New Patient Forms

Primary Insurance

Secondary Insurance

CONSENT FOR TREATMENT
I hereby authorize my consent to be examined and treated now and in the future by Physicians providing services for Dr. Julie A. Lorber.
ASSIGNMENT OF BENEFITS
I hereby authorize Dr. Julie A. Lorber PC to furnish information to insurance carriers concerning this illness. I hereby irrevocably assign Dr. Julie A. Lorber all payments for services rendered and all major medical benefits.
MEDICARE AUTHORIZATION TO RELEASE INFORMATION & PAYMENT REQUEST
I certify that the information given by me in applying for payment under the Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign benefits payable for physician’s services to the physician or organization furnishing the services.
RELEASE OF INFORMATION FOR BENEFITS
I authorize release of any information acquired in the course of my examination or treatment, which may be needed for the payment of professional charges and related services.
FINANCIAL AGREEMENT
I understand that charges for any diagnostic tests will be in addition to the consultation fee, and that I am directly financially responsible for all charges, including deductibles and co-payments incurred for medical services and/or surgical procedures rendered for myself and/or my dependents whether or not they are covered by valid insurance benefits and any balance due and owing for all non-covered or out-of-network services. I agree to pay for any legal interest, collection expense and attorney’s fees or other costs incurred, should it become necessary to assign any amount I may owe or collection.
PERSONAL INFORMATION
I certify that all statements given to the physicians and personnel are complete and accurate to the best of my knowledge. A copy of this agreement shall be considered as effective and valid as the original. This agreement will continue until revoked by me in writing. A copy of Patient’s Rights and Responsibilities and Notice of Privacy Practices has been given to me by this office.

I understand that from time-to-time Dr. Julie A. Lorber and her staff may inform me of new drugs, treatments, or other services that may be appropriate for a person in my situation (age, sex, etc.). I consent to the use of my identifiable patient information to notify me of such new drugs, treatments, or other services that may be necessary for the continuity of my care, or which may be of benefit in maintaining or improving my health with the understanding that Dr. Julie A. Lorber will not provide such information to others for marketing, fundraising, or similar purposes from my medical records.
I may revoke this consent in writing at any time except to the extent that Dr. Julie A. Lorber has already acted in reliance on this consent.
By signing this form, I consent to Dr. Julie A. Lorber’s use and disclosures of my health information for treatment, payment, and healthcare operations.

Welcome to our practice!
It is an honor to care for you and your family. Please take a few minutes to read this document and sign. We are happy to answer any questions regarding our office policies.
Appointments
We strive to keep on schedule, and we do our best to notify our patients if there is a delay in the doctor’s schedule. We ask for your patience and understanding if there is an emergency that delays your appointment. If you are late for your appointment time, we reserve the right to reschedule your appointment.
Documentation
At the time you schedule your appointment, our office staff will review the documentation that you will need to bring with you (ex. Insurance card and personal identification, etc.). Please inform the receptionist of any changes to your address, phone number or other patient information. Not having the proper documentation may cause you to be financially responsible for your office visit.
Late cancellations and missed appointment charges
Cancellation of office appointments require a minimum of 48 hours advanced notice. Failure to provide such advanced notice to the office may result in a $25 charge to your account.
If a procedure is cancelled less than 5 business days prior to your scheduled date, we reserve the right to charge a cancellation fee. The cancellation rate is 10% of the total procedure cost. If you reschedule and complete the procedure, that 10% cost will be waived minus a last- minute cancellation fee up to $250.
If you do not show up the day of your procedure without notifying our office, you will be charged a "no show" fee which is the total cost of the procedure.
Additionally, we reserve the right to charge a $50 fee for multiple reschedules.
Follow-up
Please schedule your follow-up appointment before leaving the office, as this will enable us to better accommodate any special needs.
Pre-certification
If you require a referral from your insurance, it is your responsibility to obtain the referral prior to your visit from your primary physician. We will be happy to assist you in determining your insurance requirements. Prior to scheduling an appointment for an MRI or CT scan patients must contact our office with the date and location to begin the pre-certification process. Please be advised this process may take up to 5 business days based on your insurance.
Procedure Authorization
Many procedures require prior authorization. Our office will take care of this process for you, but please be advised that this process is labor intensive. Please be considerate of our office staff’s time in planning for your procedure.
Medication Authorization
Many medications also require prior authorization which is a long process. Please be understanding of the time needed to complete this request.
I acknowledge and agree to the terms and conditions of this document.

I authorize you to furnish a copy of my medical records to Dr. Julie A. Lorber, PC. I release you from all legal responsibility or liability that may arise from this authorization.
This authorization also includes consent to fax the above records, if necessary to:

For office use

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