PATIENT INFORMATION SHEET - NJ Plastic Surgery · PATIENT INFORMATION SHEET ... HEALTH BENEFIT PLAN...

1567 Palisade Avenue, Third Floor ! 1566 Lemoine Avenue Fort Lee ! New Jersey ! 07024

PATIENT INFORMATION SHEET

Name: First _____________________________ Middle______________ Last ________________________________ Street Address ___________________________________________________________________________________ City _______________________________ State___________________________ Zip Code_____________________ Home Phone ______________________Cell Phone ______________________Work Phone _____________________ Social Security Number ______-______-______ Date of Birth ______/______/______ Age:______ �Male �Female Email Address _______________________________________________________ Marital Status �S �M �D �W Emergency Contact _____________________________ Phone____________________ Relationship______________ Your Primary care physician __________________________________________ Phone________________________ Pharmacy Information _______________________________________________ Phone________________________ Employment Status: �Employed �Student �Retired Employer Name/Address ________________________________________________ City/State__________________

Your privacy is of the utmost importance. Please indicate below if there are any restrictions in contacting you

INSURANCE INFORMATION Primary Insurance ____________________________ Policy#_____________________ Group#__________________ Secondary Insurance __________________________ Policy#_____________________ Group#__________________

POLICY HOLDER INFORMATION (if other than patient)

Name________________________________ Relation to Patient_______________ Date of Birth: _____/_____/_____ Social Security Number _____-_____-_____ Address (if different than patient)________________________________ Employer, Address, & Phone _______________________________________________________________________

HOW DID YOU HEAR ABOUT OUR PRACTICE?

�Physician Name _________________________________________ Phone _____________________ �Family / Friend Name ____________________________________________________________________ �Radio / La Mega �Radio / Amor �Internet Search � Other: _____________________________ Authorization to Release Information: I authorize Palisade Plastic Surgery Associates to release any information necessary, acquired in the course of my treatment, to process insurance claims. ***Initials___________ Authorization to Pay Benefits Directly: I authorize my insurance company to pay Palisade Plastic Surgery Associates directly for medical service rendered. I understand that I will be responsible for non-covered charges, balances after insurance company benefits, deductibles, and copayments. ***Initials___________

________________________________________________ ___________________

SIGNATURE DATE

PATIENT HISTORY QUESTIONNAIRE

Name: __________________________________________ Height_______ Weight_______ Date:_____/_____/_____ Reason for today’s visit: ___________________________________________________________________________ ! Are you currently under the care of or have you ever been treated by a Medical Physician for any significant

illness other than colds, flu, or virus? If so, please explain:

________________________________________________________________________________________________ ________________________________________________________________________________________________ Do you have any of the following conditions: If Yes, please explain: Cardiac History �No �Yes __________________________________________________________ Diabetes �No �Yes __________________________________________________________ Asthma �No �Yes __________________________________________________________ Hepatitis �No �Yes __________________________________________________________ Bleeding Problems �No �Yes __________________________________________________________ Hypertension �No �Yes __________________________________________________________ Other _________________________________________________________________________________ ! Have you had any surgical procedures in the past?

Date (mm/yy) Type of Surgery Name of Doctor Hospital ____________ _____________________ ______________________ ______________________________ ____________ _____________________ ______________________ ______________________________ ____________ _____________________ ______________________ ______________________________ ! Do you have allergies to Medications? Penicillin: �No �Yes __________________________________________________________ Local Anesthesia: �No �Yes __________________________________________________________ General Anesthesia: �No �Yes __________________________________________________________ Any others: �No �Yes __________________________________________________________ ! What antibiotics have you tolerated? ____________________________________________________________ ! Are you presently taking any medications? Aspirin: �No �Yes __________________________________________________________ Oral Contraceptives: �No �Yes __________________________________________________________ Blood Thinners: �No �Yes __________________________________________________________ Any others, including Over the Counter and Herbal Remedies: If yes, please specify below: Name Medication Dosage Frequency _____________________________________ ______________________ _________________________ _____________________________________ ______________________ _________________________ _____________________________________ ______________________ _________________________ ! Do you smoke cigarettes? �No �Yes If so, how many packs per day? ____________________________ ! Alcohol use? �No �Yes How much/often? _______________________________________ ! Recreational Drugs? �No �Yes If Yes, please specify which: ______________________________

Paul H. Rosenberg, MD

ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE

I hereby assign and convey directly to the above-named health care provider, as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above-named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named health care provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named health care provider any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above-named health care provider or its attorneys in order to claim such medical benefits.

In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above named health care provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.

I intend by this assignment and designation of authorized representative to convey to the above- named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by the above-named health care provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (above-named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above-named provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original

I HAVE READ AND FULLY UNDERSTAND THIS AGREEEMENT

Print Name_____________________________________________

Signature _______________________________________________ Date_____________________

HIPAA Information and Consent Form The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements began on April 14, 2003. This form is a “friendly” version. A more complete text is available in the office. What this is all about: There are rules and restrictions on who may see or be notified of your Protected Health information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protection to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services, www.hhs.gov. We have adopted the following policies: 1. Patient information will be kept confidential except as necessary to provide services or to ensure that all

administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare provides, laboratories, health insurance payers, as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas, such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to the office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but

must agree to abide by the confidentiality rules of HIPAA. 4. You understand and agree to inspections of the office and review of documents, which may include PHI, by

government agencies or insurance payers in normal performance of their duties. 5. You agree to bring concerns or complaints regarding privacy to the attention of the office manager or the doctor. 6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or

services. 7. We agree to provide patients with access to their records in accordance with state and federal laws. 8. We may charge, add, delete, or modify any of these provisions to better serve the needs of both the practice and

the patient. 9. You have the right to request restrictions in the use of your PHI and to request change in certain policies used

within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I, _________________________________ date_____________ do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION AND CONSENT FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.