INSURANCE INFORMATION

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Abner Wilson
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1 FRANCESCO ROTATORI, M.D. Cardiology, Vascular Diseases and Vein 20 East 46th Street, 7th Floor - New York, NY Amboy Road - Staten Island, NY Todt Hill Road, Room Staten Island, NY Ph: (917) Fax: (347) DATE: Referred by: Doctor Ins. Website Family/Friend ZocDoc PERSONAL LAST NAME FIRST NAME Sex: F M Date of Birth: SOCIAL SECURITY #: - - Reason for today s visit: Home Address: City: State: ZIP: Home Ph: Mobile Ph: Work Ph: Preferred: address: How often do you check it? Daily Weekly Other: Marital Status: Single Married Divorced Widowed PRIMARY CARE LAST NAME OF PCP FIRST NAME OF PCP Specialty: Address: City: State: ZIP: Phone Number: Fax Number: WORK HISTORY Please check ( ) off boxes that apply to you. Employed Occupation: Employer: Employer address: City: State: ZIP: Retired. Since (date): Unemployed Student INSURANCE INFORMATION PRIMARY DOB: Insurance Name: Policy Holder:

2 ID#: Relationship to insured: Self Spouse Other: Policy Holder Employer: SECONDARY Insurance Name: Policy Holder: DOB: ID#: Relationship to insured: Self Spouse Other: Policy Holder Employer: HEALTH QUESTIONNAIRE In order for your physician to more completely assess your present health condition, please complete this individual health questionnaire as carefully as possible and bring with you for your appointment. Review or Systems (please check all that apply): Cardiovascular

3 Arm Pain on Exertion Chest Pain on Exertion Chest Heaviness/Pressure on Exertion Irregular Heart Beats Known Heart Murmur Light-headed on Standing Shortness of breath when walking Swelling (edema) Other Past Surgical History: Please list ALL surgical procedures and ages or dates Year/Age Type of Surgery Allergies: (to medications, latex, iodine, shellfish, or nuts) Allergy Reaction Type Medications: (Name, dose and prescribing doctor) Medication Name Dosage: Prescribing Doctor Health History: Coronary Artery Disease Pacemaker Leg/Foot Ulcers Liver Disease Heart Murmur Stroke High Cholesterol Other: Heart Attack Congenital Heart Disease Bleeding Disorder Aneurysm

4 Leg Edema High Blood Pressure Blood clots (PE or DTV) Social History: Cancer Leg vein varicosity Diabetes HIV or AIDS Heart Failure Kidney Disease Reflux or Ulcer Caffeine None / cups per day Alcohol Average number of drinks /day or /week or none Tobacco Do you smoke? Yes No Past Cigarettes pks. /day Chew /day Cigars /day Drugs Recreational drug use: Yes No Past If yes, list: Please add any other Information about your health that you would like your provider to know here: Patient/Guardian Signature Date FRANCESCO ROTATORI, M.D. Cardiology, Vascular Diseases and Vein 20 East 46th Street, 7th Floor - New York, NY Amboy Road - Staten Island, NY Todt Hill Road, Room Staten Island, NY Ph: (917) Fax: (347) Name of Patient (print): Social Security Number: Assignment of Benefits I hereby authorize and direct my insurance carrier(s), to issue payment check(s) directly to Francesco Rotatori, M.D. for medical services rendered to me and/or my dependents regardless

5 of my insurance benefits. I understand that I am financially responsible for any amount not covered by insurance. Authorization to Release Information I hereby authorize Francesco Rotatori, M.D., staff and agents to: (1) release any Information necessary to insurance carriers regarding my Illness and treatment; (2) process insurance claims generated in the course of examination or treatment. (3) Allow a photocopy of my signature to be used to process Insurance claims. This order will remain in effect until revoked by me in writing. I have requested medical services from Francesco Rotatori, M.D., staff and agents on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course if treatment authorized. General Patient and Patient Family Responsibilities Patient acknowledges, in certain circumstances, insurance company may send a check for services provided by Francesco Rotatori, M.D., staff and agents directly to the patient/guardian. If the above occurs, the patient shall endorse and immediately forward said check to Francesco Rotatori, M.D. The patient acknowledges, they remain responsible for the full amount of the above-mentioned check plus any reasonable costs, co-payments or co-insurance associated with the collection of said funds until It is received by Francesco Rotatori, M.D. Name of person signing below (print): Relationship to Insured: Signature of Insured or Parent/Guardian: Date: FRANCESCO ROTATORI, M.D. Cardiology, Vascular Diseases and Vein 20 East 46th Street, 7th Floor - New York, NY Amboy Road - Staten Island, NY Todt Hill Road, Room Staten Island, NY Ph: (917) Fax: (347) HIPAA PRIVACY NOTICE The attached Notice of Privacy Practices contains a detailed description of how our office will protect your health information, your rights as a patient and our common practices in dealing with patient health Information. Please refer to that Notice for further Information. Uses and Disclosures of Health Information. We will use and disclose your health information In order to treat you or, to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain, payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other health care providers. Finally, we may disclose your health

6 Information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students. Uses and Disclosures Based on Your Authorization. Except as stated in more detail In the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. Uses and Disclosures Not Requiring Your Authorization. In the following circumstances, we may disclose your health Information without your written authorization: To family members or close friends who are Involved in your healthcare; For certain limited research purposes; For purposes of public health and safety; To Government agencies for purposes of their audits, investigations and other oversight activities; To government authorities to prevent child abuse or domestic violence; To the FDA to report product defects or Incidents; To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders; When required by court orders, search warrants, subpoenas and as otherwise required by the law. Patient Rights. As our patient, you have the following rights: To have access to and/or a copy of your health information; To receive an accounting of certain disclosures we have mode of your health Information; To request restrictions as to how your health information Is used or disclosed; To request that we communicate with you in confidence; To request that we amend your health information; To receive notice of our privacy practices. If you have a question, concern or complaint regarding our privacy practices, please refer to the attached Notice of Privacy Practices for the person or persons whom you may contact. Name of person signing below (print): Relationship to Insured: Signature of Insured or Parent/Guardian: Date:

Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION

Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific