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Patient Information
Initial Appointments
Notice of Privacy Practices
About Appointments
Staff Assistance and Calls
After hours Problems and Emergencies
Fees and Insurance Coverage
Coordination of Your
Medical Care
Second Opinion
Confidentiality
Medical Facility Affiliations
For Your Day Surgery Needs
Preparing for Your Day Surgery
Post-Surgery Instructions
Finances of Day Surgery
 


Please print and complete these forms. Bring them on your first visit

Patient Demographics
Patient History & Physical

HIPAA
Insurance Assignment Form

Patient informational notices, please review

Need for Referral
Cancellation and No-Show Policy
Copay Referral Policy

Miscellaneous forms

Use of Protected Health Information
Surgical Financial Policy

Consent for financial responsibility for non covered services

Urogynecological Information Packet

Initial Appointments
In order that your first visit is effective and productive and to eliminate duplication of tests, you should bring with you on your first appointment:
Copies of any blood or urine test results and x-ray reports, along with the orginal x-rays, which caused your physician to refer you to us.
A list of current or recent prescription medications, including dose and frequency or bring their containers with you.
The name of medicines to which you have had allergic reactions.
Names of all herbal remedies and vitamins you take.
Pertinent information about your medical and surgical history.
Your health insurance card(s).
A referral form if required.
Any information which will help our staff determine your medical insurance coverage
You will be asked to complete a medical history form and an information sheet with details of your address, insurance information, including authorization to provide your insurance company with information they require for payment of charges. In addition, you will be asked if you wish to authorize a relative or friend to receive medical information about your problem and care. You will also be given our Notice of Privacy Practices and asked to sign that you have received a copy.
 
Notice of Privacy Practices
Our Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
 
About Appointments
We are open for appointments 8:00 a.m. to 5:00 p.m. weekdays. If you are unable to keep an appointment, please let us know so we will be able to see someone else who may be ill. Patients whose problems are urgent and cannot wait will be seen during office hours or in a hospital emergency room depending on the severity of the problem.
 
Staff Assistance & Calls
Our dedicated nurses have been carefully trained to assist the doctors in patient examinations and scheduling of procedures.

When the doctors are in surgery or seeing patients, our medical receptionists refer calls for the doctors to the nursing staff to be sure requests are handled promptly. Our staff will help with patient requests for assistance or information and discuss questions with the doctors to resolve the problem.
 
Fees & Insurance Coverage
Charges for office visits and procedures are determined by the complexity of the visit or procedure. Shore Urology follows federal and state guidelines in establishing fees for services.

Fees and payment plans for surgical and lithotripsy procedures will be discussed in advance with the patient during a consultation with our staff.

NJUI participates in Medicare and many managed care companies. When you make your appointment, indicate the type of insurance coverage you have and our staff will assist you in determining requirements of your coverage. Deductible and co-pay charges are the patient's responsibility and are payable on arrival in the office. Payment of charges at the time of service allows us to contain expenses and patient fees.

Medicare claims will be filed for all Medicare patients and our staff will be pleased to file primary insurance claims for non-Medicare patients. We require payment of individual deductible and co-pay charges at the time of service.

Medical insurance is not a substitute for payment of medical charges by the patient, but is a method of reimbursing the patient for medical expenses paid to physicians. Payment of medical charges for a patient's care is the responsibility of the patient.
 
Coordination of Your Medical Care
Once a patient has been referred to us and care for a problem has been initiated or a problem resolved, a report is submitted to the referring physician on your treatment plan.
 
Second Opinion
Requests for second opinions will always be honored. Records and test results will be forwarded on receipt of the patient's written request.
 
Confidentiality
Your medical records are confidential and no part of your medical history will be given to your employer, friends or relatives without your written permission, except as required by law. Your written authorization is required to submit charges to your insurance company. You will be asked to sign a consent form for procedures performed at surgery centers or hospitals. We honor your privacy and comply with federal and State of New Jersey regulations effected to protect your medical privacy.
 
Medical Facility Affiliations
Central Jersey Surgery Center (see below)
Monmouth Medical Center, Long Branch
Jersey Shore Medical Center, Neptune
 
For Your Day Surgery Needs
When day surgery is indicated, we offer high quality, patient-focused care at our affiliated surgery center, the Central Jersey Surgery Center . The Center is a fully licensed, multi-specialty facility offering you an alternative to hospital care. Our highly trained physicians and professional staff are dedicated to providing each patient and their families with personal attention to ensure comfort . . . before, during and after surgery. The Center was developed by your surgeons to provide you with the highest quality of medical care available.

Located in a private, landscaped setting, the Center offers a comfortable reception area for a family member or friend and is also convenient to shopping and restaurants. Parking is reserved for patient use and is free of charge.

Central Jersey Surgery Center represents the future of ambulatory care. We offer a simple pledge... to make accessible to our patients the finest medical resources, advanced technology and experienced practitioners. We accompany that expertise with the utmost in personalized care and convenience.

To contact the Central Jersey Surgery Center directly, call 732.460.2777. The Surgery Center is located at 97 Corbett Way in Eatontown, New Jersey. Corbett Way is off of Industrial Way West. Industrial Way intersects Route 35 one mile south of the intersection of Rt. 35 and Rt. 36 by Monmouth Mall.
 
Preparing For Your Day Surgery
If day surgery is indicated, we will provide the appropriate services at our affiliated surgery center, the Central Jersey Surgery Center in Eatontown. To prepare for your surgery, read the following instructions:

One or two days before...

You will be contacted by a member of the Surgery Center's nursing staff who will review your medical history, including any medications you are taking. The nurse also will provide instructions to help you prepare for your appointment and arrival time. If any change occurs in your physical condition or you develop a cough, sore throat or fever, please contact your physician's office immediately.
The Night Before Surgery...
Do not eat or drink anything after midnight, unless advised otherwise.
Do not take any medications after midnight, unless instructed to do so by your physician. If you are a diabetic or if you are on blood pressure or heart medication, please get specific instructions from your physician. If medications need to be taken, swallow only with a small amount of water.
If you are having an endoscopic procedure in the afternoon, please get specific instructions from your physician.
 
The Day of Surgery...
Bathe or shower the morning of your surgery. You should brush your teeth, remembering not to swallow.
Bring a list of all your medications (prescription and non-prescription) and a list of drug allergies.
Wear loose, comfortable clothing and shoes.
Leave all jewelry and other valuables at home. The Center cannot be responsible for the security of these items.
Bring your insurance card(s), referral form (if applicable) and a driver's license.
Please have only one person accompany you to the Center.
 
Post-Surgery Instructions
The best part of having day surgery is going home to familiar surroundings. To assist in your recovery, we will provide written instructions for you to take home.

Since it is normal to feel drowsy after receiving sedations, you must have a family member or friend drive you home. We urge you to refrain from the following activities for 24 hours:

Signing any important papers or making significant decisions
Driving or operating any equipment
Drinking alcoholic beverages

At Central Jersey Surgery Center, care doesn't end when you leave our facility. We encourage you to promptly contact your surgeon or the Center if you have any questions about your recovery.
 
Finances of Day Surgery
As in the hospital, charges for facility services and suupplies are billed separately from your doctors' fees. After your procedure, you will receive separate bills from your doctor and the Center. Bills from anesthesiologist, pathologist, and or a laboratory are sent only if applicabale.

For those with no insurnace, we accept cash, checks, Mastercard, VISA, Discover, and American Express. payment is expected to be made on or before the day of surgery, unless other arrangments have been made. We accept most insurance plans, including Medicare. Also, if needed, we'll work with you to create a payment plan.

To ensure an efficient registration process, please be familiar with your insurance coverage before you arrive for surgery. Satisfying the conditions of an insurance policy is the responsibility of the patient so when inquiring about coverage, ask your insurance company if it covers "freestanding ambulatory" facilites. Also be sure to ask if any specific documents, such as a second surgical opinion, a letter of certification or a referral, are required.
 
Our Physicians
Jules M. Geltzeiler, M.D., F.A.C.S.*
Y. Samuel Litvin, M.D., F.A.C.S.*
Ira G. Keselman, M.D., F.A.C.S.*
Ilan Waldman, M.D., F.A.C.S.*
Betsy A. B. Greenleaf, D.O.
*Diplomates of the American Board of Urology
† Board Certified Female Pelvic Medicine and Reconstructive Surgery
 

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Our Offices
Eatontown
10 Industrial Way East
Eatontown, NJ 07724
Telephone: 732.963.9091
Fax: 732.963.9092

Morganville
25 Kilmer Drive
Building 3, Suite 214
Morganville, NJ 07751
Telephone: 732.536.8880

 
 
 
  info@njurologic.com