New Jersey Disclosure

In-Network / Out-of-Network Patient Notice

308 Springfield Avenue · Berkeley Heights, NJ 07922 · 908-771-0220 · 908-771-0110

Statutory Notice

New Jersey laws and the New Jersey Department of Health require healthcare providers to inform patients of the healthcare plans in which they participate and the facilities with which they are affiliated. In compliance with these requirements, you as the undersigned patient is hereby notified in writing, that:

Health Plans — Our Practice Participates:

Medicare
Blue Cross Blue Shield

Facility Affiliation:

DeFabio Spine and Sports Rehab, LLC
308 Springfield Avenue, Suite 1
Berkeley Heights, New Jersey 07922

Licensed Healthcare Providers:

Christopher J. DeFabio, DC
Donald C. DeFabio, DC

Patient Acknowledgment

I understand the healthcare providers with whom I am seeking healthcare services are:

In Network — they do participate with my insurance carrier. "Out of Network" — they do not participate with my insurance carrier and I am responsible for the amount of my healthcare services and charges, regardless of my insurance carrier's provisions.

I acknowledge receipt of this disclosure from my healthcare providers, acknowledge and understand its content. I certify I am at least 18 years of age, competent, not under the influence of any drug, alcohol or other substance that would impair my ability to understand this disclosure.

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