Patient Registration Forms

Peter T Hetzler MD FACS

200 White Road, STE 211 Little Silver NJ 07739 P: 732-219-0447 F: 732-219-6563
Patient Information
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
What is your Gender? *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Number *
Secondary Number
Email *
example@example.com

Surgical History
Please list past surgeries, including type of surgery, date, and treating Physician. Type "None" in the box if you have never had surgery. *

Emergency Contact
Emergency Contact *

First Name Last Name
What is your relationship to this person? *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *
Secondary Phone Number

Patient Bill of Rights
PATIENT BILL OF RIGHTS

By P.L. 1989, c. 170, the New Jersey Legislature in recognition that a hospitalized patient often feels overwhelmed and uncertain as to his condition and course of treatment, and because the declaration of a bill of rights for hospital patients may lead to fuller understanding and greater security on the part of patients, as well as greater sensitivity by the providers of medical care required that notice of those rights be provided to patients. While these "rights" are not strictly applicable to other settings, they serve as good reminders to health care providers of patient needs, and to patients as to their reasonable expectations. Every person admitted to a general hospital licensed by the State Department of Health pursuant to P.L.1971, c. 136 (C. 26:2H-1 et seq.), shall have the right:

To considerate and respectful care consistent with sound nursing and medical practices;

To be informed of the name of the physician responsible for coordinating his care;

To obtain from the physician complete, current information concerning his diagnosis, treatment, and prognosis in terms he can reasonably be expected to understand;

To receive from the physician information necessary to give informed consent prior to the start of any procedure or treatment;

To refuse treatment to the extent permitted by law and to be informed of the medical consequences of such action;

To privacy to the extent consistent with providing adequate medical care to the patient;

To privacy and confidentiality of all records pertaining to the patient's treatment, except as otherwise provided by law or third party payment contract, and to access to those records;

To expect that within its capacity, the hospital will make reasonable response to the patient's request for services, including the services of an interpreter in a language other than English if 10% or more of the population in the hospital's service area speaks that language;

To be informed by the patient's physician of any continuing health care requirements which may follow discharge and to receive assistance from the physician and appropriate hospital staff in arranging for required follow-up care after discharge;

To be informed by the hospital of the necessity of transfer to another facility prior to the transfer and of any alternatives to it which may exist;

To be informed, upon request, of other health care and educational institutions that the hospital has authorized to participate in the patient's treatment;

To be advised if the hospital proposes to engage in or perform human research or experimentation and to refuse to participate in these projects;

To examine and receive an explanation of the patient's bill, regardless of the source of payment, and to receive information or be advised on the availability of sources of financial assistance to help pay for the patient's care, as necessary;

To expect reasonable continuity of care;

To be advised of the hospital rules and regulations that apply to his conduct as a patient; and,

To treatment without discrimination as to race, age, religion, sex, national origin, or source of payment.

Please note: If you believe the care provided to you in a hospital by a doctor was improper, you may file a complaint with the Board of Medical Examiners. However, Because the regulation of hospitals is under the jurisdiction of the New Jersey Department of Health and Senior Services (DHSS), if you believe you received improper care at a hospital, you should contact the DHSS Complaint section at (800) 792-9770.
*

By clicking here, I acknowledge that I read and understand the Patient Bill of Rights outlined above.

Patient Financial Responsibility and Assignment of Benefits
PATIENT FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS
- Patient/Guarantor agrees to assign benefits to Peter T Hetzler MD FACS LLC (Dr. Hetzler). You authorize and assign payment to Dr. Hetzler of any and all insurance benefits to which you are otherwise entitled for services rendered.
- Dr. Hetzler agrees to accept the maximum amount your insurance carrier(s) allows for your claim. You will be billed for any deductible, coinsurance, or copayment amounts applied to your claim. You are also responsible for immediately forwarding any insurance payments or insurance correspondence related to the claim to this office.
- Because Dr. Hetzler is a non-participating provider with your insurance plan, you may receive an insurance check(s) directly for services rendered. Please do not cash the insurance check. Please endorse the insurance check and forward it and a copy of the explanation of benefits to: Peter T Hetzler MD FACS LLC 200 White Road Suite 211 Little Silver, NJ 07739
- Several insurance carriers will not correspond with non-participating providers directly. You must furnish a copy of any correspondence sent directly to you.
- If you do not forward the insurance payment, explanation of benefits, or claim-related correspondence within 90 days, you may be held responsible for the full charge plus recovery of all costs and legal fees.
- Delinquent Accounts may be charged for recovery of all costs and legal fees and may be charged interest at one and one half percent (1 ½%) per month for outstanding balances.
- You may be charged $50.00 for any check that is returned as not payable by your bank
- You may be held responsible for the full charge amount including amounts in excess of your insurance plan allowances if your insurance denies for non-compliance with insurance carrier requests, if your policy benefits have been exhausted, or if you fail to provide accurate insurance information.
*

By clicking here, I acknowledge that I read and understand the Patient Financial Responsibility and Assignment of Benefits outlined above.

Authorization For Health Information Disclosure (HIPAA)
AUTHORIZATION FOR HEALTH INFORMATION DISCLOSURE (HIPAA)

Please disclose the following protected health information to:

Peter T Hetzler MD FACS LLC
200 White Road Suite 211
Little Silver, NJ 07739-1150

This request is for the purpose of collecting payment of medical bills and includes the disclosure of any and all records relevant to the processing and/or payment of the medical claim(s) for services rendered by Peter T Hetzler MD FACS LLC. I understand I have the right to revoke this authorization at any time. I understand that my revocation must be in writing and addressed to the privacy officer at the address above. I understand that the revocation does not apply to information that has already been released in response to this authorization. I understand that I need not sign this authorization to assure treatment. I understand that I may inspect and/or copy the information to be disclosed. I understand that authorizing this disclosure is voluntary.
*

By clicking here, I acknowledge that I read and understand the Authorization for Health Information Disclosure (HIPAA) outlined above.
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
My authorization applies to the information described below. Only this information may be used/or disclosed *

All Information / No Restrictions I would like to list the Restrictions
Restrictions: The following information should not be used/or disclosed.
I authorize the following family members (or other individuals) to receive my protected health information:
*

By clicking here, I authorize the following persons (or class of persons) to receive my protected health information: Peter T Hetzler MD FACS and Staff, The associated billing service of Peter T Hetzler MD FACS, Insurance Carrier(s) associated directly with my treatment, Disability or Workman's Compensation Adjusters or Case Managers associated with my case.
*

I understand that if my protected health information is disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re-disclosed and would no longer be protected. I understand that I have a right to revoke this authorization at any time. My revocation must be done in writing. I am aware that my revocation is not retroactive.This authorization expires upon 3 years after my last treatment by Peter T. Hetzler, MD, FACS. I understand that I do not have to sign this authorization and that my refusal will not affect my abilities to obtain treatment from Peter T. Hetzler, MD, FACS. My protected health information will be used or disclosed upon request for the following purpose: Obtaining authorization for treatment, Disability (with proper authorization), Scheduling treatment, Social Security (with proper authorization), Billing and collecting payment for medical and surgical services, Referral to other physicians from Peter T. Hetzler, MD, FACS, Notifications from Red Bank Call Center via phone/fax/text to Peter. T. Hetzler MD, FACS and/or staff. I understand that I have a right to inspect and copy my own protected health information. Changes to the above documentation must be submitted in writing to Peter T. Hetzler, M.D., FACS. Changes will be effective immediately upon receipt of certified request.

Signature and Submission of Form
Signature *

Clear
Patient Name

First Name Last Name
Date

Month Day Year
Date
Should be Empty:

Peter T Hetzler MD FACS

Patient Information