!!!! Infectious Disease Center of New Jersey, LLC! Any Allergies: Family History:! Mom:! Dad: Your Medical History:
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1 Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: Suite 106 F: Livingston NJ Patient Name Any Allergies: Family History: Mom: Dad: Your Medical History: Are you currently experiencing any of the following? (Please check all that apply) Abdominal pain Change appetite Diarrhea Constipation Vomiting Difficulty urinating Burning during urination Frequent Urination Difficulty urinating Genital itching/rash Genital lesions Joint pain/ swelling Muscle pain Skin itching/rash
2 Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: Suite 106 F: Livingston NJ Patient Name: Please List all your Current medications: Medication Dose: Frequency: Do you have any pets? Yes NO If yes, please describe: Have you traveled recently? Yes NO If yes, please describe: Do You? Smoke: Yes NO If yes, please indicate how many cigarettes per day Alcohol Use: Yes NO If yes, please indicate how much per week Recreational Drugs: Yes NO If yes, please describe FOR FEMALES: Date of last menstrual period: Date of last pap smear: Date of last mammogram: Number of pregnancies: Number of miscarriages, if any Number of abortions, if any
3 Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: Suite 106 F: Livingston NJ Patient Name: *NOTICE OF PRIVACY PRACTICES FOR YOU TO KEEP* THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE READ AND REVIEW THIS NOTICE CAREFULLY. The Health Insurance Portability and Accountability Act of 1966 (HIPAA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information. Without specific written authorization, we are permitted to use and disclose your health care records for the purpose of treatment, payment and health care operations: Treatment means providing, coordination, or managing health care and related services by one or more healthcare providers. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities and utilization review. Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer services. In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment alternatives or other health related services. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. We are required by law to maintain the privacy of your protected health information and to provide you with notice or our legal duties and privacy practices with respect to protected health information. This notice is effective as of April 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and make a new Notice of Privacy Practices will be pasted on the effective date and you may request a written copy of the revised notice from this office.
4 Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: Suite 106 F: Livingston NJ Patient Name: If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. HIPPA ACKNOWLEDGEMENT I acknowledge receipt and understand the HIPPA privacy laws as they pertain to Infectious Disease Center of New Jersey, L.L.C. Patient / Guardian Signature Date: / / FINANCIAL AGREEMENT I authorize the release of information necessary to any entities to secure the payment of benefits submitted for services rendered by Infectious Disease Center of New Jersey, L.L.C. on behalf of myself and/or dependents. I understand information will be provided to a contracted billing service, Advanced Electronic Medical Billing, Inc., to secure the payment of benefits. I further agree and acknowledge that my signature on this document authorizes claims to be submitted for benefits for any services rendered without obtaining my signature on every claim form. I assign directly to Infectious Disease Center of New Jersey, L.L.C. insurance payments for all services rendered. Should the need arise, I also authorize Infectious Disease Center of New Jersey, L.L.C. and Advanced Electronic Medical Billing, Inc., to file a complaint on my behalf for any dispute or appeal regarding accurate and fair reimbursement for services rendered. I understand I am financially and fully responsible for all charges incurred if my insurance carrier denies payment for any reason. I understand I will be financially responsible for any deductibles, coinsurance or co-pays according to my individual benefit plan. I understand that a co-payment is due at the time of service. I understand that a delinquent balance must be paid in full prior to any scheduled appointments, unless prior payment arrangements have been made. I understand I am fully responsible for contacting my insurance company prior to services rendered, to determine if the provider participates with my specific plan, determine if any referral or pre-authorization is needed, and understand any coverage limitations. I understand I
5 Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: Suite 106 F: Livingston NJ Patient Name: will be fully liable for any visits not covered under my plan for any reason. Any credits will remain on file and will be applied to future balances unless a refund is requested. In the event my insurance carrier issues a payment directly to me, I agree to reimburse the Infectious Disease Center of New Jersey, L.L.C. for the same amount paid to me, in addition to any co-pays, deductibles or coinsurances due based on the explanation of benefits. I agree to send in a check along with the explanation of benefits upon receipt of payment within 10 business days of receipt of payment. I agree to provide the Infectious Disease Center of New Jersey, L.L.C. with current insurance information and advise the office of any changes within 30 days from the date of service. I understand that if a claim is not paid because of my failure to provide the correct insurance information in a timely manner, I am fully responsible for the charges. I understand that payment is due upon receipt of my monthly statement. I understand that I will be legally responsible for all collection costs involved including attorney s fees that are 1/3 of all balances due and owing, collection filing fees, and any fees for returned checks. Patients are responsible for providing coordination of benefit information to their insurance carrier. This information must be sent to an insurance carrier directly from the insured and or patient. I understand I am fully responsible for coordinating benefits between my primary and secondary insurance carriers. I understand that if there is a discrepancy on file between the correct primary and secondary carrier, I am fully responsible for taking the necessary steps to correct this problem to allow reimbursement to Infectious Disease Center of New Jersey, L.L.C. In the event that this coordination of benefit is not resolved, I understand I will be responsible for any outstanding balances. Cancellation policy- our office requires 24 hour prior notice for all cancellations. If this notice is not received, I understand a $50.00 cancellation fee will be incurred. Payment is due upon receipt of the invoice. I understand the above financial agreement. Please Sign below to accept this agreement. Patient or Guarantor Signature (Must be 18 Years of Age) Date
6 Infectious Disease Center of New Jersey, LLC 22 Old Short Hills Road P: Suite 106 F: Livingston NJ Patient Name: As part of our office policy there will be a fee for completing forms and preparing letters: ½ Page Letter, Short Form $ to 2 Page Forms $ or More Page Forms $50.00 Completed forms will not be released unless fee has been paid. Thank you for your cooperation. I have read the above statement and understand the terms of this agreement. PATIENT SIGNATURE DATE
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