Nephrology Associates New Patient Registration Forms

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1 Registration Information Authorization form: Last First Middle Address: City: State: Zip: DOB: / / - - Home # ( ) - - Cell # ( ) - - Address: Alternate Contact Information Phone Number Relationship to Race: Sex: M F Marital Status (Circle One) S M W D Ethnicity: (check one) Hispanic or Latino Non-Hispanic or Non-Latino Unknown Employer Information s Employer Occupation: Address of Employer Phone # Spouse s Information Spouse s DOB: / / - - Spouse s Employer: Occupation: Spouses Employers Address & Phone Number: 1

2 Registration Information Authorization form: (Page 2) Physician Information Referring MD: Phone # Primary Care Physicians Name Phone # Insurance Information: Primary Insurance Carrier: ID# Group # Insured s Relationship Secondary Insurance: ID# Insured s Group# Relationship Prescriptions benefit carrier: By signing below I hereby authorize Nephrology Associates to release any protocol or individually identifiable health information to other Providers, Facilities, or Individuals involved with my treatment or the payment thereof, as described in the privacy policies statement of Nephrology Associates. I further request that payment of authorized Medicare/Medigap/Medicaid/other insurance company benefits be made directly to Nephrology Associates for any services furnished to me, and hereby assign said benefits to them. I understand that I am required by law (section SS Act & U.S.C ) to inform Nephrology Associates of any the party that may be responsible for services provided to me. Signature of /Guardian Date Co-pays and deductible are expected to be paid at the time of services. 2

3 Authorization for Disclosure of Health Information Form I hereby authorize the use or disclosure of named individual s health information as described below: The following individual or organization is authorized to make the disclosure: Name Other (Please specify) The following information is authorization for use and disclosure: Office visit notes Lab test result Imaging test results Summaries of procedures, operations, hospitalizations Complete record Other (please specify) Reason for use & disclosure: Continuing Care Transfer of Care Insurance Personal reasons Attorney/Court Case Other (please specify) Sensitive Information: I understand that the information ibn my record may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or infection with Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services or treatment for alcohol and drug abuse. (Initials) Disclosure: I understand that any disclosure of information carries with it the potential for redisclosure and that the information then may not be protected by federal confidentially rules. (Initials) Right to Revoke: I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be in writing. I understand that the revocation will not apply to information already released based on this authorization. (Initials) Right to Inspect and Copy: I understand that I have a right to inspect and receive a copy of the information that is used or disclosed based on this authorization. (Initials) 3

4 Authorization for Disclosure of Health Information Form (Page 2) Expiration: Unless otherwise revoked, this authorization will expire on the following date, event, or condition: (If you do not specify an expiration date, event, or condition, this authorization will expire in twelve (12) months). s Name (Printed) Signature of or Representative Printed Name of Representative (if applicable) Relationship to Nephrology Associates 251 Lyerly St. Ste. 100 Chattanooga, TN B E. Third St., Chattanooga, TN Chambliss Ave. Ste. 200, Cleveland, TN

5 Release of Protected Health Information Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment, and health care operations): Relationship: Phone Number ( ) (circle one) Home Cell Other Relationship: Phone Number ( ) (circle one) Home Cell Other Relationship: Phone Number ( ) (circle one) Home Cell Other Please print the telephone number where you want to receive calls about your appointments, lab, and ex-ray results, or other health care information if other than your home phone number: **I m fully aware that a cell phone is not a secure and private line. Can confidential messages (i.e. appointment reminders) be left on your telephone answering machine or voic ? Yes or No Can we communicate and send test results through our Portal or ? Yes or No Signature of or Representative Printed Name of Representative (if applicable) Relationship to 5

6 Authorization for Disclosure of Health Information I,, have received a copy of Nephrology Associates Notice of Privacy Practices. Signature of : Nephrology Associates 251 Lyerly St. Ste. 100 Chattanooga, TN B E. Third St., Chattanooga, TN Chambliss Ave. Ste. 200, Cleveland, TN

7 Notice of Privacy Policies and Practices Dear, This notice describes how information about you may be used and disclosed, and how you can get access to this information. PLEASE REVIEW THIS CAREFULLY Our physicians and staff are committed to using your personal health information responsibly. This notice describes the personnel information we collect, and how and when we use or disclose this information. This notice is effective as of April 14, 2003, and applies to all of your protected health information (PHI) as defined by Federal regulations. YOUR MEDICAL RECORD Each time you visit our office a record of your visit is made. Typically, this record contains information about your visit, including your exam, diagnosis, test results, treatment, and other pertinent health data. This information, often referred-up as your medical record (PHI) serves as a: Basis for planning your care and treatment. Means of communication with other health professionals involved in your care. Legal document outline and describing the care you re received. Tool that you, or another payer (i.e. Insurance Company) will use to verify that services billed were actually provided. An educational tool for Medical Health Providers. Source for medical research. Basis for public health officials who might use this information to access and/or improve State and/or National Healthcare Standards. Souce of data for this Practice s planning and marketing. Tool that we can reference to ensure the highest quality of care and patient satisfaction. 7

8 Notice of Privacy Policies and Practices - Page 2 YOUR RIGHTS You have certain rights under the federal privacy standards. These include the rights to: Request restrictions on the use of your protected health information. Receive confidential communications concerning your medical condition and treatment. Inspect and receive a copy of your protected health information. Amend or submit corrections to your perfected health information. Receive an accounting of how and to whom your protected health information has been disclosed. Receive a printed copy of this notice. OUR RESPONSIBILITIES Nephrology Associates is required to: Maintain the privacy of your health information. Provide you with this Notice as to our legal duties and privacy practices with respect to information that we collect and maintain about you. Abide by the terms and obligations of this notice. Notify you, if we are unable to agree to a requested restriction. Accommodate reasonable requests you may have regarding communication of health information via alternative means and locations. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. When revisions occur, we will provide you with a revised notice on your next visit to our office. The revised policies and practices will be applied to all protected health information that we maintain. We will not use or disclose your health information without your authorization, except as described in this notice. We also will discontinue using or disclosing your health information after we have received a written revocation of the authorization according to procedures included in the authorization. 8

9 Notice of Privacy Policies and Practices - Page 3 HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION We will use your health information for Treatment: Your health information may be used by our staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example: results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment to you, or who may be consulted regarding your treatment by physicians and staff. We will use your information to receive payment for Services: Your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated in order to pay for the services you receive. We will use your information in the operations of our Practices Business: Your health information may be used to make business decisions necessary for the management, operations, and development of the practice. For example: Information on the services you receive may be used to support budgeting and financial reporting, and activities to support quality assurance. We may provide your information to Business Associates: In some instances we have contracted with separate partied to provide services for us. These associates require your health information in order to perform the services contracted, some examples of these business associates are a billing service, collection agency, answering service, and computer consultants and vendors. Communication Information to Families: Due to the nature of medical care we use our best judgment when disclosing your information to a family member, or any other person who is involved in your care or whom you have authorized to receive your information. Please inform the Practice if your family situation changes, or in case you do not want a family member or other person to have authorization to receive your PHI (personal health information). Research/Teaching/Training: We might use your information for the purpose of research, or teaching and training residents. Healthcare Oversight: Federal law requires us to release your information to an appropriate health oversight agency, public health authoriztym, or attorney, or other federal/state appointee if there are cicumstances that require it. Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. Law Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigation, and to comply with government mandated reporting. 9

10 Notice of Privacy Policies and Practices - Page 4 Appointment Reminder: The practice may use your information to remind you about your upcoming appointments. Usually, appointment reminders are first made by phone call, a brief message may be left on your answering machine. If you don t approve of these methods, or prefer alternative methods, please advise us. Other Uses and Disclosures: Disclosure of your health insurance information or its use for a purpose other than those previously mentioned requires your specific written authorization. If you change your mind after authorizing a use of disclosure or your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of you decision. Signature: FOR MORE INFORMATION, OR TO REPORT A PROBLEM If you have complaints, problems, or would like more I formation regarding this notice of Nephrology Associates privacy practices, please contact -Privacy officer (423) If you feel your privacy rights have been violated, please contact the above individual; or, you may file a complaint with: Office of Civil Rights U.S. Dept. of health and Human Services 200 Independence Ave., S.W. Room 509F HHH Building Washington, DC There will be no retaliation for filing a complaint with either the Practice s Privacy Officer or with the Office of Civil Rights. 10

11 Payment Policy (2/2015) / / Account #: Our mission at Nephrology Associates is to provide quality, cost-effective healthcare to our patients. As a courtesy, we participate in most major health insurance plans to make that care more accessible. Please take a moment to review the following information in order to better understand our policies regarding payment for services. PRACTICE RESPONSIBILITIES Provide you with quality, cost-effective healthcare services. Provide you and/or your insurance company with a timely and accurate statement of all charges for services rendered. Explain fully all charges for services rendered and acceptable payment methods. Assist with any questions regarding insurance coverage and patient due balances. PATIENT RESPONSIBILITIES Provide Nephrology Associates with proof of your current insurance information, employment, and demographic information at the time of each visit. Notify us within 10 business days if you have a change in insurance status. Understand which services are covered by your insurance plan and obtain any necessary authorizations or referrals prior to your appointment with us. Understand the requirements that must be met for payment of laboratory services and which laboratories must process your blood work for your insurance to pay. Pay in full your expected portion of the balance of your account at the time of service. This includes co-pay, coinsurance, deductibles and payment for non-covered services. Pay in full any remaining balance upon receipt of a billing statement from our office. If you are not able to pay your balance in full, please contact our Financial Advocate. BILLING Insurance reimbursement is a contract between you and your insurance company. We file all insurance claims for plans with which we have a contractual relationship. All other claims are filed as a courtesy only. If your insurance claim has not been paid or settled within 90 days from the date of service, then you may be billed for the balance. We make every attempt to code and file claims accurately according to the services rendered. Initials: 11

12 Payment Policy (2/2015) - Page 2 / / Account #: INSURANCE Nephrology Associates accepts many different health insurance plans. Our staff will work diligently to assist you in using your insurance coverage wisely; however, it is your responsibility to understand the limits and restrictions affecting coverage for services provided. There are hundreds of different insurance plans and it is not possible for our staff to be familiar with the details of each and every plan. It is your responsibility to inform us of your current insurance coverage prior to or at the time services is rendered. Insurance plans rarely cover all services or pay the entire amount of covered services. You will be expected to pay for the following at the time of service: Co-pay, co-insurance and deductible if not covered by a secondary insurance policy. The entire amount of any non-covered service. The entire amount for services or procedures if we have not yet received a required authorization or referral from your primary care physician or insurance company. The entire amount of any services rendered if we are unable to verify your insurance coverage at the time of service. Initials: MEDICARE Nephrology Associates is a participating provider with the Medicare program. Traditional Medicare pays only a portion of your bill for covered services. Unless you have secondary insurance coverage, you will be expected to pay 20% of Medicare s allowed amount, any remaining portion of your annual deductible and 100% of all noncovered services. If you have chosen a Medicare Replacement plan over Traditional Medicare, you are required to present that card prior to any services being rendered. If you fail to present a valid card for a Medicare Replacement plan until after the services are rendered, you will be financially responsible for any services that are considered non-covered. Initials: MEDICAID/TENNCARE Nephrology Associates participates with Tenncare and Georgia Medicaid. We will accept and file your Tenncare/Medicaid insurance; however, you must present a current copy of your card at each visit. If you do not bring your card to each visit, you will be considered a self-pay patient that day and will be expected to pay for your visit. Initials: 12

13 Payment Policy (2/2015) - Page 3 / / Account #: SELF-PAY s who do not have insurance coverage (or proof of coverage) are expected to pay in full at the time that services are rendered. If you are unable to pay the full amount, you must make satisfactory payment arrangements with our billing department prior to receiving services. Initials: I have read, understand, and agree to the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable co-payments, co-insurance and deductible are my responsibility. I authorize my insurance benefits be paid directly to Nephrology Associates. I authorize Nephrology Associates to release pertinent medical information when necessary for treatment, payment or operations. I consent to examination, treatment and diagnostic studies as necessary for my care. I agree to bring all medications and supplements, in their original containers (including herbs and vitamins), to each visit. I understand that it is my responsibility to notify the office if I will be unable to keep a scheduled appointment as that time has been dedicated for me. Signature of or Responsible Party Date If you have any questions regarding this Payment Policy, please ask to speak with a member of our Front Desk Staff or call our Billing Office at (423) and ask to speak with a Financial Advocate. 13

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