PATIENT INFORMATION Last Name DOB Home Address Home Phone Driver s License # Employer Name Work Address First Name Age Sex Marital Status Cell Phone SSN Email Work Phone Person to contact in case of an Emergency Home Phone Cell Phone Relation to patient Referral Name Other Referral Type MI Minor PARENT OR RESPONSIBLE PARTY (if different from patient) Name Relation to patient Address SSN Home Phone Cell Phone Work Phone INSURANCE INFORMATION (please present insurance card at the time of check in) Insurance Address Name of Insured Insured s DOB Insured s ID# Insured s Group# Sex Insured s SS# Relationship to Patient Pharmacy of Choice Pharmacy Phone Primary Care Physician Physician Phone Do you have Secondary Insurance Yes No Insurance Company Ins. Phone Name of Insured Insured s DOB Sex Insured s ID# Insured s Group# Insured SS# ln order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. Coverage will be pre-verified and you will be asked to pay any co-payment, unmet deductible, co-insurance or non-covered services. For those applicable patients, co-payments, deductibles and non-covered service fees will be collected. In the event that your account must be turned over to collections, a $25.00 fee will be added to your account. Your signature below signifies your understanding and willingness to comply with this policy. Patient/Responsible Party Signature
MEDICAL HISTORY Patient Name DOB Age Please answer all questions to the best of your knowledge Do you smoke? Yes No Occasionally Do you drink? Yes No Occasionally Are you taking any medications? Yes No Please list Are you allergic to any medications? Yes No Please list Are you currently pregnant? Yes No Might you be pregnant? Yes No Please check if you ever had any of the following: Asthma Hepatitis (type: ) Cancer (type: ) Diabetes Herpes (Shingles/Cold Sores) Leukemia High Blood Pressure Blood Disorder/Disease Neurological Disorder High Cholesterol Heart Disorder/Disease Venereal Disease Chicken Pox Lung Disorder/Disease Inherited Diseases Mumps Liver Disorder/Disease Colitis/Bowel Problems Measles Kidney Disorder/Disease Recurrent Skin Infection Autoimmune Disorders (ie. Lupus, Crohn s, MS) Other Disorders/Disease Please check if you: Bruise easily Suffer from heartburn or indigestion Bleed easily Suffer from headaches Have abnormal or rapid pulse/heartbeat Suffer from fainting Use a pacemaker heart device Suffer from recurring diarrhea Have you had any of the following in the past three months? Blood Test EKG Chest X-Ray Mammogram Pap Smear Were the results normal? Yes No If no, explain Any serious illness in your family history we should be aware of? Have you had any kind of previous surgeries? Yes No If yes, explain Did any problems occur with the surgery/anesthesia? Yes No If yes, explain Patient/Responsible Party Signature Physician s Signature
HIPAA 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. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (IPO) and for other purposes that are permitted or required by law. It also describes your rights to access protected health information. Protected Health Information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed an, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law. Communicable Disease; Health oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners, Funeral Directors, and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers' Compensation; Inmates; Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.
HIPAA NOTICE OF PRIVACY PRACTICES (continued) Your Rights: Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request even if you have agreed to accept this notice alternatively, i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main telephone number. Signature below is only acknowledgment that you have received this Notice of our Privacy Practices. Printed Name Signature
Appointment of Administrative Representative; Assignment of Benefits and Rights; Assignment of Causes of Action; and Authorization to Release Information 1. APPOINTMENT OF REPRESENTATIVE: The undersigned hereby appoints NuHealth Surgical Center, or its assignee, as my duly authorized and assignee during any: (1) Administrative claims process; (2) Appeal or Review process for a denied claim; or (3) State of Federal legal process, necessary to collect claims submitted on my behalf for health insurance benefits, but denied on my plan. The CLAIMS ADMINISTRATOR, PLAN ADMINISTRATOR or GROUP INSURANCE ADMIN- ISTRATOR for my medical insurance plan are all hereby notified and directed by me to henceforth regard any and all communications, particularly including all requests for information, received from my representative during the administrative process, as though these communications had been received from me. I understand that the United States Department of Labor has published the national minimum standards for the administrative processing and review of claims, found at 29 CFR 2560.503. 1. I ask all administrators to abide by these minimum standards. I demand complete and timely disclosure to my representative of (a) All pertinent documents, including the identity of their signatory or author, and (b) The identity of any person or entity possessing the discretion to approve or deny my claim. In addition, I demand compliance with applicable California enactments regarding full and fair review of claims. 2. BUSINESS PURPOSE AND RIGHT TO RECEIVE BENEFITS: The duly authorized representative and assignee named above in (1) is authorized to directly receive payment for the medical benefits due to me, under my insurance or plan. This assignment of benefits by me is complete. I retain no interest in the benefits due to me, under my insurance or plan. This assignment of benefits by me is complete. I retain no interest in the benefits due to me under these claims for medical care and facility fees. This assignment is given by me in return for the medical care and related services I have received, or will receive, from the health providers associated with my representative and assignee. I understand that if my claims are denied and the denial is upheld, I remain financially responsible for payment of all charges incurred to the extent allowed by law. I understand that my assignment of these rights and my appointment of an administrative representative serve a valid business purpose. That purpose is to provide an effective mechanism for my doctors and other health care providers to deal with any administrative of legal process that may be necessary to collect the benefits due for the services provided. The medical and business purpose for the assignment given here is further explained by, and based upon, the authority for assignments created under federal law in MISC v. BUILDING SERVICE HEALTH 789 F2D 1874 (9th CIR. 1986) In furtherance of this business purpose, my assignee is not necessarily my health care provider for any specific claim, but is rather the individual(s), organization, group and/or corporation designated by my providers to deal with all administrative and legal matters 3. JUDICIAL REVIEW: If my claim for benefits is administratively denied in whole or in part, I hereby assign ALL causes of action for judicial review to the individual(s), organization, group and/or corporation my personal standing under the ERISA civil enforcement procedures (codified at 29 U.S.C 11321 to be transferred to my assignee, so that he, she, they or it may seek judicial review of benefits claim denials, under 1132(a)(1)(B). My assignment also includes my right to seek review as a "claimant", under 1132(c), of any administrator's refusal or failure to provide information, 30 days after a written request. 4. RELEASE OF INFORMATION: I also authorize release of information and payment of medical benefits to the physician or supplier for services described. I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. Printed Name of Patient or Assignee Signature of Patients or Assignee Witness Signature
ASSIGNMENT OF INSURANCE PAYMENT TO NUHEALTH SURGICAL CENTER In consideration of the services rendered, or to be rendered, by the above Provider, I the undersigned do hereby assign all expense benefits under my Insurance policy which are due, or to become due to me by virtue of services performed. I hereby authorize the above named Provider to bill my insurance company directly. Furthermore, I authorize my insurance company to issue payment directly to NuHealth Surgical Center for any and all benefits accrued to me under my policy for services rendered and supplies furnished. Patient Name Patient Signature Witness Signature