Patient Forms

Osteoporosis Forms

Please Download Form and Print…

Endocrinology Forms

Hand Therapy Medical History Form

Please Download Form and Print…

If you are coming in to see one of our Hand Therapists please download and complete the form below.   Please bring it with you when you come in for your appointment. Filling out this form will enable us to serve you better and faster.
Hand Therapy Medical History Form

Prescription Refill

If you would like to request a current prescription refill from your physician, simply fill out the following form. We will confirm your details and phone the refill to the specified pharmacy. Be sure to fill out the request form in it’s entirety.

If you submit a request after hours, on a holiday, or on weekends, it will be addressed on the next business day. Prescription refill requests made online will only be honored if it is an active prescription, and approved by your doctor.

Englewood Orthopedic Associates maintains the following policy regarding prescription requests made by phone and online: Please plan ahead if you are running out of medications. While we try to address every request in a timely manner, it may be the next business day before your request can be honored. Thank you for understanding.

Click here for the Refill Prescription Form.

Authorization for Release of Information

Please Download Form and Print…
In order for us to release any of your medical information, you must sign a release form. We have made that process relatively easy by providing the form to you on this website. In order to make your visit less time consuming, we ask that you download, print, and fill out the Authorization for Release of Information and bring it to our office for your appointment, so we can facilitate your request. Filling out this form ahead of time will enable us to serve you better and faster.

Authorization for Release of Information

Medical Authorization for Alternate Caregiver

Please Download Form and Print…

In order to make your visit less time consuming, we ask that you either download, print, and fill out the Medical Authorization for Alternate Caregiver Form or you may type directly on the form, download and print it out. Please bring it with you when you come in for your appointment. Filling out this form will enable us to serve you better and faster.

Authorization for Alternative Caregiver Form

Protected Health Information Form

Below is our Protected Health Information form.  Your health information privacy is extremely important to us.  We need your permission to discuss your medical condition.  Please download this form, fill out the necessary information and bring into the office during your appointment or Fax to (201) 569-1774.

Health Info form

Office Policy Information

Billing Procedures

Primary & Secondary Insurance

Primary Insurance is the party to whom we look for payment first. Secondary Insurance, also known as Supplemental Insurance, usually is liable for the remaining portion after the primary insurance has paid. Please be sure you have provided complete and accurate information on both plans.

By New Jersey statute, the insurance carrier has 30 days to pay a claim. If payment is not received in a reasonable time, (60 days) we will ask for the patient’s assistance in working with the carrier for payment. When you, or your employer, select insurance coverage, you are bound to the terms of their contract, It is extremely important that you read and understand your health plan benefits such as any co-payment, deductibles and non-covered services within your plan. It is impossible for us to know your covered benefits, since we work with literally hundreds of different plans, so we encourage you to understand what your coverage includes to avoid frustration for you. Depending on your plan, some services are “non-covered”. This means the patient is responsible for these charges.

No Insurance Coverage

Payment at time of service is required. We offer a discount for payment at the time of your visit providing there is absolutely no insurance coverage. The discount will be discussed with our receptionist at time of check out Other forms of accepted payment include Visa, MasterCard, American Express, Discover and Debit Cards.

Workers’ Compensation Claims

We file workers’ compensation claims; however, there are some requirements prior to filing a claim.

  • Employee must file claim with his employer
  • Employer submits claim to his/her carrier
  • Insurance carrier assigns a claim number, if approved
  • You must provide us with the name and address of the insurance carrier, along with the claim number

Failure to comply with the above may result in a denied claim.


Your insurance company requires you to pay your co-pay at time of service.. Failure to pay this is a violation of your contract with your insurance company. This concept was created by the insurance industry to lower your premium by requiring the patient to pay a co-pay at every visit. Physicians also agreed to lower the amount they would accept as payment in full from the insurance companies because they were promised they would save the cost of sending statements for co-pays. Please don’t ask us to bill you, since the cost of sending a statement is often times more than your co-pay. You will be billed a $5 service charge if you do not pay your co-pay at the time of service.


This is an often overlooked or misunderstood issue. When we subscribe to insurance coverage, we agree to a “deductible” amount. The deductible amount is always the patient’s responsibility. Until the deductible amount is satisfied, your insurance is not responsible for reimbursement; however, we will submit your claim to the insurance company so the amount will go towards your deductible.

Office Policies

Financial Policy

As a courtesy to our patients, we submit claims to all insurance companies provided we have complete and accurate information. To ensure your claim is submitted in a timely fashion, please make sure the following insurance information has been included in your registration process. It is our commitment to assist you in getting your claim processed, it is still your responsibility to ensure that all services rendered by Englewood Orthopedics, on your behalf are paid in full.
Required Information

  • Your full name and address
  • A copy of your current insurance card
  • Effective date of insurance. Complete name, address and telephone number of insurance company, if it doesn’t appear on your card
  • Secondary insurance, if applicable
  • Name and address of policyholder
  • Your relationship to policyholder

Workers’ Compensation Claims

  • Employer’s name, address and phone number
  • Date of accident

Motor Vehicle Claims

  • Insured Name
  • Date of accident
  • Insurance Company Name & address
  • Claim Number, if known

Co-pays and Deductibles

Co-pays and deductibles are due at time of service.

Billing statements are mailed once a month unless there is insurance pending and in that case, you will not receive a statement until we have been reimbursed by your insurance company. However, if after 60 days we have not received payment from your insurance company, we look to you, our patient, for assistance in getting your account paid.

We recognize that health care costs can, at times, create a financial hardship, therefore, we are willing to visit with you to set up a payment plan to ease the financial burden of satisfying an account balance. There will be times when we ask you to produce financial statements to determine a financial hardship. Any of our account representatives will be happy to assist you and review the details with you.

Accepted Insurance Plans

Insurance Plans
Years ago, health care services and payments were entirely between you and your doctor. Today, the relationship is more complex – between you, your health care provider and insurance or managed health care plans.
Englewood Orthopedic Associates is affiliated with the following health insurance plans:

  • Aetna US Healthcare
  • Amerihealth
  • Amerigroup (some providers)
  • Blue Cross/Blue Shield
  • Cigna
  • Horizon BC/BS
  • MagnaCare
  • Medicare
  • Oxford
  • QualCare
  • United Healthcare

In addition, we accept many other insurance plans. We may accept your plan even if it is not listed here. Please call or email to verify if you are unsure.

Notice of Privacy Practices

Please Download Form and Print…

Notice of Privacy Practices