________________________________ Insured’s D.O.B.___________________________________
(# Telefono)
(Fecha de Nacimiento del Asegurado)
Policy #, ID, Claim ______________________________Group #_______________Insured’s SS#_________________
(# Polisa,# indeficacion, # reclamo)
(#Grupo)
(# SS del Asegurado)
Patient’s Relationship to insured: (Circle one): Self Spouse Child Other:________________________________
(Relacion del paciente con el asegurado) (Circule uno) Mismo Esposos Hijo(a) Otro:
Insured’s Employer (Empleador del Asegurado)_________________________________________________________________
Attorney’s Name,AddressPhoneFax#:_________________________________________________________________
(Nombre del Abogado, Direccion, # Telefono y Fax)__________________________________________________________________
__________________________________________________________________________________________
Secondary Ins.(Seguro secundario)
Please indicate your health/Car insurance carrier:
(Porfavor indique su seguro Medico/Carro):
Secondary Insurance Carrier______________________________________________________________________
(Nombre de Seguro)
Policy # or ID______________________________________ ______________Group #________________________
(#Poliza o/y Indentificacion)
(Grupo)
Name of Subscriber_______________________________________________________________________________
(Nombre del Suscriptor)
Subscriber Date of Birth:__________/___________/__________ Relationship to Subscriber_____________________________
(Fecha de Nacimiento del Suscritor)
(Relacion con el Suscriptor)
Subscriber SS#_____________-_______________-________
(# SS del Suscriptor)
Subscriber Employer Name(Empleador del Suscriptor):______________________________________________________________
Address (Direccion):_________________________________________________________________________________________
City (Ciudad)__________________________________________State(Estado)________Zipcode(codigo postal)________________
Telephone #( # de Telefono)(___________)_______________________________________________________________________
Please initial ONE. (Porfavor inicie UNO) ONLY 2ND INSURANCE
(SOLO SEGURO 2do)
________I have provided my health insurance card to the front desk as 2nd insurance.
(Yo he proveido mi seguro medico como seguro 2do )
________I have not provided my health insurance card to the front desk to be used as 2nd
Insurance (Yo no he proveido mi seguro para ser usado como seguro 2do)
________I do not have health insurance/ I do not have 2nd insurance .
(No tengo seguro medico/No tengo seguro medico como 2do)
I hereby authorize any Medicare and/or other Insurance benefits for services furnished be paid directly to Medical Imaging Center of North Jersey. I consent
to treatment necessary for the care of the above named patient. I authorize the release of my medical records to my referring and family physicians and to my
insurance company, if applicable. I allow fax transmittal of my medical records, if necessary. I acknowledge full financial responsibility for services rendered
by Medical Imaging Center of North Jersey and authorize transfer of all unpaid amounts to my Visa, Master Card, or America Express accounts(s) after 120
days from the date of service. I understand that payment of charges incurred is due at the time of service unless other definite financial arrangements have
been made prior to treatment, I agree to pay all reasonable attorney fees and collection costs in the event of default of payment of my charges. I further
authorize and request that insurance payments be made to Medical Imaging Center of North Jersey should they elect to receive such payment. I have read
and fully understand the above consent for treatment, financial responsibility, release of medical information and insurance.
Yo por lo presente autorizo a Medicare y/u otro benficios de Seguro para los servicios que se realizen y que sean pagados directamente a Medical Imaging Center of
North Jersey. Yo doy consentimiento para dar tratamiento necesario para el cuidado del paciente mencionado arriva. Yo autorizo la liberacion de mis registros
medicos a mi(s) Medico(s) (Familiar o El Dr que me refirio) y/o ala compañia de seguros ( si es aplicable). Yo permito la transmicion de fax de mis registros medicos,
si es necesario reconozco completa responsabilidad financiera por los servicios rendidos por Medical Imaging Center Of North Jersey. Y autorizo la tranferencias de
todas la cantidandes sin pagar a mi(s) cuenta(s) de Visa, Master Card y/o American Express despues de 120 dias de la fecha de el servicio. Yo entiendo que esos
cargos de pagos contrajo debido en el tiempo de el servicio a menos que otros areglos financieros definidos hubieran hecho antes del tratamiento(s). Yo concuerdo en
pagar todos los honorarios razonables de (el/los) abogado(s) y costos de coleccion en caso de el defecto de el pago de mis cargos. Yo autorizo a un mas y solicito que
esos pagos del seguro sean hechos a Medical Imaging Center of North Jersey, ellos deben selecionar tales pagos. Y he leido y he entiendo completamente el
consentimiento nombrados arriva para el tratamiento, responsabilidadez financieras y la liberacion de informacion, medica y/o seguros.
______________________________________
Patient’s Name (Print)
(Nombre del Paciente)
________________________________________
Signature (Patient, Parent or Legal Guardian)
Firma del Paciente o/Padre/Tutor)
______/_______/______
Date(Fecha)
PATIENT HISTORY QUESTIONNAIRE
Last Name________________________________First Name_______________________Date___/____/____
(Apellido)
(Nombre)
(Fecha)
Date of Birth____________________________Age:________Weight__________Sex_____Male____Female
(Fecha de Nacimiento)
Edad
Peso
Sexo
Masculino/Femenino
Please answer the questions to the best of your ability. If any questions are left unanswered, please review them
with the Technologist. Thank you. Porfavor responda las preguntas a su mejor capacidad. Si cualquier pregunta es dejada sin
contestar, por favor revisarlas con el Tecnólogo. Gracias.
Reason for Procedure (Razon por Procedimiento):
Please check any of the following symptoms that you are experiencing:
(Por favor indique los siguientes simptomas que usted padece/presenta)
Headache
Abdominal pain Blurred Vision Dizziness Chest Pain Nausea
Dolor de cabeza Dolor Abdominal
Vision Borrosa
Mareos
Dolor de Pecho Nausias
Ringing in Ear Pelvic Pain Memory loss Unexpected Weight Loss Seizures
Zumbidos
Dolor pelvico
Perdida de la memoria Perdida de peso
Hearing Loss
Perdida de la audicion
Back
Neck
Combulsiones Dolor de espalda Cuello
Lower back Numbness Weakness Shoulder (Right Left) Leg(Right Left) Arm(Right Left)
Cadera
Entumecimiento
Debilidad
Hombros Derecho/Iquierdo
Pierna Derecha/Izquierda Brazo Derecho/Izquierdo
Lump or Mass (Massa/Amontones)(Location)___________________________________________________
Other___________________________________________________________________________________
How long have you had these symptoms?_______________________________________________________
¿Cuánto tiempo ha tenido usted estos síntomas?
Is this related to a Motor Vehicle Accident?
Yes
¿Esta relacionado a un Accidente de Automóvil?
Si
Is this related to a Worker’s Comp Accident? Yes
¿Es relacionado Accidente del Trabajo?
Si
No
No
No
No
Is this related to “other accident”? Explain:___________________________________________________
¿Esta relacionado con "otro accidente"? Explique
Have you ever had any surgeries on the part being examined today?____Yes____No
If yes,please describe_______________________________________________________________________
¿Alguna vez ha tenido una cirugía en la parte que se le examinara hoy?
Si es, haci porfavor describa
Si
No
Have you ever (past/present) been diagnosed with having Cancer?______Yes______No
Location in your body ________________________________________________________________________
¿Alguna vez (pasado/presente) fue diagnosticado con tener Cáncer?
Si
No
Have you had Radiation Therapy or Chemotherapy?_____Yes______No
¿Ha tenido usted Terapia Radiactiva y/o Quimioterapia?
Have you ever been screened for the Tuberculosis?___Yes____No (____Positive____Negative)
If POSITIVE, are you/were on any medication?, If Yes, which one:________________________________
¿Alguna vez le han echo el examen cutaneo de Tuberculosis?___Si___No (____Positivo____Negativo)
Si POSITIVO usted toma/tomo algun medicamento?, Si es haci, Cual:
Do you have any allergies (medication,latex,food, ect)______Yes____No If yes,please list all
allergies____________________________________________________________________________
Usted padese de allergias(medicamentos, latex, comida ect)______Si_____No. Porfavor nombre todas
Are you pregnant or experiencing a late menstral period?___Yes___No
(Usted esta embarazada o tiene retraso en su period menstrual)
Si
No
MRI PATIENT SCREENING QUESTIONNAIRE
(MRI CUESTIONARIO del PACIENTE)
PATIENT INFORMATION
Name: _________________________________________Date: _____/_____/_____ Weight: ___________
(Nombre del Paciente )
(Fecha)
(Peso)
Referring Physician:____________________________________ Allergies (Alergias)_________________________
(El Medico que lo refirio) Are you Claustrophobic? Yes No (Es usted Claustrofobica/o) Si
No
The following items may interfere with MRI and some can be potentially hazardous.
(Los siguientes articulos pueden intervenir con el MRI y algunos pueden ser potencialmente peligrosos.)
Do you have any of the following? If yes, please explain.__________________________________________
(Tiene usted cualquiera de los siguiente? Si sí, explique por favor)
Si NO
Y N Brain surgery/Aneurysm clips (Cirugia de el cerebro/Clips de aneurisma)
Y N Cardiac pacemaker (Marcapaso cardiaco)
Y N Heart surgery/Heart valve (Valvula de cirugia cardiaca)
Y N Shunts/Stents/Intravascular coil (Derivaciones/stents/rollo de intravascular)
Y N Eye surgery/Implants (Cirugía/Implantes de ojos)
Y N Injury to eyes involving metal at anytime (Herida a los ojos que haya inplicado metal)
Y N Penile prosthesis (prótesis del pene)
Y N Orthopedic pins, screws, rods, plates, etc. (Alfileres,Tornillos,Barras, y/o Placas Ortopedicas, etc)
Y N Neurostimulator/Biostimulator/TENS-Unit (Neurostimulador/Biostimulator/Estimulcion Nerviosa Electrica Transcutanea)
Y N Tattoos/Tattooed eyeliner (Tatuajes/ Tatuaje deperfilador de ojos)
Y N Ear surgery/Cochlear implants/Hearing aids(Cirugia de los oidos/implantes de la coclea y/microfono auditivo)
Y N Vascular access port (Puerto o catéteres de acceso vascular)
Y N Diaphragm/IUD/Pessary (Diafragma/DIU/presario)
Y N Metal mesh implants/Wire sutures/Wire staples/Internal electrodes
(Suturas/alambre metálico/ alambre de malla/ electrodos internos/rapas)
Y N Electrical, mechanical or magnetic implants; Type:________________________________
(Implantes electricos, mecanicos y/o magneticos:)Que tipo
Y N Implanted drug infusion pump/Insulin pump (Un pompa de insulina y/o para farmacos)
Y N Implanted cardiac defibrillator (Implante de Desfibriladro cardiaco)
Y N Pacing wires, Swan-Ganz Catheter (Alambres, Cateter de Swan-Ganz)
Y N Do you know/suspect that you’re pregnant? (Usted sabe/suspecha que esta embarazada?)
Y N Metal fragments,Shrapnel/Bullets,BB Pellets (Fragmentos metalicos, perdigones, balas)
Y N Body piercing (Perforaciones con aritos, aretes ect)
Y N Dentures/Braces/Partial plate (Dentaduras, postizas/Braques/Puentes dentales )
Y N Are you pregnant or experiencing a late menstral period?
(Usted esta embarazada o tiene retraso en su period menstrual)
Y N Have you had surgery in the past six weeks? Type:__________________________________
(Ha tenido usted una cirugia en las ultimas seis semanas?)Que tipo
Y N Have you had prior diagnostic{MRI,Xrays,Ultra Sound, CT ect} studies to this area?
Type:___________________________________________
(Ha tenido usted estudios de diagnósticos previos en esta área?) Que tipo:
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Have you ever worked with cutting or grinding metal?__ _____________________________________
(Ha trabajado usted alguna vez cortando or moliendo metal?)
If yes, have you worn protective eye wear at all times? ______________________________________
(Si es, haci ha llevado usted siempre el uso de protector de ojos)
Is there any chance you could have gotten metal in your eye? ________________________________
(Hay posibilidad que ha usted se le halla podido meter metal en los ojos?
If yes, have you had an MRI or X-Ray of the orbits since then?_____Where_________________________
(Si es, el case ha tenido un MRI o Rayos X de las orbitas (ojos) desde entoces?) Donde?
A typical MRI exam is painless and could last up to one hour. The technologist will assist you into the correct
position on the MRI table and help make you comfortable during the procedure. It is extremely important to lie
very still during the exam as motion can obstruct image quality. You will hear a knocking sound when the scanner
is acquiring images.
( Un examen típico de MRI es sin dolor y podría durar hasta una hora. El tecnólogo le ayudará en la posición correcta en la mesa de
MRI y le ayudará a hacerle cómodo durante el procedimiento. Es muy importante no moverse por que el movimiento puede obstruir
la calidad de las imagenes. Usted oirá un sonido que golpea cuando el escáner adquiere las imágenes.)
I attest the information on this form is correct to the best of my knowledge. I have read and understand the
contents of this form and had the opportunity to ask questions regarding the information on this form and
regarding the MRI procedure.
Doy fe de que, a mi leal saber y entender, la información que consta en este formulario es correcta. He leído y entiendo los contenidos
de este formulario y tuve la oportunidad de hacer preguntas con relación a la información de este formulario y al procedimiento de
MRI.
_____________________________________________
Patient’s Name
Date________/________/________
(Nombre del Paciente)
(Fecha)
____________________________________________________
Signature of Patient or/Parent/Legal Guardian
(Firma del Paciente, Padre/Madre, Tutor)
_____________________________
Witness or Interpreter Signature
_______________________________
Technologist’s Signature
In consideration of professional medical services rendered by _________________(herein After “my medical
provider”)I,________________________________,hereby irrevocably:
1.
Assign any and all my legal rights with respect to collection of health or medical benefits including NoFault/Personal injury Protection (hereinafter “PIP). Afforded by ___________Insurance Company, under
policy______________regarding my health care problem or injury arising out of my automobile accident of
_____________town or city, County of __________________claim#__________________ including but not
limited to the right to file an action to compel the payment of benefits, including an arbitration before the
American Arbitration Association to collect PIP benefits, so that said medical care provider may collect money
due and owing for medical services rendered.
2.
Authorize my medical care provider to act as my agent with respect to the collection of insurance benefits,
including PIP benefits in the case of any dispute with respect to the payment of benefits. I irrevocably
authorize my medical care provider to retain an attorney to represent me, and I authorize that attorney to file
an arbitration or lawsuit in my name and on my behalf against my automobile insurance to compel my
automobile insurer to pay insurance benefits, including PIP Benefits, to my care provider.
3.
Authorize the above-mentioned care provider, and/or his assigns to obtain medical information regarding my
physical condition, from any doctor, hospital or other health care provider. I authorize my medical care
provider to release any and all information received, including medical reports, x-rays reports or narrative
reports, and to furnish any medical records or opinions requested by any insurer regarding my physical
condition and treatment rendered.
4.
Authorize and request my insurance company to pay and all medical benefits to which I may be entitled
directly to the above-named medical provider.
5.
Agree to cooperate with my medical care provider and my insurer with respect to any claim, including but not
limited to, attending request physical examination (s), any request statement under oath and completing all
necessary paperwork.
6.
I acknowledge that I am personally, financially responsible for my medical services I receive, including any
deductible, co-payment, and out of network co-payments, and any portion of my bill not paid by the above
mentioned automobile or other insurance company(ies), I shall pay all attorney fee and cost incurred by my
medical provider in the event that my medical bills are unpaid for more than sixty (60) days if my medical care
provider institutes any civil collection proceeding against me. I shall also pay 35% percent interests on all
outstanding balances more than sixty (60) days overdue
7.We agree to submit any insurance that may provide coverage for your treatment. We make no guarantee that the
insurance submitted shall pay for the services and do not agree that we shall accept whatever the insurance
may pay as full payment for the services we have rendered. The patient is responsible for obtaining any
required insurance pre-authorization. We cannot and do not waive any right to seek payment of the patient’s
co-pay and deductible amounts and the patient remains fully responsible for any balance remaining after all
insurance proceeds have been received unless our provider agreement with your insurance company requires
us to waive any balance. Reasonable collection and or attorney’s fees, including filing and service fees shall be
assessed if the amount is sent to the collection, but said fees shall not exceed those permitted by state law.
8.Patient Agrees and understands that if there is no insurance coverage or if insurance does not pay for any reason,
the patient is personally financially responsible for the entire bill plus all collection costs
_______________________________________
Signature of the patient/Parent/Legal guardian
_____________________
Parent/Legal Guardian SS#
______________________________
Patient’s Name (PRINT)
______________________
Date
Patient Financial Policy
Thank you for choosing the Medical Imaging Center of North Jersey (“MICO”) for you
diagnostic imaging services. We are committed to providing the highest quality images from the most
advanced Open MRI technology available. You are required to read and sign the following office
financial policy prior to the commencement of any testing.
You hereby authorize insurance payment(s) directly to MICO. Should payment be sent to you it
is your responsibility to return the check(s) to MICO within seven (7) days of receipt. Failure to do will
result in civil collection proceedings wherein you agree to pay our reasonable attorney’s fees and costs for
collection.
Your insurance plan is an agreement between you and your insurance carrier. We are not party to
that contract. You are responsible to know your policy or the terms under the policy of insurance you are
claiming benefits. Please be aware that some and perhaps all services which we provide may be
considered uncovered and therefore considered not medically necessary. Your balance will become your
responsibility if denied by your carrier for any reason. You reserve the right to appeal the reimbursement
for services or lack of with your carrier pursuant to the applicable insurance contract.
An individual seeking benefits from an insurance carrier has an obligation to comply with terms
and conditions of the insurance contract and cooperate with the terms and conditions of the insurance
contract and cooperate with the insurer including but not limited to attending a physical examination
submitting to an examination under oath and furnishing medical records upon request. You must appear
at these examinations. If the insurance carrier denies payment or disclaims coverage due to your failure to
cooperate you are personally responsible for your imaging charges. This will not be covered by any
insurance company.
In addition payment denied based on your failure, refusal or neglect to comply with your treating
provider’s treatment plan will result in your responsibility to pay for our services.
THIS FINANCIAL AGREEMENT IS A VALID CONTRACT BETWEEN THE PATIENT AND MICO.
I CERTIFY THAT I HAVE READ THE ABOVE INFORMATION OR THAT THE INFORMATION
HAD BEEN READ OR TRANSLATED TO ME AND THAT I UNDERSTAND MY RIGHTS AND
OBLIGATIONS AS A PATIENT UNDER THIS AGREEMENT.
________________________________
Patient Name (Printed)
__________________
Witness
_________________________________
Signature
___________________
Date
Date: _________________
To: Attorney/Insurance Company:
____________________________
____________________________
LETTER OF PROTECTION
I do hereby authorize the above facility to furnish you, my attorney/insurance carrier, with a full report of my
examination and diagnosis of myself in regard to my accident/illness which occurred/began on the day of
____________ (date).
I hereby give a lien to this facility on any settlement, claim, judgment or verdict as a result of my accident /illness.
I authorize and direct you, my attorney/insurance carrier, to pay directly to said facility such sums as may be due
and owing them for services rendered to me, and withhold such sums from such
settlement/claim/judgment/verdict as may be necessary to protect said facility adequately. I direct that full
payment of the facilities bill shall be paid.
I fully understand that I am directly and full responsible to this facility for all medical bills submitted by them for
service rendered to me and that this agreement is made solely for this facility’s additional protection and in
consideration of their awaiting payment. I further understand that such payment is not contingent on any
settlement, claim, judgment or verdict by which I may eventually recover said fee.
I agree to promptly notify said diagnostic facility of any change or addition of attorney(s) used by me in connection
with this accident. I instruct my attorney and all superseding attorneys to do the same and to promptly deliver a
copy of this lien to any such substituted or added attorney(s).
______ (initials) I understand that I need to provide my healthcare insurance card as a primary
or secondary means of payment. I may be liable for all co-pays/deductibles/penalties or
possibly the entire amount due.
I hereby authorize my attorney to forward this LOP to this facility for any unpaid bills that I
incur.
Please acknowledge this letter by signing below and returning to the diagnostic facility. I have been advised that
if my attorney does not wish to cooperate in protecting the diagnostic facility’s interest, the diagnostic facility will
not await payment but may declare the entire balance due and payable and/or may refuse to perform services.
Patient’s Name: ________________________________________________
Patient’s Signature: ______________________________________________ Date:______________________
The undersigned, being the attorney of record or authorized representative for the above named patient, hereby
agrees to observe all the terms above and agrees to withhold such sums from any settlement, judgment or verdict
as may be necessary to adequately protect and fully compensate the facility named above. Attorney further
agrees that in the event this lien is litigation that the prevailing part will be awarded attorney fees and costs.
Attorney is required to advise if there are any changes in insurance or case status. We are also to be notified if
your firm discontinues to represent the above named client for any reason. Attorney shall provide a fully executed
settlement statement/copy of release/copy of settlement check at time of disbursement. Attorney further agrees to
provide status updates every three months and upon receipt of settlement, make payment to this facility within 10
business days.
Attorney/Representative’s Name: _________________________________________
Attorney Signature: __________________________________________Date:
____________________
New Jersey Property-Liability Insurance Guaranty Association
233 Mt. Airy Road
Basking Ridge, NJ 07920
Statutory
Administrator of the Unsatisfied
Claim As
Number:
_______________________
Tel: 908-382-7100
Claim and Judgment Fund (“UCJF”)
AFFIDAVIT IN SUPPORT OF UCJF ELIGIBILITY
I, ___________________________ being of full age, being duly sworn according to law, on my oath state the following:
(Print Name)
I understand that all sections of this Affidavit
must be completed in full by me and signed
by me, the applicant. I will answer “None” or
“Not Applicable” where appropriate and will
not leave any answers blank. I understand
that all requested documents must be
submitted with or attached to this document.
1.
I understand that if I knowingly file a
statement of claim containing any false,
inaccurate or misleading information, or
intentionally omit information material to the
claim; doing so will result in the denial of
benefits and may subject me to criminal
and/or civil penalties.
Claimant Name: _________________________________ Date of Birth: ___________________ Gender: ☐ M
☐F
Month / Day / Year
2.
I have also used the following names:
________________________________________________________________.
List any names you have used including aliases, maiden names, and any other name variations
3.
The date of the accident for which this claim is filed was:
_____________________/_____/______________________.
Month / Day / Year
4.
The accident location was: ________________________________________________, ________________,
_______.
(Street Address / Intersection)
(City)
(State)
5.
On the date of the accident, I lived at: ____________________________________, _________,
_________________,
(Street address - No P.O. Boxes)
_____________, ___________.
_____________________.
(State)
(Zip Code)
(Apt. #)
(City)
I lived at this location from ______________________ to
Month / Day / Year
Month / Day / Year
If you lived at the above address for less than 3 years or if you currently live at another address attach an additional sheet of
paper listing all other addresses at which you lived during the past three years and the dates (from/to) you lived there.
6.
I have a Social Security Number (“SSN”): ☐ No ☐ Yes
o If you answered “yes” please provide your SSN __________-_______-______________
(-or- attach a copy of your card)
7.
I have an Individual Taxpayer Identification Number (“ITIN”) instead of a Social Security Number: ☐ No ☐ Yes
o If you answered “yes” please provide your ITIN __________-_______-______________
I am a Medicare beneficiary: ☐ No ☐ Yes
o If yes, please provide your Health Insurance Claim Number (“HICN”):
___________________________________
8.
9.
I have or had a Driver’s License issued to me in a U.S. State or U.S. Territory: ☐ No ☐ Yes
o If yes, attach a legible photocopy of your driver’s license if you are currently licensed - and-
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233 Mt. Airy Road
Statutory
Claim As
Number:
_______________________
Tel: 908-382-7100
o
List all other location(s) where you were licensed and provide driver’s license number(s) where possible.
__________________________________________________________________________________________
__________________________________________________________________________________________
____
If you need more space attach an additional sheet listing your driver’s license history
10.
I was covered under health/medical insurance on the date of accident: ☐ No
o If “yes” list: the Insurance Company:
Policy Holder’s Name:
☐ Yes
Policy Number:
-or- attach a copy of the front & back of your health/medical insurance card(s)
11.
Other people lived with me on the date of accident: ☐ No ☐ Yes
o If you answered “yes” list everyone that lived with you on the date of the accident:
First Name:
Middle Name:
Last Name:
Date of Birth:
Relationship to You:
If you need more space attach an additional sheet of paper listing your household member information
12.
Regarding the ownership of motor vehicles, including passenger cars, pickup trucks, sport utility vehicles and vans:
o
o
o
I was the owner of a motor vehicle on the date of the accident ☐ No ☐ Yes
I leased a motor vehicle on the date of the accident ☐ No ☐ Yes
I had a motor vehicle titled or registered in my name on the date of the accident
o
o
o
Someone that lived with me was the owner of a motor vehicle ☐ No ☐ Yes
Someone that lived with me leased a motor vehicle ☐ No ☐ Yes
Someone that lived with me had a motor vehicle titled or registered in their name ☐ No ☐ Yes
☐ No
☐ Yes
For each motor vehicle identified in the answers to question 12, provide to the best of your ability, the following -or– attach copies of the registration(s)
and either the insurance card(s) or declaration page(s) of the insurance policies covering the vehicles on the accident date
Owner:
Year:
Make:
Model: License Plate#:
VIN#:
Insurer:
Policy#:
If you need more space attach an additional sheet listing the vehicle information identified in question 12
Claimant must sign this Affidavit. The Affidavit must be notarized. Read carefully before signing.
By signing this Affidavit, I declare and confirm that:

All statements contained in this Affidavit and all documents provided are true and complete to the best of my knowledge.

I understand that the requirements of all applicable statutes, rules, regulations and the Association’s Decision Point Review
Plan must be met before my eligibility for statutory benefits pursuant to N.J.S.A. 39:6-61 et seq. can be established.

I am aware that if I knowingly file a statement of claim containing any false, inaccurate, misleading, or intentionally omitted
information material to the claim that my claim will be denied. Any person who knowingly files a statement of claim
containing any false or misleading information is subject to criminal and civil penalties.
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233 Mt. Airy Road
Statutory
Claim As
Number:
_______________________
Tel: 908-382-7100
DISCLAIMER: I permit the Association to disclose information about my claim to third parties to the extent the Association needs
to do so in order to determine my eligibility for statutory benefits, in connection with any legal proceedings or prospective legal
proceedings, in order to establish, exercise or defend its legal rights, for the purpose of fraud detection and prevention or as
required and permitted to do so by law.
Sworn to and subscribed before me this
_____day of _______________, 20_____.
____________________________________________________
CLAIMANT SIGNATURE:
_________________________________
NOTARY SIGNATURE
____________________________________________________
CLAIMANT NAME (Please Print)
_
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Dear:_____________________________
I hereby retain you on my behalf to pursue any rights I may have against my insurance company,
___________________________, for treatment rendered by ________________________in connection
Name of Insurance Company
Name of Provider
with injuries sustained in a motor vehicle accident date______________________.
Date of Accident
This is to further confirm that any claim will be filed with the National Arbitration Forum and the
application will include not only the request for payment of the medical provider’s bill but your attorney
fee and cost.
______________________________
Client’s Signature
______________________________
Client’s Name
_________________
Date
New Jersey Application for Benefits
Personal Injury Protection
Important:
Claim Number: _________________
1. To enable us to determine if you are entitled to benefits under the
Personal Injury Protection Law you must complete and sign this form.
2. You must also sign the authorizations, Affidavit and Notice attached.
3. Return promptly with any medical bills you have received to date.
Please be advised that knowingly filing a statement of claim containing any false, inaccurate or misleading information, or intentionally omitting
information material to the claim will result in the denial of benefits. Any person who knowingly files a statement of claim containing any false or
misleading information is subject to criminal and civil penalties.
Your Name (First, Middle, Last)
Gender: Male 
Female 
List any aliases, maiden names or other names you use or have used in the past
Cell Phone:
(
)
Date of Birth
Your Previous Address (If you lived at the above address for less than 3 years from the accident date)
Email:
Time of Accident
AM 
Work Phone:
(
)
-
-
Your Address (No. & Street, City/Municipality, State, County & Zip Code
Date of Accident
Home Phone:
(
)
-
Social Security No. (if none, enter “none”)
Place of Accident (Street, City/Town & State)
PM 
Brief Description of Accident
Do you or any member of your household own a vehicle? Yes 
No 
Name of Insurance Company _________________________________________
Do you have health insurance? Yes 
No 
Name of Insurance Company _________________________________________
As a result of this accident were you injured?
If “No”, sign here and return this form to us.
Yes 
Were you the driver of the vehicle?
Were you a passenger in the vehicle?
Were you a pedestrian?
Were you a member of vehicle owner’s household?
No




No  If your answer is “Yes”, complete the remainder of this form.
Signature:
Describe your injury:
Were you treated by a doctor?
Yes




Date:
Yes 
No 
If you were treated in a hospital, were you an
In-patient? 
Out-patient? 
Amount of Medical Will you have more
Bills to Date:
medical expenses?
$______________ Yes 
No 
Doctor’s Name and Address
Hospital’s Name and Address
At the time of your accident, were you in the
course of your employment? Yes  No 
Did you lose wages or salary as a
result of your injury? Yes 
No 
If yes, amount loss to date: $__________
What is your average weekly
wage or salary?
$____________
Your lost wages: Date disability from work began:
Date you returned to work:
Have you received or are you eligible for benefits under:
Yes
No
If yes, amount: $____________ Per week 
Per month 
(1) Any Workers’ Compensation Law?


(2) Employees’ Temporary Disability Benefit Statute?


If you are a Medicare beneficiary, enter your Health Insurance Claim Number
(HICN) ______________________________
(3) Medicare?


List names and addresses of your employer and other employers for one year prior to accident date and give occupation and dates of employment:
Employer & Address
Occupation
Dates: From - To
As a result of your injury, have you had any other expenses?
Yes 
No 
If your answer is “Yes”, explain on reverse side.
Signature:
_
Date:
Do Not Detach
Authorization for Medical Information
This authorization or photocopy hereof, will authorize you to furnish all information you may have regarding my condition while under your observation or treatment,
including the history obtained, X-ray and/or physical findings, diagnosis and prognosis related to this accident as well as any prior or subsequent treatment rendered
by you or your facility. You are authorized to provide this information in accordance with the Personal Injury Protection Benefits Law.
Signature: ________________________________________________________________________________________ Date: _______________________
Do Not Detach
Authorization for Wage Information
This authorization or photocopy hereof, will authorize you to furnish all information you may have regarding my wage or salary while employed by you. You are
authorized to provide this information in accordance with the Personal Injury Protection Benefits Law.
Signature: _________________________________________________________________________________________
Social Security No.: ______________________________
Date: ______________________
X-RAY PREGNACY RELEASE FORM
(FORMULARIO DE EMPRAZO PARA RAYOS-X)
I, ____________________________________________in singing this form, states to the bes
of my knowledge there is NO pregnancy, confirmed or suspected at this time.
Yo, __________________________________________al firmar este formulario, testifico segun
a mi major conocimiento y entiendo que NO estoy embarazada o supecho estar embarazada en
este momento.
_______________________________________
Patient’s, Parent,/Legal Guardian Signature
(Firma de Paciente, Padre/Tutor)
______________________________________
Patient’s Name (PRINT)
Nombre del el Paciente(ESCRIBA EN MOLDE)
____/____/_____
Date
Fecha

received a copy of the Patients Rights Form and Notice of Privacy

Transcripción

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