Essex-Hudson Urology

Transcription

1 256 Broad Street Bloomfield, NJ Phone: Fax: Patient Information Essex-Hudson Urology 243 Chestnut Street Newark, NJ S. Frank E. Rodgers Blvd Harrison, NJ Valley Brook Ave Lyndhurst, NJ Patient Full Name (last, First): Date of Birth: Street Address: City, State Zip Code: Home Phone Number: Cell Phone Number: Address: Social Security Number: Gender: Emergency Contact (Name/ Number/Relation): Marital Status: How did you hear of us? M/5/D/W /Sep o Family o Friend o Close to home/work o Yellow pages o Employer: Occupation: Ethnicity: Race: I Primary language: Physician/Pharmacy Information Primary Care Physician (Name and number): Referring physician (Name and Number): Preferred Pharmacy (Name/Number/City): Insurance Information - Primary Insurance Carrier: Primary Insurance Co. Type: Subscriber Name/ Relation/ Date of Birth: Person responsible for bill: ID# Group# Secondary Insurance Carrier: Secondary Insurance Co. Type: Subscriber Name/Relation: Subscriber Date of Birth: ID# Group# The above information is true t o the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize (Essex Hudson Urology) or insurance company to release any information required to process my claims. Patient/Guardian Signature: Date: _

2 Essex Hudson Urology History Date: / /_ Last Name: First Name: Ml: Date of Birth: / Age: Sex: Male Female BP :----- /, ~ --- Height: Weight: Chief Complaint (Reason for visit} Physician use only: C Circle all that apply ::> Pain or burning with urination Difficulty with erections Previous kidney or bladder x-rays Blood in urine (ever) Frequent urination History of bladder infections History of prostatitis Difficulty starting urination Straining to urinate Slow urinary stream Awakening at night to urinate Testicular pain or lump History of kidney stones Unable to hold urine (wet pants) Previously been to another urologist History of Present Illness 1. Location of the problem? (Abdomen, back, kidney, bladder, genitals, etc.) 2. When did you first notice the problem? 3. How severe is the problem? Not Very Moderate Extremely 4. Does anything make the problem better or worse? (Medication, body position, etc.) 5. Is the problem associated with other symptoms? (Nausea, fever, pain, etc.) 6. Are the symptoms constant or intermittent?

3 Past Medical, Surgical, Family, & Social History What other medical conditions do you have? What operations have you had? Date: Procedure: What medications do you take? Is there any Cancer or other illnesses in your family? Are you allergic to any medications or food? How much (if any) do you: Smoke: Drink Alcohol: What is your occupation? Physician use only:

4 Review of Systems Check all that apply Constitutional S)lmRtoms Fever Chills Headache lntegumentary Skin rash Boils Persistent Itch E)leS Blurred vision Double vision Yo Pain Musculoskeletal Joint pain Neck pain Back pain No Allergicflmmunologic Hay fever No Drug Allergies Ear LNose[Throat[Mouth Ear Infection Sore Throat Sinus Problems Neurological Tremors Dizzy spells Numbness Genitourinarv Urine retention Painful urination Urinary frequency Yo No No Endocrine Excessive thirst Too hot/cold Tired/Sluggish ResRiratorv Wheezing Frequent cough Shortness of breath Yo Gastrointestinal Abdominal pain Nausea/vomiting Indigestion/heartburn Cardiovascular Chest pain Varicose veins High blood pressure HematologicfLllmRhatic Swollen Glands Blood clotting problem Psychologic Are you generally satisfied with life? Do you feel severely depressed? Have you considered suicide? Ph)lsician Use Onl)l

5 Essex- Hudson Urology P.C Receipt of Notice of Privacy Written Acknowledgment Form I, have received a copy of Essex - Hudson Urology's Notice of Privacy Practices. Signature of Patient Date

6 Essex-Hudson Urology FINANCIAL POLICY Essex- Hudson Urology believes that an important part of good healthcare practice is to establish and communicate a financial policy to our patients. We are committed to providing the best possible care for if you have any questions or concerns. Please sign at the end to indicate your agreement to these terms and willingness to comply. Appointments 1. Copayments: Copayments are expected at the time of service. If you are unable to make a copayment at the time of service, Essex- Hudson Urology reserves the right to reschedule your appointment to the time when you will be able to pay your copayment. Payment for any outstanding balance is also expected at the time of service. If you are unable to pay your balance in full, you will need to make payment arrangements with the front desk staff in order to be seen by clinician. Failure to make payments per your agreement may result in rescheduling appointments or procedures until such time as you are able to make payments as agreed. 2. Procedure Prepayment: Essex-Hudson Urology collects your payment for a procedure at the time when the procedure is scheduled. Depending on your insurance, your payment may be based on an estimate of your expected financial responsibility. This is an estimate only. You are responsible for any unpaid balance after your insurance (if applicable) has been billed. In the event of overpayment, you may request a refund or any refund due will be processed by our billing department. 3. Missed Appointments and Late Arrivals: Depending on the doctor that you are seeing, if you arrive more than 30 minutes after your scheduled appointment, your visit may be rescheduled to an open appointment slot. This may mean that your appointment is rescheduled to a later date. If you do not show up for your appointment or cancel with less than 24 hours' notice, you will be responsible for a missed appointment fee. Missed office appointments are subject to a $30 charge. Missed procedure appointments are subject to a $75 charge. These charges are your responsibility and will not be billed to any insurance carrier. 4. Administrative Fees: This office charges an administrative fee of $20 for any letters, forms or medical records requests (a larger fee may apply for requests requiring more time to complete). The fee will be collected at the time of the request or will be unable to accommodate your request. Insurance Payments 5. Financial Responsibility: Your insurance policy is a contract between you and your insurance carrier. You are ultimately responsible for payment in full for all medical services provided to you. Any charges not paid by your insurer will be your responsibility, except as limited by our contract (if any) with your insurance carrier. We will utilize a credit card on file agreement to process payments due to the practice after your insurance carrier has made payment. 6. Coverage Changes and Timely Submission: You must bring a valid insurance card to every visit. Your insurance will be verified before each visit and if we are unable to verify active coverage, any and all fees for your services will be collected before any services are rendered. Insurance claims are fi!ied with participating plans where a valid insurance card is presented. You must report any insurance changes to the office immediately. There is a time limit within which Essex-Hudson Urology must submit a claim on your behalf to your insurance carrier. If we are unable to submit a claim during this period because we have not received your correct insurance information from you, you will be responsible for charges.

7 7. Self-Pay: If you do not have health insurance or if your health insurance will not pay for services determined to be medically necessary by the providers at Essex-Hudson Urology, you will be considered a self-pay patient. Your charges will be based on our current fee schedule. You may be asked to sign a Waiver of Insurance by the front desk. All self-pay patients are expected to make payments in full at the time of service. Benefits and Authorization 8. Insurance Plan Participation: We participate with many but not all insurance plans. It is your responsibility to contact your insurance company to verify that your assigned physician participates in your plan. We will submit a claim on your behalf to any insurance carrier. Out of network charges may have higher deductibles and copayments. If you have any questions regarding your insurance or financial responsibility, you should discuss them directly with one of our staff members. 9. Referrals: Referral and Prior Authorization requirements vary widely among insurance carriers and plans. If your insurance carrier requires a referral for you to be seen by a provider at Essex-Hudson urology, it is your responsibility to be aware of this fact and to obtain the necessary referral. If you require a referral and do not have a referral at the time of service, your appointment will be rescheduled to a later date when a valid referral is available. 10. Prior Authorization and Non-Covered Services: Essex-Hudson Urology may provide services that are excluded from coverage or require prior authorization. Essex-Hudson Urology, as a courtesy to our patients, makes a good faith effort to determine if services we order are covered by your insurance plan and if so, if prior authorization is required we will attempt to obtain such authorization on your behalf. Ultimately, it's the patient's responsibility to ensure that services provided are a covered benefit and authorized by your insurance carrier. 11. Out of Network Payments: ifwe are not part of your insurance carrier's network (out of network) and your insurance carrier pays you directly, you are solely responsible for payment and agree to forward any and all payments to Essex-Hudson Urology immediately. Failure to do so will result in legal action as permitted under the laws of the State of New Jersey. Account Balances and Payments 12. Reassignment of Balances: If your insuranc~ company does not pay within a responsible time, we may transfer the balance to you personally. At that point, it is your responsibility to follow up with your insurance carrier to resolve any non-payment issues. Balances are due within 30 days of receiving statement. 13. Collection of Unpaid Accounts: If you have an outstanding balance over 120 days old and have failed to make payment arrangements ( or become delinquent with an existing payment plan) we may turn your account over to a collection agency and/or attorney for collection. This may result in negative reporting to a credit bureau and/or legal action. Essex-Hudson Urology reserves the right to refuse treatment to any patient with an outstanding balance over 120 days old. You agree to pay Essex-Hudson Urology for any expenses that we incur to collect on your account, including reasonable attorney fees, court costs and collection costs. 14. Refunded Checks: Returned checks are subject to a $30 returned check fee. AGREEMENT AND ASSIGNMENT OF BENEFITS I have read and understand the financial policy to Essex-Hudson Urology and I agree to abide by its terms. I hereby assign all medical and surgical benefits and authorize my insurance carrier(s) to issue payment directly to Essex-Hudson Urology. I understand that I am financially responsible for all services that I receive from Essex- Hudson Urology. This financial policy is binding upon you and your estate, executors and/or administrators if applicable. Signed: Date:

8 Essex-Hudson Urology, PC & Experience. Expertise. 1' Cotnpassionate Care. Patient: DOB: Date: As our patient, we may need to reach you when you are not in the practice, please indicate your preferred method for us to communicate confidential health information, such as test or lab results, to you and/or others involved in your care. Please note that "appointment reminder or appointment cancellation telephone calls" may be left at the contact number(s) you list below. Please Indicate Your Communication Preferences Below: Give permission to leave health information pertaining to me, my dependent or child, at the numbers listed below: Horne Telephone Answering Machine Work Phone Cell Phone Method Yes No Area Code, Phone #, ext., for our Patient Portal Secure Registration to Receive Provider-Ordered Online Patient Education Programs Without specific permission, we will not release any health information to anyone other than you. In some cases you may wish for another person to have access to your health information. Please identify those individuals and their relationship to you (i.e. spouse, parent, son, daughter, partner, etc.): Patient Signature or Patient Legal Representative Date

9 Essex-Hudson Urology, PC & Experience. Expertise.. l Cornpassionate Care. Patient: DOB: Date: o Do Not release health information to anyone other than mysel o I Give permission to release health information pertaining to me to the individuals listed below. Name Relationship (i.e. spouse, parent, Area Code, Phone #, Ext., son, daughter etc.) Comments: I assume responsibility to inform the practice of changes in my phone number(s) or my preferences or to revoke this specific health information authorization at any time. Patient Signature or Patient Legal Representative Please Print Name Date