Office Policy and Forms

PLEASE COMPLETE THESE FORMS (below) AND BRING THEM IN WITH YOU ON THE DAY OF YOUR
APPOINTMENT. IF YOU HAVE ANY QUESTIONS PLEASE DO NOT HESITATE TO CALL THE OFFICE.

Prior to your initial office visit, we would like to familiarize you with our office procedures.

In order to see the doctor you must bring, your MRI films (MYLAR only) and report of same. If you were given paper films or disks please contact the facility that performed your MRI and tell them that you are seeing a specialist and that he requires the mylar films. Please be aware that some radiology facilities require 48 hours to make a copy of these films. Any other test results such as EMG, BONE SCAN, etc., should also be brought in with you on the day of your appointment. These test results may also be faxed prior to your visit. Dr. Siddiqi requires that you bring the film’s back with each return visit. Also we require a photo ID that we can copy for your chart on the day of your appointment.

MANAGED CARE HEALTH PLANS

Our office is participating with several managed care health plans. If you are not sure if we are participating to your plan please call the 1-800 # on your card. Some of these plans require a referral from your primary doctor and some do not. If your insurance plan requires a referral you must obtain this from your primary care doctor prior to your appointment, NO PATIENT WILL BE SEEN WITHOUT THEIR REFERRAL. Each visit will require a new referral unless your physician has written the original for more than one visit. If you are coming under any other insurance and wish to back up the visit with your medical insurance you will also need to get a referral for your visit (ie: motor vehicle accident patients who may be maxing out for their medical coverage). Our office does NOT bill for co-pays nor do we accept debit or credit cards, cash or check’s only. Your co-pay is due at the time of your visit.

MEDICARE & SUPPLEMENTAL

We DO accept assignment for Medicare patients. We will want to make copies of your medicare and supplemental insurance cards on the day of your appointment.

WORKMEN’S COMPENSATION

All New Jersey workers compensation patients must have prior approval from the workmen’s compensation insurance carrier before their appointment. Pennsylvania workers compensation patients do not need prior approval, however, your claim must be open when we call to verify your coverage.

MOTOR VEHICLE INSURANCE

We accept your automobile insurance however you must have an open claim and provide us with the name, address, phone number, claim number, and the name of the adjuster in charge of your claim. We will also need to make a copy of your motor vehicle insurance card and declaration page.

FORMS

Please download and complete the following forms, and bring them with you at the time of your visit. You will need Adobe Acrobat Reader to view and print these forms. You may download Adobe Acrobat Reader here.

Patient Registration Form
Medical History Form
Patient Health History Form
Functional Questionaire
Financial Policy

THANK YOU FOR YOUR COOPERATION AND WE LOOK FORWARD TO YOUR VISIT.