New Patient Health History Form

Personal Information

Health Insurance Information

Please tell us the reason for your visit.

Your History – Please indicate below what conditions you have had both in the pastand present:

For Females Only:

Medications – Please list all prescriptionsyou are currently taking below:

Please List all medications you are allergic to: 

HIPPA FORM

We are required by State and Federal Law to maintain the privacy of your patient file and the protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.

We reserve the rights to alter or amend the terms of this privacy notice. IF changes are made to our privacy notice we will notify you, in writing, as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.

If you have a complaint regarding our privacy notice, our privacy practices, or any aspect of our privacy activities, you should direct your complaint to: 

Dr. Luis Mizraji. Privacy Officer
If you would like further information about our privacy policies and practices, please contact:

Dr. Luis Mizraji. Privacy Officer
You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you lodge a complaint with this office or with the Secretary, your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.

This notice is effective as of the date of execution listed below. This notice, and any alterations or amendments made here to will expire seven years after the date upon which the record was created. My signature acknowledges that I have read through this document and that upon my request I have received a copy of this notice for my personal records.

If you are a minor, your parent or guardian must sign or in the event of other representation issues, please have the following executed by the appropriate representing party.

FAMILY CHIROPRACTORS OF MONTCLAIR

MISSED APPOINTMENT AND CANCELLATION POLICY

Family Chiropractors of Montclair are committed to providing exceptional care.

Unfortunately, when one patient cancels without giving enough notice they prevent another patient from being seen. 

If you miss or cancel an appointment without 12 hour notice (excluding emergencies involving medical, urgent care, or bereavement) you will be charged a $25.00 fee.

Please call us at (973)783-5666 12 hours prior to your scheduled appointment to notify us of any changes or cancellations.

To help insure you don’t miss your appointment please ask the front desk about our text message alerts or for an appointment reminder card.

Thank you in advance for your cooperation!

Health Insurance Financial Policy

Since most health insurance plans have a deductible, you must pay 100% of your charges until your deductible is satisfied. Once you have met your deductible, we will accept authorization for direct payment of benefits to this office. You must provide us a copy of your health insurance card.

Upon receipt of this information, we all contact your company to verify the eligibility of chiropractic benefits. All information provided to us by your insurance company included any policy limitations or exclusions will be discussed with you. Since most health insurance plans do not reimburse health care expenses 100%, you may be responsible for your co-payment/co-insurance. CO-PAYMENTS ARE DUE AT THE TIME SERVICES ARE RENDERED.

Patients selecting this option understand this office submits bills and awaits direct payment from insurance companies as a courtesy, and that in no way relieves patients of their financial responsibility to this office. If your insurance company denies or delays reimbursement to this office for any reason, the allowable expenses are your responsibility. MONITORING ANY POLICY LIMITATIONS IS CONSIDERED THE RESPONSIBILITY OF THE PATIENT.

I authorize all insurance companies, third party payers and attorney's to make direct payment of my benefits to Family Chiropractors of Montclair for all monies due to my account for the services I have received. If my policy prohibits assignment, I direct my insurance company to mail all checks made payable to me, directly to Family Chiropractors of Montclair at 39 Watchung Plaza, Montclair, NJ 07042.