Faculty Group Practice Patient Demographic Form

Transcription

1 Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone SSN Date of Birth Gender Male Female Work Phone Cell Phone Marital Status Single Married Divorced Widowed Separated Partner Other Race Ethnicity Preferred Language address Financially Responsible Party Is patient responsible party/guarantor? Yes No(If you are over the age of 18 and not in the care of an institution you are the guarantor as you are the person financially responsible for any charges you may incur during your visit) Name Address City/State/Zip Relationship to Patient Occupation Employer Address Date of Birth Home Phone Work Phone Cell Phone Emergency Contact Name Home Phone Relationship to Patient Work Phone Cell Phone Referral Info Referring Physician s Name Physician Address Physician Phone/Fax (if known) ( ) PCP Info Primary Care Physician s Name (Check if same as Referring Physician above ) Physician Address Physician Phone/Fax (if known) ( ) Primary Insurance Company Policy # Group # Insurance Information Patient s Relationship to Insured Self Spouse Child Other Subscriber s Social Security # Gender Male Female Name of Subscriber (if other than patient) Date of Birth Employer of Subscriber Work Phone ( ) Secondary Insurance Company Policy # Group # Patient s Relationship to Insured Self Spouse Child Other Subscriber s Social Security # Gender Male Female Name of Subscriber (if other than patient) Date of Birth Employer of Subscriber Work Phone ( ) By signing below, I acknowledge that the information I provided is correct to the best of my ability. Patient Signature: Guarantor Signature (if other than patient): Date: / / Date: / / Form Revised: 7/29/2011

2 Please provide the following information to help us better understand your medical history and your current health issues. Last Name First Name M.I. Street Address City State Zip Code Date of Birth Male Female Home Phone Work Phone Cell Phone Address Parent/Guardian (If patient under 18) Name of Primary Care MD Phone Phone CURRENT HEALTH: 1. What is the main reason that you came to the Sports Medicine clinic today? 2. What is your current pain level on a scale of 0 to 10? (0=no pain, 10=extreme pain) Please circle one: Did your doctor or other health professional refer you to Sports Medicine? Yes No Name/number: Address: MEDICAL/SURGICAL HISTORY 4. Do you have any chronic medical conditions? (ex: diabetes, heart disease, stroke, high blood pressure) Yes No If yes, please list: 5. Have you ever been hospitalized (medical, psychiatric, substance abuse etc.)? Yes No If yes, please list reason for hospitalization and dates: 6. Have you ever had surgery? Yes No If yes, please list types of surgery and dates: MEDICATIONS 7. Are you currently taking any medications (including prescription, over-the-counter, birth control pills, vitamins, supplements)? Yes No If yes, please list: MD use only: FORM REVIEWED (initial & date)

3 Last Name First Name M.I. ALLERGIES 8. Do you have any allergies? (Please include medication, food, or environmental allergies) Yes No If yes, please list and describe allergic reaction: SOCIAL HISTORY 9. Do you smoke? No Yes, number of packs per day: for how long? 10. Do you drink alcohol? No Yes, number of drinks per week: 11. Do you use any other types of drugs or take any prescription medications not prescribed for you? Yes No If yes, please list: 12. Occupation or year in school: 13. Do you play any particular sports? Yes No If yes, what is your main sport? (List only one): Hours per week: Other sports? Hours per week total: 14. Do you do other types of exercise? Yes No If yes, please list: Hours per week total: FAMILY HISTORY 15. Family history of arthritis or other rheumatologic diseases? Yes No If yes, please list: 16. Family history of an injury or symptoms similar to what you have now? Yes No If yes, please explain: 17. Family history of bleeding or clotting disorders? Yes No If yes, please explain: 18. Family history of heart disease or sudden death? Yes No If yes, please explain: CURRENT SYMPTOMS 19. Do you have now, or have you recently had, any of the following?: Fevers/chills Yes No Nausea/vomiting Yes No Abdominal pain Yes No Diarrhea Yes No Constipation Yes No Incontinence (inability to hold urine or stool) Yes No Weakness Yes No Chest pain Yes No Shortness of breath Yes No Headache Yes No Numbness Yes No Rashes Yes No Loss of consciousness Yes No Seizures Yes No Joint swelling Yes No Morning stiffness Yes No ADDITIONAL INFORMATION 20. Is there anything else you would like your doctor to know? Signature of Patient (or parent/guardian if patient under 18) Date MD use only: FORM REVIEWED (initial & date)

4 Langone Medical Center Pharmacy Information With the installation of Epic, the new electronic medical record system, at this practice, your doctor is now able to e prescribe. This means that any prescriptions the doctor may give you today will be automatically routed to the pharmacy of your choice and we will no longer have to provide you with handwritten prescriptions. In addition, when you run out of refills on your medication, the pharmacist can now electronically send renewal requests to this office for approval. **Note: Controlled medications are not eligible for e-prescribing. Patient Name: Please complete the information below if you are interested in e-prescribing. Name of Pharmacy: Address: City: State: Zip Code: Phone Number: Fax Number: Preferred Pharmacy Name of Pharmacy: Address: City: State: Zip Code: Phone Number: Fax Number: Alternate Pha rmacy Laboratory Information Please indicate by placing a checkmark next to one of the options below to identify your preferred laboratory. Some insurance plans require that covered patients utilize specific laboratories; failure to follow their guidelines can lead to bills that become the patient's responsibility. If you do not know which laboratory to select, please contact your insurance carrier. If you do not select a laboratory, the practice will default any lab tests to NYU laboratory. LabCorp Quest Labs NYU Lab Other External Location IPlease provide name of external location:

5 Langone Medical Center Medicare Secondary Payer Form DATE. PATIENT NAME. Dear Medicare Patient: As a direct result of mandated Medicare Secondary Payer (MSP) regulations, we are required to gather the following information to determine if Medicare is your primary insurance. 1. Is the illness/injury due to an automobile accident, liability accident, or Workman's Compensation? t5i Yes t5i No 2. Is illness covered by the Black Lung Program or Veteran's Administration program? t5i Yes t5i No 3. If under 65, are you a renal dialysis patient in your first 30 months of Medicare entitlement? t5i Yes t5i No 4a. If under age 65, is your Medicare coverage due to disability? t5i Yes t5i No 4b. Is patient covered by a large group health plan through patient's employer or spouse's current employer? S. If 65 and over, is patient covered by Employer Group Health Plan through patient's or spouse's current employer? t5i Yes LiI No t5i Yes LiI No Registrar Notes: A. If patient responds "No" to questions 1-5, Medicare is primary. B. If patient responds "Yes" to any questions, Medicare is secondary and primary insurance information must be obtained. Name of Insurance Company Address of Insurance Company Name of Policy Holder Policy Number Policy Holder's Employer Policy Holder's Employer Date of Accident (if applicable) Patient's Signature

6 Langone Medical Center Faculty Group Practice Financial Policies Thank you for choosing NYU Langone Medical Center for your medical care. We appreciate that you have entrusted us with your health care and we are committed to providing you with the best patient care possible. Because healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you better understand your responsibilities as a patient. We will do our best to assist you with understanding your proposed treatment and in answering questions related to submitting your insurance claim for reimbursement. Your health insurance policy is a contract between you and your health insurance company or your employer. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals, pre-certifications, pre-authorizations, limits on outpatient charges, and any requirements for specific physicians, labs and/or hospitals to use. You should be knowledgeable of any deductibles, copayments, and/or coinsurance. This applies to all payors regardless of whether or not our physicians participate. If you are uncertain about your current health insurance policy benefits you should contact your plan to leam the details about your benefits, out-of- pocket fees, and coverage limits. PLEASE KEEP THESE POLICIES FOR FUTURE REFERENCE Insurance Coverage Please provide us with your current insurance plan infonnation at the time of each visit and notify us of any changes. We will request a copy of your insurance card to copy or scan and keep on file for our records. Please be aware of and provide any required referrals or authorizations in advance of the appointment or service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification. Our doctors belong to many insurance plans but participation differs by doctor. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the costs of care. We will help you find out if you have out-of-network benefits and submit a claim to your plan on your behalf. Refer to our out-of-network policy below for more details. Please let us know at any time if you do not want us to submit a claim to your plan. Address Change It is important that we have your correct address infonnation on file. Please advise us anytime there is any change to your address, telephone or other contact infonnation. Co-payments/Co-insuranceslOeducti bles You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time of service. Other Bills You may receive services at NYU Langone Medical Center such as anesthesia, radiology testing, pathology, or other services. These doctors provide vital services and are involved in your care even though you may not be present at the time. There may be additional charges for these services. In addition, you may receive in-patient or out-patient hospital care at NYU Langone Medical Center. If so, you will receive a hospital bill for those services. Hospital bills are separate from our doctor services. If you have questions, you may contact the hospital billing office at (800) Rev. 07/28/2009

7 Langone Medical Center Payments Payment is due at the time services are provided or upon receipt of a statement from our billing office. We accept payment in the form of cash, check, money order or credit card (American Express, MasterCard, Visa and Discover). Returned checks are subject to a fee of $ We do not accept traveler's checks.. Non-Medical Fees Additional fees may apply to the following: Returned Checks Copying of medical records Completion of disability or other forms Missed Appointments We require a 24 hour cancellation notice for most office visits. Procedures and surgeries may require 48 hours or more. If you miss your appointment. or do not cancel with the required notice, additional fees may apply: Office Visit: $50 New Patient Visit: $75 Second Office Visit $75 Procedure/Surgery Per Dept Policy Out-of Network Providers If the doctor is not in your insurance plan. the following apply: Full payment is due at the time of service for routine visits. Payment expected on the date of service may be an estimate of your total charges. You will be quoted an estimated fee before services/procedures are performed. A deposit is required prior to the date of service for elective surgeries and procedures. After your appointment, we will submit a claim to your plan for services performed. Depending on your plan. payment may be sent to you. If you receive this payment, you must reimburse NYU Faculty Group Practice immediately. Non-Covered Services Medicare Patients. Medicare may not cover some services your doctor recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully. Non-Medicare Patients. Any service not covered by your plan are your responsibility and must be paid in full at the time of service or upon receiving a bill. Refunds A refund is issued when an overpayment has been identified. If you feel a refund is due, please contact our billing office at (877) Failure to Pay If you do not pay your bill. your account may be sent to an outside collection agency. If your account is sent to a collection agency. you will need to contact them directly to settle your balances. Policy and Fee Changes These policies and fees are subject to change. We will do our best to keep you informed of any modifications. We know medical care can become expensive. If you have concerns about your ability to pay, you can contact us for help in managing your account. If you have questions about these policies, feel free to ask any of our staff for more details or call our billing office at (877) Rev. 07/28/2009

8 _ Langone Medical Center FACULTY GROUP PRACTICE FINANCIAL POLICIES AND PATIENT RESPONSIBILIT 1. RELEASE OF INFORMATION: I authorize NYU School of Medicine, my treating physicians and their respective designees, to use and disclose my health information for all purposes necessary for treatment, payment and health care operations, including but not limited to release of information requested by my insurance company (or carrier) and any information necessary for discharge planning purposes. Initials 2. ASSIGNMENT OF INSURANCE: I hereby authorize my insurance benefits to be paid directly to NYU School of Medicine. understand I am financially responsible for non-covered services. I authorize the release of any medical or other information necessary to process insurance claims on my behalf. Initials 3. FINANCIAL LIABILITY: I have been provided a copy of the NYU School of Medicine financial policies and agree to the specified terms. I hereby agree to pay all charges due (or to become due) to NYU School of Medicine for care and treatment. including co-payments and deductibles as provided under my plan. Benefits, if any, paid by a third party, will be credited on account. I understand that I will be responsible for any charges if any of the following apply: My health plan requires prior authorization or referral by a Primary Care Physician (PCP) before receiving services at NYU School of Medicine and I have not obtained such an authorization or referral or I receive services in excess of such authorization or referral, and/or My health plan determines that the services I receive at NYU School of Medicine are not medically necessary and/or not covered by my Insurance plan, and/or My health plan coverage has lapsed or expired at the time I receive services at NYU School of Medicine, and/or I have chosen not to use my health plan coverage. Initials 4. MEDICARE SIGNATURE ON FILE (Medicare Patients Only): I request that payment of authorized Medicare benefits be made either to me or on my behalf to all providers who treat me during my hospital stay or any services furnished to me by those providers. I authorize the holder of medical and other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services. Patient's Medicare Number Patient Signature 5. ANCILLARY SERVICES: I understand I may receive certain ancillary medical services while I am at NYU School of Medicine; such as, anesthesia, interpretation of cardiac tests, imaging services (e.g., x-rays, MRls) and pathology specimen examination. I understand that some physicians may not provide services in my presence, but are actively involved in the course of diagnosis and treatment. I hereby authorize payment directly for these services under the policy(s) or plan(s) issued to me by my insurance carrier. I understand that I may incur additional charges as a result of these ancillary services; I agree to pay all charges due with respect to such services to the extent the charge is due after credit is given for benefits paid on my behalf by any third party payor. Initials 6. CANCELED OR NO-SHOW APPOINTMENTS: I understand that I may incur a cancelation fee if I do not provide 24 hour notice of cancelation, or if I do not keep my appointment and have not canceled. Initials I have been provided the Faculty Group Practice Patient Financial Polices. I understand the infonnation listed above which has been fully explained to me. Patient Signature Date Guarantor Signature Date Form Revised: 8/17/09

9 o Langone Medical Center NYU Faculty Group Practice NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT By signing below, I acknowledge that I have been provided a copy of the Notice of Privacy Practices as required by the Health Insurance Portability and Accountability Act (HIPM). In this notice I was advised of how health information about me may be used and disclosed by NYU Faculty Group Practice physicians and staff. I was also told how I may obtain a copy of this information and correct errors in my health information. Print Name of Patient Signature of Patient (or Financially Responsible Party) Relationship to Patient Date Revised: 8/10/09

10 NYU Langone Medical Center ELECTRONIC HEALTH INFORMATION SYSTEM FACT SHEET What is the NYU Langone Medical Center Electronic Health Information System? The Hospitals, the Faculty Group practices and many of the individual physicians and physician practices that make up the NYU Langone Medical Center community and who are directly involved in your care are able to create and access your health and pharmacy records electronically. This electronic health information system helps us provide you with better treatment. I What are the advantages to having an electronic health record? I We can provide better care with more complete records of your medical history. This includes information about your allergies, medications, test results, or other past records, including health insurance coverage. Paper records may be stored in separate locations and would be otherwise unavailable to us when needed. The Health Information System lets us see your records faster. You will be asked to give your providers consent to create and access your medical records in the NYU Langone Medical Center Health Information System. You are entitled to a copy of the signed consent form. If you consent to the creation of and access to your electronic health record, but later change your mind, you can revoke (take back) your permission by contacting the NYU Langone Medical Center's Privacy Officer or the practice manager in your physician's office. Which healthcare providers may participate in the Electronic Health information System? The following providers are currently part of the NYU Langone Medical Center community: NYU Hospitals Center, including: Tisch Hospital Rusk Institute Physicians at NYU Faculty Group Practice Offices NYU Hospital for Joint Diseases Physicians in Private Practices with NYU Clinical Cancer Center privileges at NYU Hospitals Center Other healthcare providers not listed above may join in the future as the NYU Langone Medical Center community grows. lis your health information kept private and confidential? Yes. Every healthcare provider that shares or uses information through the NYU Langone Medical Center Health Information System must obey strict security and privacy rules. Your health information will only be shared with providers directly involved in your care.

11 I A special message about sensitive information. State and federal laws have stricter rules about keeping certain types of health information confidential. This includes: Information from facilities licensed by the NYS Office of Mental Health. Information from federally assisted alcohol and drug abuse programs. Information about certain healthcare services to minors, including family planning and abortion services, testing for HIV and sexually transmitted diseases (STD's), and mental health and substance abuse treatment Genetic test results. Information about diagnoses, lab results or medications for HIV or AIDS. The NYU Langone Medical Center Electronic Health Information System will include any of the above types of sensitive information that exists in or is added to your medical record, so that all of your providers who need this information to provide your care and have access to the System will have a complete medical record. IPenalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access or use of your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call , your doctor's office or the NYS Department of Health at IWhere can I get more information? For more information or to ask questions, please contact: NYU Langone Medical Center Privacy Officer 550 First Avenue New York, New York Call your physician's office 2

12 ~ ~ ~ NYU Langone Medical Center Electronic Health Information System I have received the NYU Langone Medical Center Electronic Health Information System Fact Sheet. It describes (1) the purpose of the NYU Langone Medical Center Electronic Health Information System; (2) how it works; and (3) how the providers participating in the NYU Langone Medical Center Electronic Health Information System will record and access my health information. I understand that by signing this form, NYULMC providers directly involved in my care may access my health information, including my electronic prescription records, and that it will be available to my other health care providers in the system, as described in the Fact Sheet. I acknowledge receipt of the Electronic Health Information System Fact Sheet and consent for all of my providers who participate in the NYU Langone Medical Center Electronic Health Information System to create and/or access and use my electronic health record (EHR) in order to provide my medical care. I understand that this consent will remain in effect unless revoked in writing. Signature of patient or representative authorized by law Date fit not the patien-rname (print) of person---rauthorfty-to sign this-form-on-behaif ofthe l!signing this form: Ipatient (example: parent. legal guardian or! i I health care proxy): i I! 1 L.. *~ I "". --' ~ 10/

13 Name: DaB: Date: Age: Hospital for Joint Diseases NYU LANGONE MEDICAL CENTER Mehul R. Shah M.D. Assistant Professor, Orthopaedic Surgery Sports Medicine Division Physician Address Fonn Please fill in the information completely! The data is essential to office efficiency. These addresses are important for communication, insurance verification and authorization, and surgical planning. Call your doctors ifyou don't have the information. Referring Physician: 0 Full Name: 0 Full Address: 0 Telephone #: Family PhysicianIPCP/PMDllnternist 0 Full Name: 0 Full Address: 0 Telephone #: 303 Second Ave NY, NY tel: