|I hereby agree to be treated by Garden State Orthopaedic Associates, P.A. (Dr. Kenneth A. Levitsky, Dr. Douglas S. Holden, Dr. Samuel J. Snyder, Dr. Adam D. Bernstein, Dr. Steven Shamash, Dr. Brian Van Grouw, Dr. Ryan Cassilly, Dr. Frederick Fakharzadeh, William Thomson, PA-C, or Bryan D. Sheldon PA-C, Long Bui-Le PA-C, Jeffrey Lee PA-C)
I acknowledge full responsibility for the payment of services rendered to me and agree to pay for such services in full, regardless of insurance or third party involvement, unless otherwise prohibited by law • I have been informed as to my innetwork or out-of-network status prior to my visit • I authorize the practice to release to my insurance company or any of my third party payors any information needed to determine my insurance coverage • I authorize you to file claims with all insurance and third party carriers and further authorize and direct my insurance benefits to be paid directly to Garden State Orthopaedic Associates, P.A. 28-04 Broadway, Fair Lawn, NJ 07410 Tax ID #222814819
Please note that our office makes supplies available for your convenience. All medical supplies must be paid for at the time of your visit.
Patients are responsible to pay a 1% per month finance charge on all unpaid balances which exceed 30 days.
I verify the accuracy of the above information and authorize release of information as provided.