The Rubino OB/GYN Group respects you and your time. We strive to make it easy for you to get the care you deserve as quickly and easily as possible. Utilizing our online registration form below allows you to complete your New Patient Registration in the convenience of your home prior to your appointment, ensuring your scheduled appointment time.

Patient Information Sheet

Patient Medical History

Family Physician Phone

Pharmacy Phone

Do You Have Any Medical Problems?

Have You Ever Had Any Surgeries?
Yes No       If Yes, Please List

Do you have any family memebers with any medical problems (mom/dad, siblings)?
Yes No       If Yes, Please List

Do You Smoke?     Yes No      If Yes, How Much?
Do You Drink?     Yes No      If Yes, How Much?

Number of Pregnancies    Number of Miscarriages    Number of Deliveries
Date of Last Menstrual Period                Periods are     Regular Irregular

Do You Have Any Allergies To Any Foods or Medications?
Yes No       If Yes, Please Explain Reaction

Please List Any/All Medications (including vitamins or birth control) That You Are Presently Taking

How did you hear of our practice/who referred you?

Nearest relative not living with you Relative Phone Landlord (if applicable) Landlord Phone

Insurance Information

Primary Insurance Carrier
Subscriber’s Name
Patient’s Relationship To Subscriber
Date of Birth & SS#, If Other Than Patient

ID#     Group#
Do You Have A Copay? Yes No      If Yes, How Much?
Does Your Insurance Cover Annual Well Women Visits? Yes No
*If you do NOT know and we code your visit as a routine exam, we can NOT change the code if the Ins. Co. denies the visit!

Secondary Insurance Carrier
(We DO NOT submit to secondary carriers but will accept payment from them only if we participate with them.  You must submit to your secondary carrier [unless you are a Medicare Patient]. )

Subscriber’s Name & Date of Birth

Secondary ID#       Secondary Group#

Assignment of Benefits

I Authorize Payment of Medical Benefits To:   Rubino OB/GYN Group, PA
                                                                101 Old Short Hills Road, #410
                                                                West Orange, NJ 07052
I Authorize Rubino OB/GYN Group (ROG) to submit claims to my primary insurance carrier on my behalf. I also authorize assignment of benefits directly to the office, and release of my medical records requested by my insurance carrier(s). I also acknowledge that if ROG does NOT receive payment from my Insurance carrier, I will be held responsible for the balance of my bill. I have read all the information on this form and have completed the above answers.  I certify this information is true and correct to the best of my knowledge.  I will notify you of any changes in my status or the above information.

I acknowledge that I must pay any applicable copay at the time of my visit and that failure to pay will result in rescheduling of my appointment.   I agree that if I do not present valid insurance information at the time of my visit I will pay the full charge for an office visit prior to receiving service.  If valid insurance information is provided at a later date, ROG will reimburse me the appropriate amount following payment by my insurance carrier.  I acknowledge that if I fail to provide the proper insurance information at the time of the visit I may be subject to an administrative charge to refile insurance claims.  I acknowledge that any patient balances billed to me are due within 30 days of the statement date and that simple interest of 1% per month will be applied to outstanding balances that are not paid by the due date.  I acknowledge that I will be subject to a $25 charge for failing to cancel a scheduled appointment.

To retain a completed copy for your records
Click the print button BEFORE submiting the form