Automobile (No Fault) Insurance Assignment of Benefits

Transcription

1 Automobile (No Fault) Insurance Assignment of Benefits To my auto insurance carrier: Name of Insurance: Claim/ Policy No: Date of Accident: Adjuster: I,, request that payment of authorized medical benefits for Name of Insured Name of Patient, who is covered under my automobile policy, be made on my behalf and assigned to University Orthopedic Associates, LLC, TIN# for any auto related injuries. In the event my covering insurance carrier pays benefits directly to me, I will be financially responsible to return any and all monies to University Orthopedic Associates, LLC. Date Insured s Signature Witness

2 Patient Information: Last Name: First Name: Middle Initial: SS#: Address: City: State: Zip: Home Phone #: Work Phone #: Cell Phone #: Sex: address: UOA Provider: Referring MD: PCP: Marital Status: Employer Address: Referring MD Address: PCP Address: Date of Birth: Employment: Full time Part time Not Employed Self Employed Retired Military Duty Student: Full time Part time Not a Student Spouse/ Parent Information: (Account) Name: Relationship to Patient: Address: City: State: Zip: Home Phone #: Work Phone #: Cell Phone #: Sex: Male Female Date of Birth: SS#: address: Employer Address: Insurance Information: (Policies) Coverage Type: Primary Insurance Company: Specialist Copay: Effective Date: Subscriber s Name: Patient s Relationship to Subscriber: Subscriber s Date of Birth: ID#: Group #: Policy Phone #: Benefits Assigned: Yes No Initials Coverage Type: Secondary Insurance Company: Specialist Copay: Effective Date: Subscriber s Name: Patient s Relationship to Subscriber: Subscriber s Date of Birth: ID#: Group #: Policy Phone #: Benefits Assigned: Yes No Initials Coverage Type: Worker Comp Insurance Company: Claim ID#: Proceed to 2 nd page for Completion and Signature Injury Date: Body Part:

3 Coverage Type: Auto Insurance Company: Claim ID#: Injury Date: Body Part: Additional Information: Race: Asian Native Hawaiian Other Pacific Islander Black/ African American American Indian/ Alaska Native White More than 1 race Unreported/ Refused to report Ethnicity: Hispanic/ Latino Not Hispanic/ Latino Unreported/ Refused to report Language: Preferred Contact Number: How did you hear about UOA: Referred by name/ source: Payment Method: How will you be paying for services rendered? Cash Check Credit Card MC/VISA/Discover Number: Exp. Date: Emergency Contact: Name: Phone #: Relationship to the patient: Personal Health Info Release: Provider can release necessary information related to my course of treatment Provider is not allowed to release my medical records Patient Affirmation: I certify the above information is correct to the best of my knowledge. I also understand that I am financially responsible for all charges whether or not covered by insurance. I authorize treatment by the physicians at University Orthopaedic Associates, LLC. Signature: Date: Authorization for Assignment of Benefits Please accept this Assignment of Benefits as a blanket Assignment of Benefits for charges on services rendered and submitted by University Orthopaedic Associates, LLC on my behalf. I, the undersigned, authorize and request that (Please print your insurance carrier s name here) for such services as listed above, change the assignee and make payment for benefits which may be due herein to: University Orthopaedic Associates, LLC Tax ID # Signature of Policy Holder Date ID # Group Number Patient s Name Relationship to Policy Holder A copy of this Assignment of Benefits will be considered an original and binding. In accordance with N.J.S.A. 17B: 24-4, Assignments, states the following regarding an insurance carrier honoring assignment of benefits: Any such assignment, whether made before or after the effective date of this law, shall entitle the Insurer to deal with the assignee as the owner of all rights and benefits conferred on the insured under the policy in accordance with the terms of the assignment.

4 Patient Agreement Patient or Responsible Party: Please acknowledge your consent and understanding of the following terms regarding patient care at University Orthopaedic Associates, LLC (herein to as UOA, LLC) by initialing and signing where indicated. Terms and Policies Initials Authorizing Release of Information: I authorize UOA, LLC to release any necessary medical records to the appropriate parties (insurance company, pharmaceutical company, etc.) in relation to determining responsibility for medical benefits and obtaining reimbursement for professional services. Professional Fees: I understand that I am financially responsible for any and all charges for professional services, whether or not paid by an insurance carrier or health plan. Exceptions are when patient financial responsibility is limited by statutory regulation (such as an authorized Workers Compensation claim, Medicare fee schedule, and Motor Vehicle fee schedule) or by managed care (HMO, PPO, etc.) contract. In cases of claims being submitted to my insurance carrier, it is my responsibility to financially cover any deductibles, co-payments, and non-covered services as stipulated by my specific insurance plan. I may request that payment of my authorized benefits be made on my behalf and assigned to UOA, LLC. Any payments/explanation of benefits issued directly to me for care received at UOA, LLC must be forwarded to UOA, LLC insurance department for posting in a timely fashion. Disability Forms/ Reports: Requests for completion of disability forms, reports, or other paperwork may require an advance fee. Please allow 5 business days for completion of any disability forms. Medical-Legal Reports/ Testimony: I acknowledge this office s policy regarding medical-legal reports and testimony. Medical record copies and radiology imaging will require written authorization and pre paid fees related to preparation and delivery. Upon written authorization and pre-paid copying /clerical/postage fees, copies of medical records will be provided. The physicians do not testify, nor make court appearances. Permanency evaluations and narrative reports are prepared at their discretion. If this policy is unacceptable to me or my attorney, I am aware that I should seek further Orthopaedic treatment elsewhere. Records will not be released until patient s balance is paid in full, unless essential for medical care. Managed Care: To validate your managed care agreement/ fee schedule, proof of your insurance coverage must be provided at the time of service, along with any necessary authorizations/ referrals. All associated copayments will be collected at the time of your office visit. Cost of Collection: I understand that a delinquent account may result in additional billing costs. Balances sent to a collection agency or attorney will result in a collection surcharge of $50.00 or 19% of the balance owed, whichever is greater. Returned checks will result in a $30.00 fee or the actual bank charge, whichever is greater. No Show Policy: We maintain the right to charge a No Show fee if you do not show for your scheduled physician appointment and proper notification to our office was not made prior to the appointment time. The fee is $ We provide access by phone and to cancel and or reschedule an appointment. Workers Compensation/ No Fault Accidents: It is the patient s responsibility to clearly identify those medical injuries/ conditions, which he/she believes are due to a motor vehicle accident, or are work related at the time of the initial visit. Initials Workers Compensation Claims: Submission of claims to be covered by Workers Compensation requires written authorization from your employer or its Workers Compensation Insurance Carrier prior to your first visit. Denied charges due to lack of proper authorization will be your responsibility. Your private insurance cannot be used to cover treatment for injuries/conditions sustained at work, unless workers Compensation coverage has been denied, does not exist, or your case has been settled. Motor Vehicle (PIP) Claims: Insurance claims resulting from Motor Vehicle accidents must be submitted to my Motor Vehicle (PIP) carrier and cannot be billed to my private insurance unless PIP coverage has been denied, does not exist, or private insurance was selected as the primary carrier. I am responsible for any deductible or co-payments under my PIP coverage. I hereby assign all rights and benefits under my auto insurance policy directly to UOA, LLC. I agree to have a lien placed against any settlement I receive due to this accident to pay any open balances due to UOA, LLC. Signature of patient, parent, or guardian Printed name of patient Date Printed name of parent/ guardian 4/7/14-Forms-NP-PTAG

5 NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully YOUR RIGHTS When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record Ask us to correct your medical record Request confidential communications Ask us to limit what we use or share Get a list of those whom we ve shared information Get a copy of this privacy notice Choose someone to act for you File a complaint if you feel your rights are violated. You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say no to your request, but we ll tell you why in writing within 60 days. You can ask us to contact you in a specific way (for example, home, office or cell phone) or to send mail to a different address. We will say yes to all reasonable requests. You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree to your request, and we may say no if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say yes unless a law requires us to share that information. You can ask for a list (accounting) of the times we ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures for those about treatment, payment and healthcare operations, and certain other disclosures (such as any you asked us to make). We ll provide one accounting per year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. You can complain if you feel we have violated your rights by contacting our Privacy Officer at 2 Worlds Fair Drive, Somerset, NJ OR (732) You can file a complaint with DHHS Office of Civil Rights. Visit We will not retaliate against you for filing a complaint. YOUR CHOICES For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care. Share information in a disaster relief situation. Include your information in a hospital directory. Contact you for fundraising efforts. If you are not able to tell us your preference (for example, if you are unconscious) we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

6 In these cases, we never share your information unless you give us written permission In the case of fundraising: Marketing purposes. Sale of your information. Most sharing of psychotherapy notes. We may contact you for fundraising efforts, but you can tell us not to contact you again. OUR USES & DISCLOSURES How do we typically use or share your health information? We typically use or share your health information in the following ways. Treat you We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. Bill for your services We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. Run our We can use and share your health information to run our practice, organization improve your care, and contact you when necessary. OTHER USES & DISCLOSURES Example: We use health information about you to manage your treatment and services. How else can we use or share your health information? We are allowed or required to share your information in other ways usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see Help with public health and safety issues We can share health information for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone s health or safety Do research We can use or share your information for health research. Comply with the law Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers compensation, law enforcement and other government requests We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we re complying with federal privacy law. We can share health information about you with organ procurement organizations. We can share health information with a coroner, medical examiner, or funeral director when an individual dies. We can use or share health information about you: For workers compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security and presidential protective services Respond to lawsuits and legal actions We can share health information about you in response to a court or administrative order, or in response to a subpoena. OUR RESPONSIBILITIES We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information, see: Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request in our office and on our website. Effective April 14, 2003 Revised September 23, 2013 Revised Logo

7 NOTICE OF PRIVACY PRACTICES RECEIPT I acknowledge that I was provided with the Notice of Privacy Practices of the Medical Practice named at the top of this page. Print name of patient: Signature of patient: Date: SSN: For personal representative of the patient (if applicable): Print name of personal representative: Signature of personal representative: For practice use only: Signature of practice Employee: Date: Relationship to patient: Date: The following is an authorization for miscellaneous services this office uses. We will make every effort to abide by your instructions. Please provide the following information: Appointment Reminders/ Test Results (laboratory, x-rays, etc.): If we need to reach you regarding an appointment or test results, we will make every effort to reach you personally. If we cannot reach you personally, we will only leave a message asking you to call our office during regular business hours. Please check all items below that apply to you. May we send an appointment reminder card to your home address? Yes No May we call to remind you of an appointment or regarding test results? Yes No Please call me at the following number(s): Home Phone: Cell Phone: Work Phone: Address: If we get an answering machine/voic , may we leave a message? Yes No If we get a family member, may we leave a message? Yes No Policy for discussing your medical information with family members: Our office will never discuss your medical information with a family member unless you have authorized us to do so. Please indicate the family members authorized to discuss your medical care by checking all items that apply to you and providing the name(s) where applicable. Spouse Parent(s) Child(ren) Sibling(s) Other(s)

8 Last Name: Date of Birth: Which physician are you seeing today? First Name: Today s Date: History and HPI Forms: Who referred you to UOA? Primary Care Physician and Contact Information: Have you had a bone density scan (for osteoporosis)? No Yes If yes: Where: Year: Social History: Marital Status: Single Married Divorced Separated Widowed Living Conditions: Alone Spouse Family Member Assisted Living Occupation: Student Retired Disabled Unemployed Primary Affected Area: Choose most significant area for today s visit USE THE FOLLOWING PAGE FOR ADDITIONAL AREAS AFFECTED AREA: Cervical Spine Thoracic Spine Lumbar Spine Shoulder Clavicle Upper Arm Elbow Forearm Wrist Hand Hip Pelvis Thigh Knee Lower Leg Ankle Foot Location of Problem: Right Side Left Side Bilateral Symptoms: Onset of Injury: (Choose One) Date: Weeks Months Years Injured At: Athletics Home MVA Retail Business School School Athletics Work If School or School Athletics, which school: How did the injury occur: Aggravated By: Daily Activities Exercise Lifting Overhead Motion Sports Throwing Work Relieved By: Activity Compression Wrap Elevation Heat Ice Injections No Relief NSAIDS Pain Medication Physical Therapy Rest Tylenol List all other medications you are taking including non-prescription medications. I am not taking any medications Medication #1 Medication #2 Medication #3 Medication #4 Name: Dosage: Frequency: Route: Medication #5 Medication #6 Medication #7 Medication #8 Name: Dosage: Frequency: Route: Preferred Pharmacy: Phone #: Town: I attest the information provided above is accurate to the best of my ability. Patient s Signature