Forms

Forms & Policies

New Patients must complete 3 Initial Forms:

(We ask that you complete theses forms prior to your appointment.)

1. Registration Form (either Advocare Adult Patient Registration or Advocare Child/Dependent Registration depending on age)

2. Annual Consent & Acknowledgement Form

3. Health History Form

Please click below to download the forms.

Annual Patient Packet Forms

Adult Patient Registration (PDF)

Annual Consent and Acknowledgement (PDF)

Aviso de Prácticas de Privacidad (PDF)

Child Registration (PDF)

Consentimiento y Reconocimiento Anual (PDF)

Notice of Privacy Practices (PDF)

Pediatric Family Registration (PDF)

Registro de Niños (PDF)

Registro de Pacientes Adultos (PDF)

Registro Familiar Pediátrico (PDF)

Adult Patient Registration (PDF)

Annual Consent and Acknowledgement (PDF)

Aviso de Prácticas de Privacidad (PDF)

Child Registration (PDF)

Consentimiento y Reconocimiento Anual (PDF)

Notice of Privacy Practices (PDF)

Pediatric Family Registration (PDF)

Registro de Niños (PDF)

Registro de Pacientes Adultos (PDF)

Registro Familiar Pediátrico (PDF)

18-year old: ADULTHOOD Letter (PDF)

ABN – Advanced Beneficiary Notice of Noncoverage (Medicare only) (PDF)

ABN – Aviso Anticipado de No Cobertura Para el Beneficiario (Medicare Solamente) (PDF)

Authorization for Use & Disclosure of Protected Health Information (PHI) - Spanish (PDF)

Authorization to Bring a Minor (PDF)

Autorización para traer a un menor de edad

Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)

Cancellation of Prior SureScripts: Opt-Out (PDF)

Case Registration (PDF)

Credit Card on File Consent Form - Pediatrics (PDF)

Credit Card on File Consent Form – Pediatrics (Spanish) (PDF)

Credit Card on File Consent Form (PDF)

Credit Card on File Consent Form (Spanish) (PDF)

Estimated Cost: Out-of-Network Services (PDF)

Healow Trifold (PDF)

Health Information Exchange (HIE): FAQs (PDF)

Health Information Exchange (HIE): Opt-Out (PDF)

Informed Consent: In-Office Procedures (PDF)

Informed Consent: Surgical Procedure or Invasive Treatment Procedure (PDF)

Newborn Insurance Reminder (PDF)

Notice of Privacy Practices - Arabic

Patient Consent to Draw/Test Blood (PDF)

Patient Financial Responsibility (PDF)

Patient Photograph/Video Information Release Authorization (PDF)

Patient Portal: FAQs (PDF)

Patient Portal: Flyer (PDF)

Patient Preventative Visit and Problem Visit Same Day Acknowledgement Form - Spanish (PDF)

Patient Preventive Visit and Problem Visit Same Day Acknowledgement (PDF)

Patient Preventive Visit and Problem Visit Same Day Acknowledgement Form - Pediatric (PDF)

Patient Preventive Visit and Problem Visit Same Day Acknowledgement Form – Pediatric (Spanish) (PDF)

Practice & Payment Philosophy (PDF)

Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Recordatorio de Seguro Para Recién Nacidos (PDF)

Request for Amendment to Protected Health Information

Restriction of Disclosure to Health Plan (PDF)

SureScripts: Opt-Out (PDF)

Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)

Vaccine Consent - Spanish

Vaccine Consent - Turkish

Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)

(Medical Records Release)

New Jersey Immunization Information System (NJIIS): Consent (PDF)

English

Patient Portal Proxy Authorization (PDF)

(18 years or older)

Patient Forms

18-year old: ADULTHOOD Letter (PDF)

ABN – Advanced Beneficiary Notice of Noncoverage (Medicare only) (PDF)

ABN – Aviso Anticipado de No Cobertura Para el Beneficiario (Medicare Solamente) (PDF)

Authorization for Use & Disclosure of Protected Health Information (PHI) - Spanish (PDF)

Authorization to Bring a Minor (PDF)

Autorización para traer a un menor de edad

Cancellation of Prior Health Information Exchange (HIE): Opt-Out (PDF)

Cancellation of Prior SureScripts: Opt-Out (PDF)

Case Registration (PDF)

Credit Card on File Consent Form - Pediatrics (PDF)

Credit Card on File Consent Form – Pediatrics (Spanish) (PDF)

Credit Card on File Consent Form (PDF)

Credit Card on File Consent Form (Spanish) (PDF)

Estimated Cost: Out-of-Network Services (PDF)

Healow Trifold (PDF)

Health Information Exchange (HIE): FAQs (PDF)

Health Information Exchange (HIE): Opt-Out (PDF)

Informed Consent: In-Office Procedures (PDF)

Informed Consent: Surgical Procedure or Invasive Treatment Procedure (PDF)

Newborn Insurance Reminder (PDF)

Notice of Privacy Practices - Arabic

Patient Consent to Draw/Test Blood (PDF)

Patient Financial Responsibility (PDF)

Patient Photograph/Video Information Release Authorization (PDF)

Patient Portal: FAQs (PDF)

Patient Portal: Flyer (PDF)

Patient Preventative Visit and Problem Visit Same Day Acknowledgement Form - Spanish (PDF)

Patient Preventive Visit and Problem Visit Same Day Acknowledgement (PDF)

Patient Preventive Visit and Problem Visit Same Day Acknowledgement Form - Pediatric (PDF)

Patient Preventive Visit and Problem Visit Same Day Acknowledgement Form – Pediatric (Spanish) (PDF)

Practice & Payment Philosophy (PDF)

Professional/Provider: Out-of-Network Disclosure Notification (PDF)

Recordatorio de Seguro Para Recién Nacidos (PDF)

Request for Amendment to Protected Health Information

Restriction of Disclosure to Health Plan (PDF)

SureScripts: Opt-Out (PDF)

Vaccine Administration Record: Consent/Refusal to Vaccinate (PDF)

Vaccine Consent - Spanish

Vaccine Consent - Turkish

Authorization for Use & Disclosure of Protected Health Information (PHI) (PDF)

New Jersey Immunization Information System (NJIIS): Consent (PDF)

Patient Portal Proxy Authorization (PDF)

Assessment Forms

Edinburgh Postnatal Depression Scale (PDF)

(Complete prior to the 1 month checkup)

MCHAT, Revised Follow-Up: Checklist Only (PDF)

(Modified Checklist for Autism in Toddlers - Complete for 18 and 24 month well child checks)

MCHAT, Revised Follow-Up: Packet with Checklist (PDF)

(Modified Checklist for Autism in Toddlers - Complete for 18 and 24 month well child checks)

NICHQ Vanderbilt Assessment: Follow-Up (Parent) (PDF)

NICHQ Vanderbilt Assessment: Follow-Up (Teacher) (PDF)

NICHQ Vanderbilt Initial Assessment (Parent) (PDF)

NICHQ Vanderbilt Initial Assessment (Teacher) (PDF)

PSC-Y Report (PDF)

(Pediatric Symptom Checklist - Youth Report)

Required Forms

Advocare Non-Discrimination Notice (PDF)

Advocare Patients Bill of Rights (PDF)

Advocare Payer List (PDF)

Explanation of Individual's Right to Appeal Health Insurance Determinations (PDF)

(New Jersey Only)

Grievance Procedure – Spanish (PDF)

Grievance Procedure (PDF)

Non-Discrimination – Spanish (PDF)

Patient’s Bill of Rights – Spanish (PDF)

Right to an Observer

Right to an Observer – Spanish (PDF)

New Patient Forms

New Patient History