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1 115 Christopher Columbus Drive, Suite 301 Jersey City, New Jersey WELCOME TO DRS MEDICAL ASSOCIATES LLC. PLEASE COMPLETE THE FORM LEGIBLY AND ENTER AS MUCH INFORMATION AS YOU CAN! Note that employer and social security information is needed to verify insurance information. Today s Date (mm/dd/yyyy): Last Name: First: Middle: Address: Address Line 1: Address Line 2: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth (mm/dd/yyyy): Sex: M / F / T Marital Status: Social Security Number: Occupation: Employer Name: Yrs Employed: Do you have an Advanced Directive: Y / N Race: Ethnicity: Language(s) Spoken: Preferred Pharmacy and Telephone Number: How were you referred to our practice? Local Emergency Contact s Name: Relation: Phone: Address: STANDARD INSURANCE INFORMATION: (This section does not need to be filled out if a physical card is presented) NAME of POLICY HOLDER: Policy Holder DOB: Policy Holder Phone Number: Relation to Patient: Effective Date of Coverage: NAME OF INSURANCE COMPANY: Claims Mailing Address: City: State/Zip: Address Associated with Insurance Policy (If different than home address): INSURED S ID # GROUP # DEDUCTIBLE AMT: COPAY: Page 1 of 6

2 AUTHORIZATION FOR VERIFICATION OF INFORMATION: I certify that to the best of my knowledge the statements contained herein are true. I authorize DRS MEDICAL ASSOCIATES LLC and/or its assignee to verify statements made herein. RELEASE OF MEDICAL INFORMATION: I hereby authorize DRS Medical Associates LLC to release medical information relating to my condition as appropriate to all parties as deemed appropriate by DRS Medical Associates. I authorize the release of any medical information necessary to process claims for insurance reimbursement or payment. I further authorize payment to DRS Medical Associates LLC of any medical benefits resulting from medical or surgical services rendered by DRS Medical Associates LLC. FINANCIAL RESPONSIBILITY: I agree to be responsible for all claims and charges incurred on my behalf. I understand that DRS Medical Associates LLC will bill the insurance company and will be reimbursed for the services rendered to me. I agree and understand that I will be expected to pay for services at the time of each visit. I further agree to pay all collective costs, responsible attorney fees, and other costs that may be incurred to enforce collection of any amounts outstanding. If any payment(s)/explanation of benefits are issued directly to me for care received at DRS Medical Associates LLC, I shall forward such payment(s)/explanation of benefits to DRS Medical Associates LLC for posting in a timely fashion. In cases of claims being submitted to the insurance carrier, it is my responsibility to financially cover any deductibles, co-payments, co-insurance and non-covered services as stipulated by my specific insurance plan. MISSED APPOINTMENTS: I understand and acknowledge that DRS Medical Associates LLC maintains the right to directly charge me (as well as every other patient, except Medicaid patients) a No Show fee in the amount of $25.00 if I do not show for my scheduled appointment and/or did not provide DRS Medical Associates LLC with at least 24 hours notification prior to my appointment about cancelling or rescheduling my appointment. If the No Show fee is charged, I agree that I shall promptly make such payment to DRS Medical Associates LLC. In case of any cancellation, I will use my best effort to re-schedule such cancelled visit within 1 to 2 weeks. Signature Date Printed name Page 2 of 6

3 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF DRS MEDICAL ASSOCIATES LLC s NOTICE OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION PATIENT NAME: Date of Birth: I,, on behalf of, acknowledge receipt of DRS MEDICAL ASSOCIATES LLC s Notice of Privacy Practices dated and I consent to the Provider s use and disclosure of health information and insurance/payment information which specifically identifies the patient identified above or which can reasonably be used to identify the patient identified above for treatment, payment and health care operations of the Provider in accordance with the Notice of the DRS Medical Associates Privacy Practices. I also consent to the restrictions contained in the Notice of Privacy Practices. I hereby authorize DRS Medical Associates LLC to release my patient health information ( PHI ) to the following named individuals ( Recipients ): Name/Phone Number Relationship Type of Information Allowed to Disclose (Circle One) Medical / Billing Medical / Billing Medical / Billing I also understand that this consent is voluntary and that DRS Medical Associates LLC may not condition treatment on my execution of this Acknowledgement. I understand that I have the right to request that DRS Medical Associates LLC restrict how the patient s health and insurance/payment information is used or disclosed to carry out treatment, payment or healthcare operations. Page 3 of 6

4 I understand that I may revoke this consent at any time by notifying DRS Medical Associates LLC in writing, but if I revoke my consent, such revocation will not affect any actions that DRS Medical Associates LLC took before receiving my revocation. I understand that the information used or disclosed pursuant to this consent may be subject to re-disclosure by the Recipients listed above and, in that case, will no longer be protected by HIPAA (as defined in the Notice of Privacy Practices). The consents hereunder expires when I am no longer a patient of DRS Medical Associates LLC or have revoked this consent. (Check One) I DO DO NOT GIVE PERMISSION to DRS Medical Associates LLC to leave information at my Home Phone, Cell Phone, Work Phone, and/or with my family members (listed above) in regard to treatment plans, referrals, test results and/or billing and payment information. Other than those releases authorized by HIPAA as described in the Notices of Privacy Practices, PHI will only be released to the persons listed on this consent. If you choose not to authorize any family members or friends for disclosure of PHI, DRS Medical Associates LLC will not be able to release any information, including appointment or patient billing questions to anyone other than the patient. Signature of Patient/Parent/Guardian Date Printed name of Patient/Parent/Guardian Relationship to the Patient Page 4 of 6

5 CONSENT TO ACCESS EXTERNAL PRESCRIPTION HISTORY PATIENT NAME: Date of Birth: I,, on behalf of, authorize DRS MEDICAL ASSOCIATES LLC, and its affiliated providers to access and view the external prescription history for the patient listed above. I understand that a prescription history from multiple unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by the providers and staff of DRS MEDICAL ASSOCIATES LLC and may include past prescriptions from several years ago. MY SIGNATURE BELOW CERTIFIES THAT I HAVE READ, UNDERSTAND AND AUTHORIZE THE ACCESS OF EXTERNAL PRESCRIPTION HISTORY. Signature of Patient/Parent/Guardian Date Printed name of Patient/Parent/Guardian Relationship to the Patient Page 5 of 6

6 Controlled Substances Policy 1. No refills of controlled substances will be given on the first visit. 2. There must be a separate visit to assess the need for the chronic controlled medicine. 3. We will ask you to obtain prior notes and testing that support the diagnosis which requires a chronic controlled medication. 4. A referral to the appropriate specialist may be made after the evaluation, who will then be the only physician who can prescribe the controlled medication. 5. You may receive an alternate medication to help control your chronic medical problem. 6. After hours and on weekends, the doctor on call WILL NOT call in any additional prescriptions or refill medications over the phone. 7. You are responsible for your prescriptions. Stolen or lost refills will not be replaced. 8. NO early refills will be given. 9. You must only use one designated pharmacy-no EXCEPTIONS. 10. You must inform us of any prescription drugs you are obtaining through other physicians. Failure to do so may result in discharge from our practice. 11. It is illegal to share prescription drugs and to alter or forge prescriptions. We reserve the right to discharge patients engaging in such activities. 12. We reserve the right to obtain random drug testing. There is a zero tolerance policy for illegal substance use. 13. We reserve the right to discharge patients engaging in activities considered drugseeking, such as persistent medication use past the period indicated by the physician; repeated visits to emergency rooms with pain complaints; use of illegal substances; and other activities in this category at the discretion of our physicians. Patient Signature Printed Name Date Page 6 of 6