Patient Forms and Policies

For your first appointment, please do the following:

  • Complete the appropriate Evaluation Packet before your first appointment click here.
  • Bring any/all X-rays, MRIs, and Medical Records that may pertain to your current problem/injury.
  • Bring your current health information card and photo identification to each visit. If your visit will be billed under Worker’s Compensation or Motor Vehicle Insurance, you must also bring your health insurance cards for secondary billing purposes.

When you arrive for your appointment, you will be asked to electronically sign that you have reviewed and understand our policies. All policies are defined below:


I Authorize/Agree:

The release of any of my medical records to NERA when additional information is needed for my treatment. NERA to release my medical information to any other physician or provider to whom I am being referred to for treatment. The release of my medical information to my insurance carrier should they need additional information to process and pay for any medical services I receive. Payment of my medical benefits to the above stated physician or provider for services rendered to me. To accept financial responsibility for any services not covered by my insurance or any other third party payer.

Medicare Patients:

I request that payment of authorized Medicare benefits be made either to me or on my behalf to NERA for any services furnished me by physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare Services and its agents any information needed to determine these benefits or the benefits payable for related services.

Worker’s Compensation / Auto Insurance Patients:

Worker’s Compensation or Auto Insurance may deny your claim under some circumstances. We routinely ask our patients to provide us with their Secondary Insurance information, as well as a referral for that insurance from their Primary Care Physician, if required. If claim is denied, you must assume responsibility for payment of your bill.

Act 66 of 1988:

Act 66 of 1988 requires us to notify you that your NERA physician may refer you for a medical service, product or device to a facility or business in which he or she has a financial interest. If this occurs, you will always have the freedom to choose an alternate provider or place of service. Some NERA physicians have a financial interest in Northeast Rehab Medical Fitness, Northeast Rehab Physical Therapy, Center of Specialized Surgery, Healing Arts Center, Northeast Rehab Chiropractic and Armour and Insight Pharmacies.


Insurance Information:

You are responsible to notify us of your insurance and to provide the necessary information about your insurance plan, therefore please have your current insurance card with you at all times. Please notify us at the time of check-in of any changes in insurance, address, phone numbers, etc.

Please remember insurance coverage is a contract between you and your insurance company. The ultimate responsibility for understanding your insurance benefits and for payment to your doctor rests with you. While you may have insurance coverage to pay your medical bills, you are ultimately responsible for all charges. Not all services are covered in all insurance contracts. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges.

To find out what your insurance plan covers and what your financial obligation may be, call the Customer Service or Member Services department of your insurance company (the phone numbers are on your insurance card) prior to your appointment. Make sure that both your physician and the place of service (Hospital, Ambulatory Surgery Center) where services may be performed are listed as a participating provider by your insurance company. It is possible that only the physician or the Hospital/Surgery Center participates with your insurance plan.


Referrals are the patient’s responsibility. If your insurance requires a referral for your visit and there is not one in place, you will be responsible for payment at time of service or your visit will be rescheduled.

Referrals typically have an expiration date and a limited number of visits. You should be careful to monitor dates and visits.


Payment for service is due at time of service. All co-payments are due at time of service. If you are not prepared to pay your co-pay on the date of service, your appointment will be rescheduled. We accept cash, checks, Master Card, Visa and Discover.

Returned Check Fee – Your account will be charged a $25 fee for each returned check. In addition, you will be asked to bring cash to our office or mail a Cashier’s check to cover the returned check and the fee.

Past Due Accounts – Patients who have not made an effort to make payment arrangements may be turned over to a collection agency. Patients who have allowed their account to be turned over to a collection agency will be expected to satisfy their financial obligation to us before returning to see our physicians.

Our Billing Department is available to discuss any questions you may have regarding your account at 877-842-7164 Opt # 8, Monday through Friday 9:00 AM- 4:30 PM.


Arrival Time vs. Appointment Time:

There are several forms and insurance documents which need to be completed at each visit. Routine forms also need to be updated at least annually, sometimes more often. To make the check in process as efficient as possible we ask that you adhere to the following arrival times:

  • New patients: Arrive 30 minutes prior to the scheduled appointment time.
  • If scheduled for an EMG: Arrive 30 minutes prior to the scheduled appointment time.
  • Returning patients: Arrive 15 minutes prior to the scheduled appointment time.

Cancelling or Rescheduling Appointments:

If you should need to cancel or reschedule an appointment, the office requires 24-hour notice.

No Show Policy:

All patients who No Show for their appointments will be charged a $25 No Show Fee. This charge is not billable to your insurance company. If you continue to miss appointments without prior notification, the physician and providers of NERA may decline to provide services.

Late For Appointments:

If you are not here by the requested arrival time, we may need to reschedule your appointment.


If you need a copy of your medical records for another healthcare provider, you will need to complete a Medical Record Release form provided in our office. To obtain records for your personal use, please contact our office to obtain fee information. All balances should be paid before records are transferred. There is a $25 Form Fee for all forms filled out by the physicians. Completion of forms takes 7-10 business days. Forms must be picked up at the office; they cannot be faxed or mailed.


Our Medical Assistant’s phone triage hours are from 9:00AM-4:00PM, Monday through Friday. Please understand they are assisting patients and providers throughout the day. Please leave detailed information and you will receive a call back within 48 hours. If you are experiencing an emergency, please call 911 or go to an Emergency Room.

Requests for medication refills:

  • Refills requests must be made at least two business days before your medication is due. Requests made after this time will not be expedited.
  • When using your NERA Patient Portal or leaving a message in our Prescription Refill Voice Mail system, please leave your name, date of birth, pharmacy information and phone number where you may be reached.
  • Please do not leave repeat messages as this will delay response time.
  • Refill requests will be addressed 9:00 AM- 4:00 PM, Monday through Friday. Requests made after 4:00 PM will not be addressed until the next business day
  • Please check with your pharmacy for completed refill requests. We will only call you if there is a question regarding your refill.
  • Early refills will not be given.
  • It is not our practice to make changes to your prescriptions by telephone. You may be scheduled for an office visit to address medication concerns or changes.
  • New prescriptions, changes to prescriptions or medication refills will not be addressed after office hours, on weekends, or on holidays.
  • We do not accept walk-ins for refill requests.
  • Lost or stolen prescriptions/medications will not be replaced.
  • No refills will be given for canceled or no show appointments.
  • Please refer to your Medication Agreement for more information regarding Prescription Refills.


Service Animals: While we welcome service animals for persons with disabilities, no other animals are allowed in the offices.

Weapons and Firearms: Weapons of any type and firearms are prohibited within NERA offices, regardless of whether the person is licensed to carry a firearm.