1016 MAIN AVE CLIFTON, NJ 07011 Tel: 973-546-5700 Fax: 973-546-8898

PATIENT REGISTRATION

PLEASE PRINT AND COMPLETE ALL ENTRIES PATIENT NAME (LAST -- FIRST -- MIDDLE INITIAL) ADDRESS

CITY, STATE ZIP HOME PHONE CELL PHONE

PATIENT DATE OF BIRTH PATIENT SSN SEX Male Female Transgender Other

MARITAL STATUS Single Married Other______________

RACE American Indian or Alaska Native Pacific Islander Asian White Black or African American Other Hispanic

PRIMARY LANGUAGE English Spanish Russian Korean Other ______________

ETHNICITY Hispanic or Latino Non Hispanic or Latino Other _____________

PATIENT EMPLOYER NAME PATIENT EMPLOYER ADDRESS (STREET ADDRESS - CITY - STATE - ZIP) EMPLOYER PHONE

INSURED/RESPONSIBLE PARTY INFORMATION RELATION TO PATIENT: spouse parent guardian NAME (FIRST -- LAST -- MIDDLE INITIAL) ADDRESS (if different from patient)

HOME PHONE WORK PHONE SSN BIRTH DATE EMPLOYER

INSURANCE INFORMATION PRIMARY INSURANCE NAME ADDRESS (STREET - CITY - STATE - ZIP) PHONE

GROUP NUMBER ID NUMBER EMPLOYER EMPLOYER PHONE

SECONDARY INSURANCE NAME ADDRESS (STREET - CITY - STATE - ZIP)PHONE

PHONE

GROUP NUMBER ID NUMBER EMPLOYER EMPLOYER PHONE

VISION PLAN ID NUMBER

IN CASE OF EMERGENCY CONTACT RELATIONSHIP PHONE NUMBER

PRIMARY CARE PHYSICIAN NAME ADDRESS

CITY, STATE ZIP PHONE FAX

REFERRING DOCTOR PHONE

PHARMACY INFORMATION NAME PHONE

ADDRESS

23 W. PALISADE AVE ENGLEWOOD , NJ 07631 Tel: 201-408-4441 Fax: 201-408-4452

Rev: 4/10/19 

HIPAA: PATIENT RIGHTS AND RESPONSIBILITIES 

It is the policy of NJ Eye and Ear to treat all patient information confidentially. This includes patient records and conversations. We will investigate any reported violation of this policy. We make every effort  to provide our patients with an environment, which  is  safe,  private and respectful of our patient’s needs. We will do everything we can to see that your experience with us is professional in every way. 

NJ Eye and Ear is committed to your participation in care decisions. As a client, you have the right to ask questions and receive answers regarding the course of clinical care recommended by  any  of  our  health  providers,  including  discontinuing  care.  We  urge  you  to  follow  the healthcare  directions  given  to  you  by  our  providers.  However,  if  you  have  any  doubts  or concerns, or if you question the care prescribed by our providers, please ask. By signing this form,  I agree that NJ Eye and Ear may send automated text messages  to my cell phone  for appointment reminders, news and promotional information. I understand that standard text messaging rates will apply to any message received from NJ Eye and Ear. I understand that I may revoke this permission at any time by notifying NJ Eye and Ear in writing. 

Patient Rights: 1. The  patient  has  the  right  to  receive  information  from health  providers  and  to  discuss  thebenefits, risks, and costs of appropriate treatment alternatives. Patients should receive guidance from their health providers as to the optimal course of action. Patients are also entitled to obtain copies or summaries of their medical records, to have their questions answered, to be advised of potential conflicts of interest that their health providers might have, and to receive independent professional opinions. 2. The patient has the right to make decisions regarding the health care that is recommended byhis or her health provider. Accordingly, patients may accept or refuse any recommended medical treatment. 3. The patient has the right to courtesy, respect, dignity, responsiveness, and timely attention tohis  or  her  needs,  regardless  of  race,  religion,  ethnic  or  national  origin,  gender,  age,  sexual orientation, or disability. 4. The patient has the right to confidentiality. The health provider should not reveal confidentialcommunications or information without the consent of the patient, unless provided for by law or by the need to protect the welfare of the individual or the public interest. 5. The patient has the right to continuity of health care. The health provider has an obligation tocooperate in the coordination of medically indicated care with other health providers treating the patient. The health provider may discontinue care provided they give the patient reasonable assistance and direction, and sufficient opportunity to make alternative arrangements. 

Rev: 4/10/19 

Patient Responsibilities: 1. Good communication is essential to a successful health provider‐patient relationship. To theextent possible, patients have a responsibility to be truthful and to express their concerns clearly to their health providers. 2. Patients have a responsibility to provide a complete medical history, to the extent possible,including information about past illnesses, medications, hospitalizations, family history of illness and other matters relating to present health. 3. Patients have a responsibility to request information or clarification about their health statusor treatment when they do not fully understand what has been described. 4. Once  patients  and  health  providers  agree  upon  the  goals  of  therapy,  patients  have  aresponsibility  to  cooperate  with  the  treatment  plan.  Compliance  with  health  provider instructions is often essential to public and individual safety. Patients also have a responsibility to disclose whether previously agreed‐upon treatments are being followed and to indicate when they would like to reconsider the treatment plan. 5. Patients should also have an active interest in the effects of their conduct on others and refrainfrom behavior that unreasonably places the health of others at risk. 

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent in writing,  signed by  you. However,  such  revocation  shall  not  affect  any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

The  patient  understands  that:  Protected  Health  Information may  be  disclosed  or  used  for treatment, payment of health care operations. The Practice has a notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Policies. The Patient has the right to restrict the uses of their information but  the Practice does not have  to agree  to  those  restrictions.  The Patient may revoke  this  Consent  in  writing  at  any  time  and  all  future  disclosures  will  then  cease.  The practice may condition treatment upon the execution of this Consent. 

Rev: 4/10/19 

PATIENT FINANCIAL RESPONSIBILITY & AUTHORIZATION 

Thank you for choosing NJ Eye and Ear for your medical needs. We are committed to providing you  with  the  highest  quality  healthcare.  We  ask  that  you  read  and  sign  this  form  to acknowledge your understanding of our patient financial policies. 

Patient Financial Responsibilities: 

The patient (or patient’s guardian, if a minor) is ultimately responsible for the paymentfor treatment and care.

We will bill your insurance for you.  However, the patient is required to provide the mostcorrect and updated information regarding insurance.

Patients are responsible for payment of copays, coinsurance, deductibles and all otherprocedures or treatment not covered by their insurance plan.

Copays are due at the time of service.

Coinsurance, deductibles and non‐covered items if not available at the time of service aredue 30 days from date of service/ receipt of billing.

Patients  may  incur,  and  are  responsible  for  payment  of  additional  charges,  ifapplicable.  These charges may include‐ charge for returned checks ‐ $30.00

We  charge  a  No  Show  fee  of  $25.00  after  a  patient  does  not  attend  a  confirmedappointment.

Patient Acknowledgement and Authorization: 

We respect patient confidentiality and only  release personal health  information about you  in accordance with the State and federal law. The attached notice describes our policies related to the use of the records of your care and how you may get access to this information. Please review this policy carefully. 

By  my  signature  below,  I  acknowledge  that  I  have  received  and  read  the  privacy  notice provided by NJ Eye and Ear. I hereby authorize NJ Eye and Ear and the physicians, staff, and hospitals associated with NJ Eye and Ear to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payers, and/or other physicians or healthcare entities required to participate in my care. This Consent was signed by: 

Patient Name: ______________________________________ 

Patient/Guardian Signature: ___________________________     Date: ____________________ 

Release of Medical Records

Patient Name: __________________________________ Date of Birth: ________________

Patient Address: ________________________________________________________________

Phone Number: _______________________________

A mutual patient of ours, _________________________, is requesting their medical records to

be sent to New Jersey Eye and Ear, so we may continue in aiding in their health and care. By

signing below, the above named patient gives permission to release all information our office

may need.

Thank you for your assistance with the request.

Doctor’s Name / Facility Name: __________________________________________________

Office Address: _______________________________________________________________

Phone Number: ________________________ Fax Number: __________________________

Please send records to 201-408-4452

Thank you.

__________________________ ______________________

Patients Authorization Signature Date

__________________________ ______________________

Witness Date

Kevin Ende, M.D.

Director of Otolaryngology (Ear, Nose and Throat)

Facial Plastic and Reconstructive Surgery

Hair Restoration

23 W. Palisade Ave. Englewood, NJ 07631 • P:201-408-4441 • F:201-408-4452

Ear YES NO Explain

Changes in hearing

Cotton swab use

Discharge

Ear trauma

Earache

Itching

Ringing in the ears

Use of Hearing aid

Vertigo/Dizziness

Positive result on hearing loss test

Head and Neck

Cancer of head and neck

Daytime sleepiness

Facial numbness

Facial swelling

Headaches

History of trauma

Mouth and throat

Acid reflux

Coughing

Bleeding gums

Dental issues

Difficulty swallowing

Hoarseness/Vocal Changes

Oral lesions/Masses

Painful Swallowing

Sensation of fullness

Sore throat

Throat clearing

Tonsil infection

Nose and Sinus

Itching

Lack of Smell

Nasal trauma

Nose bleeding

Obstruction of airflow

Post nasal drip

Runny nose

Seasonal allergies

Sinus pain

Sinusitis

Sneezing

Snoring

Watery eyes

Allergy Testing

We offer both surgical and nonsurgical cosmetic treatments such as: Botox, Fillers, Facial Peels, Cosmetic Facial Surgery,

Hair Restoration and Laser Hair Removal

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For more info visit DrEnde.com or scan the qr code while you wait