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Patient's Name:
Thank You for choosing our practice to provide you with medical care. We are committed to serving you with high quality care. Letting you know in advance of our office policy allows for a good flow of communication. If you have any questions, please do not hesitate to ask a member of our staff.

INSURANCE: We participate in many insurance plans. If you are insured by a plan we participate with, you will be required to present and up-to-date insurance card. Insurance policies have become increasingly complex over the years making it impossible for our office to know each specific plan and their limitations. Therefore, it is your responsibility to know your insurance benefits. We will submit your claims and assist you in any way we reasonably can to get your claims paid. This is the reason we require a copy of your insurance card be faxed or mailed before you visit. Your insurance company may need you to supply certain information to them directly. It is your responsibility to comply with their request. Please contact your insurance company with any questions you may have regarding your coverage.

MEDICARE: We are a participating Medicare provider. Medicare, as well as your secondary insurance, (if any) will be billed for you. However, that does not mean that all services are covered. Patients are responsible for paying their annual deductible. Once your deductible has been met, you are responsible for 20% of the allowed amount for an item or service if not covered by your secondary insurance.

SECONDARY INSURANCE: Your medical claim will be forwarded to your secondary insurance (if any) after payment and/or explanation of benefits (EOB) is received from your primary insurance.

COPAYMENT & DEDUCTIBLES: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

SELF PAY: Payment in full is due at the time of service if you do not have health insurance coverage.

NON-COVERED SERVICES: Please be aware that some the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for payment of these services.

REFERRALS/AUTHORIZATION: We are required to follow guidelines of your managed care plan which mandates us, that when you visit a specialist such as ours, you must have a referral from your primary care physician prior to seeking specialty care. Therefore, if you do not have a referral from your PCP at the time of a visit, you will be financially responsible for all services received, due in full upon completion of the visit. If a referral is presented within 48 hours from your visit, a refund will be issued once your visit has been paid. You will also be given the option to reschedule your appointment.

PATIENT BILLING: You will be sent up to three notices for your financial responsibility (co-insurance/deductible) after payment is received from your insurance company. After the third and final notice, your account may be forwarded to collections and 12% interest may be applied. Please let the billing office know if you have any difficulties resolving your bill. We accept Cash, Check, Amex, Visa/Mastercard & Amex. An additional $25 fee will be charged for any returned checks. In the event your insurance company should happen to send payment to you, the patient, we expect that you will forward it to our office to be applied to your balance.

PRIVACY STATEMENT: In accordance with the federally mandated program, The Health Insurance Portability & Accountability Act of 1996 ("HIPPA"), any information disclosed in your records will remain confidential and will not be used for any other reason except in providing quality care and treatment as well as to submit your claim to your insurance company and contact you as needed. A copy of this Notice of Privacy Practices is offered and available if you so request.
Dated: Saturday, February 17, 2018

Call 732-458-4600 for appointments and more information.
Patients from Monmouth County or Ocean County and want an appointment with Dr. Lygas or Dr. Pellegrino
Patients from Brick, Bricktown, Brielle, Wall, Manasquan, Spring Lake, Avon, Avon by the Sea, Long Branch, Sea Girt, Neptune Township, Bradley Beach, Belmar, Lake Como, spring Lake Heights, Neptune, Farmingdale, Ocean Township, Point Pleasant, Point Pleasant Beach, Howell, Bayhead, Mantoloking, Seaside Park, Lakewood, or in Ocean County, NJ, call 732-458-4600 for a Brick Office appointment with Dr. Theodore Lygas or Dr. John Pellegrino.

Patients from Toms River, Forked River, Manahawkin, Long Beach Island, Berkeley Township, Bayville, Beach Haven, Ocean, Manchester, Whiting or any of the Senior Villages, call 732-458-4600 for a Toms River or Barnegat office appointment with Dr. Lygas or Dr. Pellegrino.

Patients from Freehold, Freehold Township, Upper Freehold, Marlboro, Manalapan, Colts Neck, Howell, Eatontown, Jackson, Plainsboro, Monroe, Old Bridge, or Englishtown, call 732-458-4600 for a Freehold or Brick office appointment with Dr. Lygas or Dr. Pellegrino.

Monmouth County patients can be seen in the Brick or Freehold office. Ocean County patients can be seen in the Brick, Toms River, or Barnegat office.

Zip Codes we service: 07722, 07731, 07735, 07717, 07719, 07727, 07740, 07753, 07754,
07762, 07799, 07801, 07802, 07803, 07806, 07869, 08008, 08015, 08527, 08721, 08722,
08723, 08724, 08730, 08731, 08732, 08736, 08740, 08741, 08742, 08750, 08751, 08752,
08753, 08754, 08755, 08756, 08757 and any surrounding towns.