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Richard M. Seldes, MD

Medical Forms

Provided below are various forms that require completion prior to your visit and/or surgery. Please download the appropriate forms as directed by your physician and/or staff by clicking on the name of the form. Please bring the completed form/s with you to your scheduled visit. This will help expedite the registration process. Thank you.

Please Note: It is the responsibility of the patient as customers of his/her insurance carrier to confirm any needed referrals etc. before they come for their office visit. As a courtesy the staff will give the patient as much information in anticipation of their visit that they may prepare.

New Patient with an HMO Plan
REFERRALS REQUIRED

If you are a new patient with an HMO you must fill out and sign the registration form, hipaa compliance form, have your insurance card, your copay if necessary and your referral at the time of their office visit. Not having any of these items will delay and/or may result in rescheduling of your appointment.

* Patient Registration Form
* HIPAA Compliance Form


New Patient with a PPO Plan
NO REFERRALS REQUIRED

If you are a new patient with a PPO you must fill out and sign the registration form, hipaa compliance form & have your insurance card and copay if necessary at the time of your office visit.

* Patient Registration Form
* HIPAA Compliance Form


New Patient with Workers' Compensation

If you are a new patient with a Workers' Compensation claim you must fill out and sign the registration form, hipaa compliance form and both workers' comp forms. In addition you should have all of the patient's case information and lawyers' information with them at the time of their office visit.

* Workers' Compensation Form
* Patient Registration Form
* HIPAA Compliance Form


New Patient with No Fault

If you are a new patient with no fault you must fill out and sign the registration form, hipaa compliance form and both No fault forms. In addition, you should have all of the insurance information and lawyers' information with you at the time of their office visit.

* No Fault Forms
* Patient Registration Form
* HIPAA Compliance Form


Surgery Forms

If you are a new patient having surgery with us, please review the following forms.

* Pre-Operative Instructions
* Pre-Operative Clearance


Post-Operative Forms

If you are a patient who just had surgery with us, please review the following forms.

* Post-Operative Instructions: ACL Reconstruction
* Post-Operative Instructions: Knee Menisectomy
* Post-Operative Instructions: Shoulder Surgery

If you cannot access the forms, please click on the icon to download the free Adobe Reader software.

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