Complete New Patient Forms

Dr. Matthew F. Wachtler, DPM, FACFAS

882 Pompton Ave, Suite B-1, Cedar Grove, NJ 07009 (p) 973-857-1184 (f) 973-857-3114
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Date of Birth
Month/Day/Year
Social Security Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Doctor
Pharmacy Name / Location
Reason For Visit
Height / Weight
Ft, in. / lbs
Allergies
Medications
Past Medical History
(examples: High Blood Pressure, High Cholesterol, Diabetes, Heart Disease, Liver Disease, Kidney Disease, Hepatitis, HIV, Thyroid disorder, any other medical conditions......)
Past Surgical History
Family Medical History - Father
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Mother
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Brother
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Sister
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Family Medical History - Other
(Cancer, Heart Disease, Diabetes, or other medical conditions)
Tobacco/Smoking Status
Alcohol Use
Current Flu Vaccine
Current Pneuomnia Vaccine (>65 yrs old)
Advanced Directive (>65 yrs old)
Marital Status
How did you hear about our office?

Other
Emergency Contact
Name / Contact Number
Signature - Medical History Form
HIPAA Consent Form

I understand that under the Health Portability and Accountability Act 1996 (HIPAA) I have certain rights to privacy regarding my health information. I also understand that Cedar Grove Foot & Ankle Specialists originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, test results, diagnoses, treatments and any plans for future care and treatment at Cedar Grove Foot & Ankle Specialists. I understand that this information can be used as:
- A basis for planning my care and treatment and followup among multiple healthcare providers who may be involved in that treatment directly or indirectly.
- A means of communication amoung the many healthy professionals who contribute to my care
- A means by which a 3rd party can verify that services billed were actually provided and obtain payment from 3rd party payers
- A tool for routine healthcare operations such as assessing quality and receiving the competence of healthcare professionals
My Health information may also be discussed with the following people upon their request:
Name / Relationship
I prefer to have notification of my healthcare information by the following methods. Please check all application
Name

First NameLast Name
Date

MonthDayYear
Date
Signature - Received HIPAA Consent Form
Notice of Privacy Practices

Acknowledgement of Receipt

I acknowledge that I was provided an opportunity to read (if I chose to), a copy of the notice of Privacy Practices and understood the notice.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature - Notice of Privacy Practices Receipt
Insurance Information
Primary Insurance Company and Policy Number / Group Number
Insurance Company and Policy Number
Secondary Insurance Company and Policy Number / Group Number
Policy Holder Name and Relation
Policy Holder Name and Relation: Self / Spouse / Child
Policy Holder SSN
Policy Holder DOB and Gender
Financial Responsibility / Insurance Benefits / Notice of Collection Action

I understand that I am responsible for knowing the benefits of my insurance plan. In doing so, it is my responsibility to verify proof of insurance by ensuring that the office has the most current/valid insurance on file. I understand that all co-payments are due at the time of service and I am also responsible to pay other amounts due; these amounts may include deductibles, coinsurances, charges denied by my insurance as not covered or not medically necessary and/or any fees incurred should my account require collection action (late fees, collection agency, court or attorney fees). Also, I understand that on occasion, the office may contact my insurance to obtain benefit information as a courtesy to me, however the information obtained from the insurance company is not a guarantee of payment, which may still result in my responsibility.
Signature - Financial Responsibility / Insurance Benefits / Notice of Collection Action
Front of Insurance Card (Take Picture or Upload)

Cancelof
Back of Insurance Card (Take Picture or Upload)

Cancelof
Drivers License (Take Picture or Upload)

Cancelof
Should be Empty:

Dr. Matthew F. Wachtler, DPM, FACFAS

Insurance Information