Primary Medical Insurance
I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in the above information. I authorize the release of any medical information necessary to process an insurance claim and request that payment of benefits be made to the physician unless my account has been paid in full.
LIST ALL MEDICATIONS YOU ARE TAKING (Prescription, over-the-counter or herbal) or Larry 1, Shemcn, lvf.D FRCS (C) to obtain medication history via electronic means directly from insurer/pharmacy
MEDICAL /SURGICAL HISTORY: HAVE YOU EVER BEEN DIAGNOSED WITH ANY OF THE FOLLOWING?
Ear / Nose / Throat: (HEENT)
REVIEW OF SYSTEMS:
Please mark where applicable:
We are committed to providing you with the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Finencial Policy is important to our professional relationship. Please asic if you have any questions about our fees, financial policy or your financial responsibility.
PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. WE WILL REQUEST TO PHOTOCOPY YOUR INSURANCE CARD(S) FOR YOUR FILE.
REFERRALS — If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, YOU WILL BE REQUESTED TO SIGN A FINANCIAL WAIVER. It is then your responsibility to provide us with the refetral within 48 hours or you will be personally responsible for that day's services.
CO-PAYMENTS — By law we MUST collect your carrier designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit.
OUT OF NETWORK PLANS — You will be responsible for any balance your plan indicates as due on their explanation of benefits form. We will adjust the charges to coincide with your plan's UCR (Usual, Customary and Reasonable) charges. All patients will be responsible for their co-insurance and deductible. If we do not 'participate' with your plan, we will send a courtesy bill to that carrier on your behalf However, should they not pay your claim within 45 days, you will be responsible for the MI amount due. Should you receive'payment from your insurance carrier, please forward it to the physician's office. Private Insurance Authorization for Assignment of Benefits/Information Release: I, the undersigned, authorize payment of medical benefits to _ Lary J. Shemen, M.D for any services furnished. 1 understand that I am financially responsible for any amount not covered by my contract. 1 also authorize any holder of medical information about me to release to my insurance company (or their agent) information concerning health care, advice, treatment or supplies provided to rue. This information will be used for the purpose of evaluating and administering claims of benefits.
SELF-PAY PATIENTS - Payment is expected at the time of service unless other financial arrangements have been made prior to your visit.
MEDICARE - We will submit claims to Medicare. The patient will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one.
Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits be made on my behalf TO Larry J. Shama, M.D2RCS for anyservices furnished to me. I authorize any holder of medical information about me to release to the CMS (and its agents) any information to determine these benefits payable for related services. This information will be used for the purpose of evaluating and administering claims of benefits.
DIVORCED/SEPERATED PARENTS OF MINOR PATIENTS — The parent who consents to the treatment of a minor child is responsible for payment of services rendered. Larry J. Shemen, MD FRCS will not be involved with separation or divorce disputes.
ALLERGY SHOT PATIENTS — If you are an allergy patient who is consenting to receive allergy shots as part of your treatment plan, it is important that you understand your benefits and responsibilities related Co the cost of this type of therapy. Once you consent to receive allergy shots, your doctor will write a prescription for allergy scrums specifically for you based on your particular allergies.
You are responsible for the timely payment of your account. Should it become necessary for us to use an outside agency to co I lect payment form you, you will be additionally responsible for whatever charges we incur as a result of this.
WE ACCEPT CASH, CHECKS, MASTERCARD, VISA, OR DISCOVER CARD.
THANK YOU for taking the time to review our policies. Please feel free to ask.any questions or share with us special concerns.
I hereby agree that you may contact me for whatever reason concerning my account on any and all of the phone numbers 1 have provided to you, including but not limited to home phone, work phone, cell phone or any other phone number.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. In accordance with New York and/or New Jersey State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV- related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination be cause of the release or disclosure of HIV-related information, I may contact New York State Division of Human Rights at (212) 480-2493 or the New York City Commission on Human Rights at (212) 306-7450 or the New Jersey Division on Civil Rights (973) 977-4500. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in item 2), and this redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THEN ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9(b).
Authorization to Discuss Health Information
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.
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