70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Employment: Employed Unemployed Retired Employer: Employer Address:

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1 70 Hatfield Lane Goshen, New York SSN: First Name: MI: Last Name: Prefix (Ms., Mr.,) Sex: M F DOB: Marital Status: Single Married Divorced Widowed Spouse Name: Employment: Employed Unemployed Retired Employer: Employer Address: Patient Address: Apt#: City: State: Zip Code: address: Home#: Work phone: Cell Phone: Occupation Student Yes or No-Full time or Part time Race Language Religion Who referred you to the practice? Name: Phone Number: Street address: Fax Number: City: State: Zip Code: Primary Care Physician/Family physician (If different from referring physician) Name: Phone Number: Street Address: Fax Number: City: State: Zip Code: Private Insurance: Insurance Information-Primary Insurance Company Address: Group Number: Effective date Policy Number:

2 Copay: Relation to patient (if not self) SSN: Name of Insured (If not patient) DOB Sex Worker s Compensation or No-Fault-Date of Accident Place of Accident Carrier Case Number Case Manager Contact Insurance Information-Secondary Insurance Company: Address: Group Number: Effective Date: Policy Number: Copay: Relation to patient (if not self) SSN: Name of Insured (If not patient) DOB Sex Emergency Contact Information Relation First Name: Last Name: Home Number: Work Number: Cell Phone Assumption Of Responsibility and Assignment of Benefits Agreement I request that payment of all authorized (Medicare, Private, Commercial Carrier, No Fault, Works Compensation) to be made on my behalf to Goshen Medical Associates, PC for any services furnished to me by Goshen Medical Associates, PC. I authorize Goshen Medical Associates to release medical information about my insurance company and/or the Health Care Financing Administration and its agents that may be needed to determine these benefits or the benefits payable for related services. This agreement will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other service not paid by your insurance. If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled, including Medicare; private insurance, and other health plans to Goshen Medical Associates, PC. I understand that I am financially responsible for all charges whether or not paid by said insurance. I authorize said assignee to release all information necessary to secure payment. Signature X Date:

3 Individual Patient s Authorization The Use And/Or Disclosure Authorized: Please list the name of the people and/or organization (or the kinds of people and/or organizations) that you are authorizing to receive and use your protected health information. Individual Patient s Signature: I have had the chance to read and think about the content of this authorization form and I agree with all statements made in this authorization. I understand that by signing this form, I am confirming my authorization. I understand that by signing this form, I am confirming my authorization for use and/or disclosure of the protected health information described in this form with the people and/or organizations named in this form. I am also aware that any changes in authorization must be done in writing. Signature:X D.O.B. Print Name: Date: Personal Representative s Name: Print Name: Signature: X Relationship to Individual Patient Medicare Patients I authorize any holder of Medical or other information about me to release to the Social Security Administration or its intermediaries or carriers, or to the billing agent of this physician, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to my self or the party who accepts assignments. Signature X: Date: Office Cancellation Policy Please be aware that if your appointment is not cancelled at least 24 hours in advance you will be charged a fee of $ Please Note: This fee is NOT covered by your insurance and will be your responsibility. Thank you for your cooperation. Signature: X Date:

4 70 Hatfield Lane Goshen, New York Phone Fax Authorization for Use and Disclosure of Health Information Patient Name: Date of Birth: Address: By signing this form, I hereby authorize Goshen Medical Associates to disclose the health information described below to: to disclose the health information described below to Goshen Medical Associates. Type of Information to be disclosed: (please circle all that apply) Health Information relating to the following treatment or condition Health Information for the dates(s) Other specific description All my health information Reason for this Authorization At my request Other (Specify) This authorization expires on (date or event): I understand that I may refuse to sign this authorization. Treatment, payment, enrollment in a health plan or eligibility for benefits will not be conditioned on signing an authorization if to do so would be prohibited by Federal or State Law. I understand and authorization may be required to participate in research or where health care services are provided solely for the purpose of creating health information for a third party, and that if I refuse to sign an authorization those services may be denied.

5 I may revoke this authorization in writing. If I do, it will not affect any previous actions already taken in reliance upon my authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. I may revoke this authorization by writing a letter and mailing it certified mail, return receipt requested, to the Privacy Office at the healthcare provided listed above. Once health information is disclosed pursuant to this authorization, it may be redisclosed and may no longer be protected by privacy laws. Patient/Legally Authorized Representative Printed Named Date Relationship to Patient

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