Marlton Office – New Patient Forms

PULMONARY AND SLEEP ASSOCIATES OF SOUTH JERSEY, LLC
750 Route 73 South Suite 401
Marlton, NJ 08053
Phone: 856-­‐375-­‐1288
Fax: 856-­‐375-­‐2325
NIOSH “B” Reader
Board CerGficaGons
Pulmonary Medicine
CriGcal Care Medicine
Sleep Medicine
Please bring the following items with you to your appointment:
1. Completed PaGent InformaGon Sheets
2. Completed Sleep Survey if you are being seen for ObstrucGve Sleep Apnea
(If you have already had a sleep study, please bring a copy of the study with you to your appointment if possible).
3. Chest X-­‐Ray and/or CAT Scan Films or CDs for a Pulmonary Consult
Do not use inhalers/nebulizer medicaGons (short-­‐acGng meds) up to 4 hours prior to first appointment. Do not use long-­‐acGng meds (Spiriva, Advair, etc) up to 12 hours prior to first appointment.
4. Health Insurance Card
5. Copy (if applies to your insurance)
6. Drivers License
7. PrescripGon Plan Cards (if applicable)
8. Referral (if it is required by your insurance)
ATTENTION PATIENTS
The doctors and staff greatly appreciate your courtesy in keeping all appointments promptly.
NO SHOW APPOINTMENTS: Follow up paGents will be charged $25.00 for each no show appointment. New paGents will be charged $50.00 for a no show appointment.
Appointment CancellaGon: 24 hour cancellaGon noGce is required.
Referral: If a referral is required by your insurance, you must have the referral at the Gme of your appointment. Otherwise, your appointment may be rescheduled.
Copay: All copays are due at Gme of service. A $15.00 service fee will be added to your account if your copay must be billed. Pulmonary and Sleep Associates of South Jersey, LLC [ ] Ammar Alimam, M.D. [ ] Ira Horowitz, M.D. [ ] Donald Auerbach, M.D. [ ] William Morowitz, M.D. [ ] Steven Baumgarten, M.D. [ ] Thomas Nugent, M.D. [ ] John Bermingham, D.O. [ ] Alan Pope, M.D. [ ] Aaron Crookshank, M.D. [ ] Irene Swift, M.D. [ ] Michael Driscoll, D.O. [ ] Antonio Velasco, D.O. [ ] Thomas Grookett, M.D. [ ] Fredric Noller, P.A MEDICAL RECORD RELEASE FORM ____________________________________
_______________
Patient Name
Date of Birth I hereby authorize the below listed entity to release medical information to
Pulmonary and Sleep Associates of South Jersey. Name: ______________________________
Telephone#: _________ Address: _____________________________
Fax#: ______________ Medical Information Requested: All Records Specific Records from ______________ to _______________ Immunizations & Physical Examinations Radiology Films {X-Ray, Mammography, Ultrasound, CT, MRI, etc.} Please send to the physician checked above to the address circled below: Cherry Hill Office:
Marlton and Burlington Office 107 Berlin Road
750 Rt 73 South, Suite 401 Cherry Hill, New Jersey 08034-3526
Marlton, New Jersey 08053-4145 Ph: 856-429-1800 Fax: 856-429-1081
Ph: 856-375-1288 Fax: 856-375-2325 _______________________________
Signature of Patient or Legal Guardian
___________________ Date This release authorizes the disclosure of records for one year from the date signed above. I understand that these records are protected
under Federal and/or State law and cannot be disclosed without written consent unless otherwise provided by law. I further understand
that the specific type information to be disclosed may, if applicable, include: diagnosis, prognosis, and treatment for physical and/or
mental illness, including treatment of alcohol or substance abuse, auto-immune deficiency syndrome (AIDS), AIDS related complex (ARC) or
human immunodeficiency virus (HIV) infection for any admissions. I understand that I have the right to revoke this consent at any time
unless the facility, which is to make the disclosure of information, has already done so in reliance on the consent.