Faculty Group Practice Patient Demographic Form

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1 Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred SSN Date of Birth Gender Marital Status Single Married Divorced Widowed Separated Partner Other Male Female Religion (optional) Race/Ethnicity (optional) Address Financially Responsible Party Emergency Contact Is patient responsible party/guarantor? Yes No (If you are over the age of 18 and not in the care of an institution you are the guarantor as you are the person financially responsible for any charges you may incur during your visit) Name Address City/State/Zip Relationship to Patient Occupation Employer Address Home Phone ( ) Preferred Name Home Phone ( ) Preferred Work Phone ( ) Preferred Relationship to Patient Work Phone ( ) Preferred Cell Phone ( ) Preferred Cell Phone ( ) Preferred Referral Info Primary Care Physician Name (if applicable) Physician Address (if known) How did you hear about us? Physician Phone/Fax (if known) ( ) / Primary Insurance Company Policy # Group # Insurance Information Patient s Relationship to Insured Self Spouse Child Other Subscriber s Social Security # Gender Male Female Name of Subscriber (if other than patient) Date of Birth Employer of Subscriber Work Phone ( ) Secondary Insurance Company Policy # Group # Patient s Relationship to Insured Self Spouse Child Other Subscriber s Social Security # Gender Male Female Name of Subscriber (if Other Than Patient) Date of Birth Employer of Subscriber Work Phone ( ) By signing below, I acknowledge that the information I provided is correct to the best of my ability. Patient Signature: Guarantor Signature (if other than patient): Date: / / Date: / /

2 With the installa+on of Epic, the new electronic medical record system, at this prac+ce, your doctor is now able to e prescribe. This means that any prescrip+ons the doctor may give you today will be automa+cally routed the pharmacy of your choice and we will no longer have to provide you with handwri>en prescrip+ons. In addi+on, when you run out of refills on your medica+on, the pharmacist can also electronically send a renewal request to this office for approval. **Note: Controlled medica+ons are not eligible for e prescribing. Pharmacy Informa>on Collec>on Form Please complete the informa+on below if you are interested in e prescribing. Preferred Pharmacy Alternate Pharmacy Name of Pharmacy: Name of Pharmacy: Address: Address: City: City: State: State: Zip Code: Zip Code: Phone Number: Phone Number: Fax Number: Fax Number:

3 FACULTY GROUP PRACTICE FINANCIAL POLICIES AND PATIENT RESPONSIBILITY 1. RELEASE OF INFORMATION: I authorize NYU School of Medicine, my treating physicians and their respective designees, to use and disclose my health information for all purposes necessary for treatment, payment and health care operations, including but not limited to release of information requested by my insurance company (or carrier) and any information necessary for discharge planning purposes. Initials 2. ASSIGNMENT OF INSURANCE: I hereby authorize my insurance benefits to be paid directly to NYU School of Medicine. I understand I am financially responsible for non-covered services. I authorize the release of any medical or other information necessary to process insurance claims on my behalf. Initials 3. FINANCIAL LIABILITY: I have been provided a copy of the NYU School of Medicine financial policies and agree to the specified terms. I hereby agree to pay all charges due (or to become due) to NYU School of Medicine for care and treatment, including co-payments and deductibles as provided under my plan. Benefits, if any, paid by a third party, will be credited on account. I understand that I will be responsible for any charges if any of the following apply: My health plan requires prior authorization or referral by a Primary Care Physician (PCP) before receiving services at NYU School of Medicine and I have not obtained such an authorization or referral or I receive services in excess of such authorization or referral, and/or My health plan determines that the services I receive at NYU School of Medicine are not medically necessary and/or not covered by my Insurance plan, and/or My health plan coverage has lapsed or expired at the time I receive services at NYU School of Medicine, and/or I have chosen not to use my health plan coverage. Initials 4. MEDICARE SIGNATURE ON FILE (Medicare Patients Only): I request that payment of authorized Medicare benefits be made either to me or on my behalf to all providers who treat me during my hospital stay or any services furnished to me by those providers. I authorize the holder of medical and other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services. Patient s Medicare Number Patient Signature 5. ANCILLARY SERVICES: I understand I may receive certain ancillary medical services while I am at NYU School of Medicine; such as, anesthesia, interpretation of cardiac tests, imaging services (e.g., x-rays, MRIs) and pathology specimen examination. I understand that some physicians may not provide services in my presence, but are actively involved in the course of diagnosis and treatment. I hereby authorize payment directly for these services under the policy(s) or plan(s) issued to me by my insurance carrier. I understand that I may incur additional charges as a result of these ancillary services; I agree to pay all charges due with respect to such services to the extent the charge is due after credit is given for benefits paid on my behalf by any third party payor. Initials 6. CANCELED OR NO-SHOW APPOINTMENTS: I understand that I may incur a cancelation fee if I do not provide 24 hour notice of cancelation, or if I do not keep my appointment and have not canceled. Initials I have been provided the Faculty Group Practice Patient Financial Polices. I understand the information listed above which has been fully explained to me. Patient Signature Guarantor Signature Date Date Form Revised: 8/17/09

4 NYU FACULTY GROUP PRACTICE PRIVATE CONTRACT WITH MEDICARE BENEFICIARY This agreement is between Dr. ( Physician ), whose principal place of business is, and patient ( Patient ), who resides at and is a Medicare Part B beneficiary seeking Services covered under Medicare Part B pursuant to Section 4507 of the Balanced Budget Act of Physician has informed Patient that Physician has opted out of the Medicare program effective on / / for a period of at least two years and is not excluded from participating in Medicare Part B under Sections 1128, 1156, 1892 or any other section of the Social Security Act. Physician agrees to provide the following medical Services to Patient (the Services ): Evaluation & Management, Consultation and Professional Component Services. In exchange for the Services, the Patient agrees to make payments to Physician pursuant to the Physician s Fee. Patient also agrees, understands and expressly acknowledges the following: Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B. Patient is not currently in an emergency or urgent health care situation Patient acknowledges that neither Medicare s fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services. Patient acknowledges that MediGap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement. Patient acknowledges that he or she has a right, as a Medicare beneficiary, to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted out. Patient agrees to be responsible to make payment in full for the Services and acknowledges that Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided. Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim was submitted. Patient acknowledges that a copy of this contract has been made available to him or her. Patient agrees to reimburse Physician for any costs and reasonable attorney fees that result from violation of this Agreement by Patient or his beneficiaries. Executed on [date] by: (Patient name) (Physician name) (Patient Signature) (Physician Signature) Revised 8/11/09

5 NYU Faculty Group Practice NON-PARTICIPATING FINANCIAL AGREEMENT I have been advised by NYU School of Medicine that my physician does not participate with my insurance plan and therefore, I will be fully financially responsible for these services. As such, I agree to the following: Office Services (Doctor Visits) Payment for routine office visits is expected in full at the time services are rendered. I will be informed of the estimated payment at the time of scheduling. A courtesy claim will be sent to my insurance carrier on my behalf. In some cases the actual amount of total charges may not be known at the time of service. Should the actual charges be more than the payment made at time of service, I will be billed for and responsible for any remaining balances. Should the actual amount be less than I paid, I will receive a refund or elect to have the overpayment applied to other patient responsible balances. Testing Services Not Part of the Doctor Visit (EKG, Echo, etc.) A courtesy claim will be sent to my insurance carrier on my behalf. I will be billed for and responsible for any balances not paid by my insurance. Elective Surgeries (Inpatient and Office-Based) I will be informed of the estimated amount at the time of scheduling and asked to sign a financial agreement prior to provision of the service. A minimum pre-payment of 20% of the estimated charges will be collected prior to the service being rendered. A courtesy claim will be sent to my insurance carrier on my behalf. The amount quoted prior to the service is an estimate and actual charges may vary; I will be billed for and responsible for any remaining balances. I understand that all balances are due upon receipt of statement from NYU.* Print Patient Name Patient Signature Print Physician Name Insurance Plan Date *Your insurance company will be billed. However, after 58 days you will be responsible for the entire amount if your insurance company has not paid. Revised: 8/10/09

6 NYU Langone Medical Center Notice of Privacy Practices NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT FORM I have received a copy of NYU Langone Medical Center s Notice of Privacy Practices. By providing my address, I consent (agree) to receiving notifications, including breach notifications, through the Medical Center s secure messaging system. Patient Name: Personal Representative Name (if applicable): Personal Representative s Authority (ex: parent, guardian, health care proxy): Address: Signature: Date: Effective as of 05/23/

7 NYU LANGONE MEDICAL CENTER NYU Hospitals Center and NYU School of Medicine Consent for Electronic Health Information System I have received the NYU Langone Medical Center Electronic Health Information System Fact Sheet. It describes (1) the purpose of the NYU Langone Medical Center Electronic Health Information System; (2) how it works; and (3) how the providers participating in the NYU Langone Medical Center Electronic Health Information System will record and access my health information. I acknowledge receipt of the Electronic Health Information System Fact Sheet. I have read and understand the Fact Sheet. I also understand that by signing this form, I am agreeing to permit all NYULMC providers directly involved in my care to create, access, use and/or share my health information (including my electronic prescription records) for treatment, payment and healthcare operations and, to permit my health information to be available to my other health care providers, all as described in the attached Electronic Health Information Fact Sheet. I also understand that there are other uses and disclosures of Protected Health Information that are permitted under applicable law and are outlined in the Notice of Privacy Practices. I understand that this consent will remain in effect unless revoked in writing. Upon revocation, I understand that, except in an emergency, I can no longer be treated at NYU Langone Medical Center or by NYU providers who use the NYULMC EHR in their office practice. Signature: Date: Time: AM/PM (Patient or person authorized to sign) If the consenting party is other than the patient, print name and relation to patient: Page 1 of 1 (Rev. 07/13)

8 NYU Langone Medical Center ELECTRONIC HEALTH INFORMATION SYSTEM FACT SHEET What is the NYU Langone Medical Center Electronic Health Information System? The Hospitals, the Faculty Group practices and many of the individual physicians, physician practices and other providers that make up the NYU Langone Medical Center community and who are directly involved in your care are able to create, access and share your health and pharmacy records electronically. What are the advantages to having an electronic health record? Paper health records may be stored in separate locations and would be otherwise unavailable to us when needed. It is also more difficult to combine into a paper record information about care provided to you by different hospitals, physicians, laboratories, etc. The electronic health record lets us see your records faster and helps us to keep more complete records of your medical history. This includes information about your allergies, medications, test results, or other past records, including health insurance coverage and billing and payment for services you received. An electronic health record also helps us to better coordinate care because NYU Langone Medical Center hospital and healthcare professionals may share information from your health records with one another and with other providers (such as physicians not on staff at NYU Langone Medical Center hospitals, other hospitals, nursing homes, home health agencies, and pharmacies) if: (i) the provider that receives the information is a provider with whom you have a treatment relationship, and/or (ii) the information will be used for treatment, payment, continuity and coordination of care, discharge planning, billing, improving quality and effectiveness and reducing the cost of care, reviewing the qualifications of or training healthcare professionals, or addressing fraud and abuse issues. Therefore, having a more complete record of your care and the ready access to it helps us to provide better care. You will be asked to give your consent for your providers to create, access, use and/or share your medical records in the NYU Langone Medical Center Health Information System. You are entitled to a copy of the signed consent form. If you give this consent, but later change your mind, you can revoke (take back) your permission by contacting the NYU Langone Medical Center s Privacy Manager or the practice manager in your physician s office.

9 Which healthcare providers may participate in the Electronic Health information System? The following providers are currently part of the NYU Langone Medical Center community: Physicians at NYU Faculty Group Practice Offices NYU Hospitals Center, including: Tisch Hospital Rusk Institute NYU Hospital for Joint Diseases NYU Clinical Cancer Center NYU Ambulatory Care Center Center for Musculoskeletal Care Physicians in Private Practices with privileges at NYU Hospitals Center Physicians at Other NYUHC Outpatient Centers Other healthcare providers not listed above may join in the future as the NYU Langone Medical Center community grows. A special message about sensitive information. Certain state and federal laws have stricter rules about keeping certain types of health information confidential. This includes: Information from facilities licensed by the NYS Office of Mental Health. Information from federally assisted alcohol and drug abuse programs. Information about certain healthcare services to minors, including family planning and abortion services, testing for HIV and sexually transmitted diseases (STD s), and mental health and substance abuse treatment. Genetic test results. Information about diagnoses, lab results or medications for HIV or AIDS. The NYU Langone Medical Center Electronic Health Information System will include any of the above types of sensitive information that are a part of your medical record. By giving consent you are agreeing to the creation of, access to, and use and sharing of your medical information, including health information related to your treatment for mental health, developmental disabilities, HIV/AIDS testing and services, genetic testing and counseling services, drug and alcohol abuse, abortion, family planning, or sexually transmitted diseases, even if (a) such information was obtained prior to the date of the visit on which I sign the consent form or (b) I am tested, diagnosed or treated for the conditions to which my restricted information relates for the first time during that visit or a later visit while the consent is in effect ( restricted information ). Such access, use and sharing shall be by and between NYU Langone Medical Center hospitals and healthcare professionals for treatment, continuity and coordination of care, and billing for services provided. 2

10 Any NYU Langone Medical Center hospital and healthcare professionals may share your restricted information between and among one another and other providers if: (i) the provider that receives the information is a provider with whom you have a treatment relationship and (ii) the restricted information will be used for treatment, continuity and coordination of care, billing for services provided, or discharge planning. Your restricted information may also be disclosed for Health Care Operations as described within the NYU Langone Medical Center hospitals Notice of Privacy Practices (such as reviewing and improving the quality, effectiveness and cost of care, reviewing the qualifications and training of healthcare professionals and addressing fraud and abuse issues.) If you choose to have your private health insurance, Medicare, Medicaid, or other insurance or payment program pay for your treatment, any NYU Langone Medical Center hospital or healthcare professional may use and release your restricted information to the entity responsible for payment or their agent to obtain payment for the treatment and services provided to you by the NYU Langone Medical Center hospital or healthcare professional. Is your health information kept private and confidential? Yes. No one can guarantee that information in medical records will be totally free from access, use and disclosure other than in the ways you agree to in your consent. However, the Medical Center and every healthcare provider or staff member that shares or uses information through the NYU Langone Medical Center Health Information System must obey strict security and privacy rules that permit your health information to be used and shared only as more fully described in this Fact Sheet. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access or use of your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call , your doctor s office or the NYS Department of Health at Where can I get more information? For more information or to ask questions, please contact: NYU Langone Medical Center Privacy Manager One Park Avenue New York, New York Call your physician s office 3

11 Faculty Group Practice Financial Policies Thank you for choosing NYU Langone Medical Center for your medical care. We appreciate that you have entrusted us with your health care and we are committed to providing you with the best patient care possible. Because healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you better understand your responsibilities as a patient. We will do our best to assist you with understanding your proposed treatment and in answering questions related to submitting your insurance claim for reimbursement. Your health insurance policy is a contract between you and your health insurance company or your employer. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals, precertifications, preauthorizations, limits on outpatient charges, and any requirements for specific physicians, labs and/or hospitals to use. You should be knowledgeable of any deductibles, copayments, and/or coinsurance. This applies to all payors regardless of whether or not our physicians participate. If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of- pocket fees, and coverage limits. PLEASE KEEP THESE POLICIES FOR FUTURE REFERENCE Insurance Coverage Please provide us with your current insurance plan information at the time of each visit and notify us of any changes. We will request a copy of your insurance card to copy or scan and keep on file for our records. Please be aware of and provide any required referrals or authorizations in advance of the appointment or service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification. Our doctors belong to many insurance plans but participation differs by doctor. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the costs of care. We will help you find out if you have out-of-network benefits and submit a claim to your plan on your behalf. Refer to our out-of-network policy below for more details. Please let us know at any time if you do not want us to submit a claim to your plan. Address Change It is important that we have your correct address information on file. Please advise us anytime there is any change to your address, telephone or other contact information. Co-payments/Co-insurances/Deductibles You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time of service. Other Bills You may receive services at NYU Langone Medical Center such as anesthesia, radiology testing, pathology, or other services. These doctors provide vital services and are involved in your care even though you may not be present at the time. There may be additional charges for these services. In addition, you may receive in-patient or out-patient hospital care at NYU Langone Medical Center. If so, you will receive a hospital bill for those services. Hospital bills are separate from our doctor services. If you have questions, you may contact the hospital billing office at (800) Rev. 07/28/2009

12 Payments Payment is due at the time services are provided or upon receipt of a statement from our billing office. We accept payment in the form of cash, check, money order or credit card (American Express, MasterCard or Visa). Returned checks are subject to a fee. We do not accept traveler s checks. Non-Medical Fees Additional fees may apply to the following: Returned Checks Copying of medical records Completion of disability or other forms Missed Appointments We require a 24 hour cancellation notice. If you miss your appointment, or do not cancel with the required notice, additional fees may apply: Office Visit: $50 Second Office Visit $75 New Patient Visit: $75 Office Procedure /Surgery $150 Out-of Network Providers If the doctor is not in your insurance plan, the following apply: Full payment is due at the time of service for routine visits. Payment expected on the date of service may be an estimate of your total charges. You will be quoted an estimated fee before services/procedures are performed. A deposit is required prior to the date of service for elective surgeries and procedures. After your appointment, we will submit a claim to your plan for services performed. Depending on your plan, payment may be sent to you. If you receive this payment, you must reimburse NYU Faculty Group Practice immediately. Non-Covered Services Medicare Patients. Medicare may not cover some services your doctor recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully. Non-Medicare Patients. Any service not covered by your plan are your responsibility and must be paid in full at the time of service or upon receiving a bill. Refunds A refund is issued when an overpayment has been identified. If you feel a refund is due, please contact our billing office at (877) Failure to Pay If you do not pay your bill, your account will be sent to an outside collection agency. If your account is sent to a collection agency, you need to contact them directly to settle your balances. Policy and Fee Changes These policies and fees are subject to change. We will do our best to keep you informed of any modifications. We know medical care can become expensive. If you have concerns about your ability to pay, you can contact us for help in managing your account. If you have questions about these policies, feel free to ask any of our staff for more details or call our billing offce at (877) Rev. 07/28/2009

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