EFTA00304446.pdf

r. tNlillsopas lat•CA.,/%1O1 Faculty Group PrACtitt Patient Demographic En Nut riares IS. Fn. MI al Chan .loore) EPS-re 04 TER:gay NW ideas , i e eV0.40.+; 0 nCaq Ina; I .C.0 9 I tat Addis 4 eASer 71ST STREET' Ley !JEW Y0(. Stet 0 by I °Ca-) Nak (ell .. Patna O Watt O Patted Er -W.j Due of Mk Marital Stem TEUZG,11;:3 it4 . 1 =C.,* c xunwd a Dmate 0 wormat °scans c ram a Ober Etta) Putted Itatte Lawn aye er16uSH al LA S A S pat reseveste powspraratioe Mar.Thkelt mean die spe of 1$ aid potatoes at the pai fin/sully responsible for. say cap an easy near that r ot mil seam tnifgallion .Iv, tc de ant a pm j i Nat TEPFRO C -Tviini Attu ge.far 11k CayiStetaZtp sal , NI LC.0 I Rettost b kat Sfk.F ► L Occupitta 73A ti 'Leg. Fereloree mai Address CLI-h/f OW eCVaCA+i 0 ‘ Law? Dot of On. I-2&-s3 Wort Patrol 0 engirt O Cal Poland Er 11 DJaae gAg•frIA SI-RAI-14K, Mash. to Pat r -gr it Vs Host Pete 1 ) Potted° Nock Phone I 1 Palatal O ref band le •• a Ite erns rhyucts Neat D_R__ Figisert C&S- L. 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Fete Rrand 12110I EFTA00304446 el Langone MEDICAL CENTER Patient Pre-Visit Worksheet Defieftment of Nestle Miry tot It Welt , hew York OS 10011 rei 212.10-1030 fa 212 20-41C legal NOME elk; P. 46J E-PS-re,r4 AARN Date of girth o ' Iteason for Visit: Misdeal History 0 None Do you hats • history of fainting or seizures, 0 NO oyes Surgical History - Please Inc dotes. if any 0 HOMY Parefes -.Plea list Reactions: O hone 0 Later 0 Other. Social History-. Highest Lent of Education.. OCOleitIOR: Mantal er S/ngle °Married 0 Divorced °Widowed °Partnered Tobacco Use MONS Ust illicit Drug Use farney Medial History. Current Medication with Usage. Is it okay to leave you • ~email with possible confidential informitINI:O NO 0 TE SS. Patient Signature _ -4-11-15? blame of Person cOro011ithre this form Neat Mar be taltro DARR: -9 [(3 Sgnature. EFTA00304447 QI VU Langone tri:ics. HMO% wins Oncost of Man surlily Mt tag Mistime New York NY 10016 Tel 212461-3010 ta. na2634492 Thank you for choosing NYU FGP Plastic Surgery Associates fax your healthcare needs. We appreciate you as a patient and intend to be as available and informative to you throughout your entire experience with us We are providing you with an env-view of common insurance terms and protocol so that you can better understand what your insurance coverage means. As a patient at out practice. you may be responsible for same out of pocket costs (all n0fl reimbursed cepoutsfor health care required to be paid by the enrollee or insured person) depending on your insurance coverage. The costs meiotic, your in-payment (co- nay) (a fixed amount that a subscriber pays to the beakh cart posies foe a wafted service), your co-Insurance (a Aura cox prooston by *hick cowed matters of a bath plan pay forapreemrogeof billed savXes usually applied after the dniuctdrk has been met and in addaion ill any co payment). and your deductible (fixed amoutit that a mambo' pays out of pocket for health care, in asifitien topremiums before insuraixe enrage or rombursements n calculated) You arc expected to pay your copal and any other pertinent payments at the time of your Ash. We sill inform you when you make your appointment with us whether we participate with your insurance or not. If we participate with your insurance. you will he using your in-network benefits li we do not participate with your insurance, please be sure that your insurance has out of net work cm-crate (bent/ as for matrix-tit rewind born a mon participategprenettr) II you do decide to move forward with a surgical procedure with us, we will obtain a pre-certification (an authors-Wien provided by your insurance company after a Mire Of diagnosis and propose, I trearmou plans prior to treatment ) The precertification is not a guarantee of benefits or payment and the procedure must. IMO the medical necessity guidelines in order for your insurance to cover it. We can provide you with the procedure code(%) that corresponds to the procedure that is anticipated to be performed before your procedure takes place You can contact your insurance company (by using the Member Services number located on the back of your insurance card) and provide them with the cade(s) so that they can let you know what their reasonable anti customary rate is This will also allow the insurance company to provide you with an MIRIAM of what your nut of pocket responsibility may be based on your insurance benefits. Please note t hat these codes are nix guaranteed to be billed until after the procedure is performed; they might change U the physician deems necessary while perromiing the procedure. There is also a post op period associated with your procedure This is a pre-set amount or time in which you mall not be charged for any follow up office visits that are related to the procedure performed • The postoperative period for most minor procedures that arc performed in the office is 10 days from the date of service. • The post operative period for most swim:alprocedure.. no-formed in the hospital P. 90 clays from the date of service. However, any type of preeedure, injection. x ray, or office visit regarding a separate issue, performed within these 90days, is billable to your insurance company and a Copayrnent, coinsurance, or deductible may apply once the claim is processed per the insurance. Only past-operative office visits alone are not billable. After the 10 or 90 day period, all visits art billable in full. INITIAL THAT I HAVE READ AND UNDERSTAND All ABOVE STATED EFTA00304448 I understand that NYUSCMW of *Declare. my Metro physicians end then re I, _tr. a-3 metre my health norintibm for all papoose necessary to vestment. Parfroft Int Mph ell', &orations. rtr-kar39 bre net limed to orate of inkonnation mounted by my insurance consort (ce UMW) and any anlorrnalon nasality for chichirso bionnbip purposes • ASSIGNMENT OF INSURANCE: I terry autncrue my macrame benefits to be pact orectty to NYU School of Median. I tmoentans I em francs/ ay resoonsfse to non-onred rwoes I auncna the release of any medical Cr other intormati0n necessary to process mance Plain on my NNW • FINANCIAL MERLIN: I In bean pros ded a copy of the NYU School of Molione Synod policies and agree to the eroded bre thereof agree to pay al °woe du (ot to become an) to NYU School of lamk:Me ice care and tnealthert Marc co-payments and CleilattiMes es provided uncle( my peen Safes R ers, pod by. thed patty, creditol do loccult. I rderstand thalweg be reeponabe ter any charges W any of the Wrong *My • My tsar plan mare rot referral by • Primary Care Physician (PCP) before tearing ..tae. at NYU School Of Medicine amt hie not obtained tsch a referral or sermes El excess oftener.* andfor • My troth pan dernees that the swam I receive at NYU Sara Cl Modern are not leleclitielly necessary woof not coveted by my Insurance Alen, andlce • My heath plan coverage has betted cc expired at Me erne I receive annoys DI NYU School of Metkine, antr • I hive chosen not to We my hoar plan coverage, worm • The physician I see does and pewee, with my health can plan • MEDICARE SIGNATURE ON FILE (Medicare Pares Only): I Mum* flan PaYforc of aurcond Unica, teas bs male eat to me or on my NOW to Y prat* who reams *ay my hospital say or any sans lurrad to me by tote powders I ailtionze the holder of medic.* and other micanabon wbeiRar to rdsase d Medicare and Rs agents any information needed to debenture them Poeta or benefits for (OS iier/oes Patient's Medicare NumberO10 ' 'H 33d6 patent signature • ANCILLARY SERVICES: I understand I may mere cotton ancaary medical sown wry* I am et NYU Bacot of Ileficinfr such as rester allevPlatetii30 of mew tett racing services (0 g., ■lays. MIMI) and penology soodmen etaminebon. I understand Mel scow "iodine nay net prow* services Si my presence. but mooch* mord nth carted calpseis and Pestraert I hereby auditor) psyment Chrecdy for rem errs under the mecy(s) of pate) issued to me by my InituranCe canner. I undenNand that I may was asestionel charges as a realtchntee ancelary SOS I agree to ploy all Charges due let raped 10 WO elowes to the Mtn the dope re due NW ant is even for beret pod on my behalf by any rued pony payer • CANCELED OR NO-SHOW APPOINTMENTS: I unSeettand that based on tan pop of incivial phyran oncost may incur a cenceismon tee d 1 do not pew& the mound rows of antelabon or Aldo not keep my aporement any have not centre I nave been provided the F acuity Group Practice Patient F listed above which has • n fully espial inn Revised 9111rtOl• rm+irantorSpnatun al Policies I one. no land the Information n Gas EFTA00304449 TraTirmaryarrygrzywr I mam! NYU Langone Health I understand that as a service to its patients, NYU Langone )faculty Group Practice) provides bill pay reminders to patients that may be placed using a prerecorded message or text message By providing my cell phone number to NYU Langone and signing below, I am giving consent to receive these calls or text messages at the number maintained in my NYU Langone medical record. i understand that if my cell phone number is updated at NYU Langone, t will receive the calls or text messages to the new number, unless I have opted out as described below I also understand that this consent will apply to any NYU Langone Faculty Group Practice office that may use this service. 0 t GIVE CONSENT for NYU Langone to contact me regarding bill pay reminders on my cell phone. CI I DENY CONSENT for NYU Langone to contact me regarding bill pay reminders on my cell phone. I understand that I can opt-out at any time by emading my name and date of birth (for verification) to NYUPthiniirenServicestpnyulnic ort submitting a message via MyChart. or by providing written notice to: NYU Langone Physician Services, PO Box 415662, Boston, MA 02241 EFTA00304450 IIBUr HEALTH INFORMATION EXCHANGE. CARE EVERYWHERE AND HEALTHIX CONSENT FORM In this Consent EOM, you can choose *tether to allow the heath care providers lusted on the NYU Langone MeiScat Getter Heath Informabon Exchange (NYUL Noah HIFI **bate Mteihtlath-Calnect fried 'iv CHIE ParticiPeltal and non- NYU heath ewe providers who may request access to your medal records for purposes of current treatment (Care Evermshere Provides') b obtain access to your medical records Waugh a COMOuter network Operated by the NYUL Hest HE In order for a Care Evernihehe Provider to know tom Scansion Pug be irealtabla through the NYUL Heal HE. you must the them that you we sere a patient of an HE Parecipant and put such information may be avarLabb upon request This can hip coin the medical records you have N deleibrit places where you get health care and make them sassed* electronically to Vie prodders resting you You may LSO use this Consent Form to tepee wheeler Ce not to ithOw &motors-es, agents or members of the mai4cal Hatt or NYU Homatais Center to see and obtain access to yaw electronic heath records through Heat- whoth a a Health information Exchange. Or Regional Health Information Organization iRHIO, nct-fororctit orgarazabon recognized by the state of New York TM can aiKi he mewl Si. medical records you haven different traces Where you get healthcare and make them mutable electonically to the providers twang you This consent also gores your pernmnion for any NYU Langone Heath proverb in Sill you at a patent or member, to access your records from your other healthcare Pr0sedels eteh0rted to disdoee infonneicm through Heelhat A carpets list or current Heath's Information Sources is avibiebie born Heart end Mt be obtained at any ere by checking the Hearn **byte at t O thwiw hegehut rig or by Pang Heeithia•Bn405-47411 Upon riga your provider win print this hst for you from the Heather webtfe YOUR CHOICE WILL NOT AFFECT YOUR ABILITY 70 GET MEDICAL CARE OR HEALTH INSURANCE COVERAGE YOUR CHOICE TO GIVE OR TO DENY CONSENT MAY NOT BE THE BASIS FOR DENIAL OF HEALTH SERVICES. The NYUL Heat HIE and Hulett share Horn ation about geodes health electronically and securely to improve ire Of health care services This kind of slump is celled sheath or health inforrnabon technology (health IT) To learn more about *heath n New York State read the brochure -Better ink/anew Means Beeer Care • You can ask your heath care prodder for it or go to the waste wewenealtrany on) PLEASE CAREFULLY READ THE INFORMATION ON THE FACT SHEET BEFORE MAKING YOUR DECISION. Your Consent Choices You can NI out tin form now or in the future You have the Wowing Voices check one boa Er below II a I. I GIVE CONSENT to ALL of the HIE Partecipancs listed on the NYUL Health HIE **baste and Care Everywhere Providers to access ALL of my aleatoric hewn information through the NYUL Health HIE and I GIVE CONSENT to ALL employees, agents and members of the medical staff of NYU Hospitals Center to access ALL of ni) eleaorsc health inforrriebOw through HEALTHIX n comealon wit any of tie permitted b.:fp:Es:es descrIbeC En the fact sheet including provkling me any heart can, services, educing rnefir^cy care 2 1 DENY CONSENT to ALL of the HIE Participants hated on the NYUL Health HIE watisite and Care Everywhere Providers to access my ee;trcr. rl:,,rnat]on through the NYUL Health HIE or HEALT MIX ice x- y p-Erpose then in a rnecbca:rt,crgenCY NOTE. UNLESS YOU CHECK THE "I DENY CONSENT' BOX. New York State law allows the people treating you in an emergency to get access to your medical records. including records that are available through the NYUL Health HIE. IF YOU DON'T MAKE A CHOICE, the records will not be shared except In an as allowed by Now York SW. LAW. Tt : irJ u- 1953 PRINT Name of Patent Patent Date of Birth Signature fraiH raterirs L Pnnt Nemo of Legal Representarom of applicable) -4- - I- IY Date Relationship of Legal REXesentatne to Patent (rf applicable) EFTA00304451 NYU Langone N... Health NYU Langone Health Notice of Privacy Practices NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT FORM Bs signing this form, I acknoss ledge that I has c reccisal a copy of NYU Lanese Health's Notice of Prism." Practice.. Patient Name: Signature: Personal Represenotis e's Name (it Applicable Dale: —4- - I I- I? Personal Representatise's Authorits tc.g., parent, guardian, health ran prosy): Effectist as of 1110112017. EFTA00304452 ACCESS YOUR HEALTH INFORMATION ONLINE IIENEFrf S OF MYCHART Ai UP YOUR ACCOUNT SECURITY OF YOUR NEALTI4 INFORMATION • View your test and lab results • Access your medical records, medications, immunizations. and mom • Schedule appointments • Request prescription refills • Send secure messages to your doctor's office • Access your billing statements and make payments visit MytilitinJIrdraC.Oll 31116 click Sligo Up Now to create your usemarne and password or download the app from guises. MOISRA ACCESS Once you have created smir own username and password using a desktop or laptop computer, download the MyChart app on your Apple' or Android"' device. Select NYU Ungone Medical Center from the list of hospitals, and sign In. Wain is password-protected and encrypted. This means your information is safe and secure Fran unauthorized access. QUESTIONS If you have questions about using My Chart. please call 866.262.6458. N.... WALT'S!Int EFTA00304453 Adult SIsChart at Ni 1. Langone Prtiss terns Rennes; and tuthurrration Form Requirements and Procedures • Proxy access to the MyChan at NYU Langone record of an ink* may be granted by the patient or his her legal representative. • Roth the paints requesting access and the patient or hillier legal temmcntatise must sign this form. • The proxy must have hisher own MyChart at NYU Langone account because the patient's chart will he accessed through the proxy's MyChart at NYU Langone record. I aaderstaad that: • My Chart at NYU Langone is intended as a secure online source of confidential medical information. • MyChart at NYC Langone is not to be used is an emergency. • Use of MyChart at NYU Langone is voluntary and I am not required to author tic proxy access. • I mum select a confidential password to maintain my password securely and change my, password if 1 believe it may have been compromised in any way. • If I share my MyChart at NYU Langone If) and password with another person. that person may be able to stew my or my child's heath information, as well as information about any adult who has authorized me as • MyChart at NYU Langone proxy. • If I have proxy access. I MST log in to my own MyChart at NYU Langone account and click on -View Other Records" to ace= another patient's record. • MyChart at NYU Langone contains selected. limited medical information from a patient's medical recast and is not the complete medical record. My milsdies within MyChart at NYU Langone may be tracked by computer audit and entries I make may become part of the medical record. • Access to MyChart at NYU Langone is provided by NYU Langone :Medical Center as a convenience to its patients and that NYU Langone Medical Censer has the right to deactivate access at any time for any reason. Completing this form to W establish a MyChart al NYU Leagose record for the patient and proxy. Return completed forms to your provider's office or to If you already have a MyChart at NYU Langone account. you will receive a MyChart at NYU Langone message when access to the additional patient's record is available. typically S to 7 business days atter completed request and authorization fora is received. PROXY: lam requesting access to the medical incarnation available on MyChart at NYU Langone for the patient named below and agree to abide by the above teats and conditions of MyChan at NYU Langone and all other tans and condition viewable online within MyChan at NYU Langone. cpsert Nam: "Tap; Reic Dale or Binh: /*- 0 -53_ Email: cLeck-ion2) 9frnil • CO" AckfresaPhone ems-r FIST ST nittjq Pio I / _2 -+.50-98Ss- a? - c3s - 34 39 Proxy Signature Relationship to Patient Data PATIENT OR PATIENT REPRFSENTATIVE: I acknowledge that Ilan read and understand this Request and Authotintion Fonts_ I agree to its terms and choose to desire* the person named abase as my MyChart at NYU Langone Proxy. thereby allowing my proxy to access my MyChart at NYU Langone medical record. Name: Address/Phone N: Patient Dale of Dinh: 'I: Relationship to Patient Date EFTA00304454 NYU POICAt Langone M ci Nun 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-prescnbing. Please complete the information below if you are interested in e-prescribing. Patient Name: TG Fr-: Pei eposTe/J Preferred Pharmacy Name of Pharmacy: Address: City: State: Zip Code: Phone Number: Fax Number: VITAI-ICALMAMI4AgNACIal AVe . Ne-w NOCte.. hl DOLS — ?( -1 / 1-3' Alternate Pharmacy Name of Pharmacy: Address: City: State: Zip Code: Phone Number: Fax Number: cry s 1 ) t1A1-1,-AAci Nevi tic N too • 354,4—,STAV-0 - • 5O 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. LibCorp Quest Labs NYU Lab Other External Location Please provide name of external location: EFTA00304455 1411"U Langone MEDICAL CENTER itassag wris Dessa.hherd of Pilaff Wiry 305 Cast 33.0 Witt Now Tort NY 100$ rt. 212.263.3030 fa. 212.2634092 rwloato.t :re F e I G PS - re IN1 0m• al astir - Consent for Diagnostic & Treatment Photographs I iralatssard eat pnotoilralas an or tier in wawa*. iiiiikuniultateri. deposer foss awskel latataill/PlflealtraonooTT by the phymetans of MU NOM Wiry. 0rt DP* Conde* flololo Flat Ms Ma lawis leant Ueda flodslearat Piero Saaclee. Sheaf Shinn& OIMI Safi MOM. NOW Thank and &wry ado attire Mine Pialtbneri *flan4a yours WWI/ MOW^ Wilkffsa Sward to eat Siewmasly. I Walorstard that loan to coroarst to Thai ptertTraggr. Pa Tab Patty Surgery Sc tigli ai *COM Wry it !WAWA. PPP- 42\1 EPS 7-E him Patient/Guanfan dame aelaoonsivip to Mort -11_40,e Date bin ass want rammer to recant iltUrsitrotthe haste Surbfrt to roes, Ouse prose ewth vow: (Please Pont) Noway Email / Call Consent ts nowt and hum •00sot saint; MAW Sugary and The imoode of Into Meats noi..fro ass Fenner n carnal ta tartar IkNI NM St We is teal oo.e moons/ aallialiol we wa nowt tort Si adorwrotiors if you wish to be cornea waft caw inciting Otis prate sate 1.3 cal y0u. TOtrittono Moonfror. DMch•cNngWsbccpuapetwecan a meson at the prewided about ass often lint tenth oh 1.10sers a12pm - Zorn fp To sowsplatenbe horn w enactor us Pent sal antis to ors with the a Vahan. lbe Me on itye subject Dar Date EFTA00304456 This Medicare card shows If you have Part A, Part B or both. It Is for your use only. Show your card when you get health services. Use your name end claim number as shown on this card any time you write or talk to Medicare. Cut out and keep this card. Important:Turn over to read more. Ina/SONOSSI ""' —"'"1.11.0 AADC PSI T00004 JEFFREY E EPSTEIN 6100 RED HOOK QUARTER 83 ST THOMAS, VI 00802 li• MEDICARE i ' HEALTH INSURANCE 1400.MEDICARE (1-800-633-4227) J KIE0A4‘ JEFFREY E EPSTEIN CA-TU12 •L419 7.7 090-44-3348-T MALE HOSPITAL (PART A) 01-01.2018 MEDICAL (PART 8) 02-01.2018 EFTA00304457 ints+ Rarccr a n3 UnitedHeaItticare >00I46, 7010107 OOS01] J.EPSTEIN 410E RED MOOS CU AAAAA St THOMAS VI 00012.1000 ali if I r MILI MIMI IN NOW es. .nil IN EFTA00304458 ••••••• ti.1.1•• liNtnietlittattligt • II st en V eZt eliZaVarapOk Waits it. ors fro Web .... `M[ Cam :al *soot cuts A...Cu...weft von *final. 7742 wer 4401O PrOMWel 177-642- In 0 C.-me ."••••••IPJ.11O•••• 44. wen Clans PO WI >4611:0 ArtNek CA riSSX M "3 MOM,' 1..J mins* IN , a itiampun ••• hmmoom SeD how,. ifttlavalp Cuss Owra. •0 Mr nose as MT. M 1 s:3 0.1444. ***** ..•••• 14 ****** IL la EFTA00304459