EFTA00308055.pdf

NYU Langone vICAL CP.TtR Faculty Group Practice Patient Demographic Form Patient Information Name (Legal Last. First. MI and Chosen Name) Entail address Street Address City State Zip Home Phone ( ) Preferred 0 Work ( Phone ) Preferred 0 Cell Phone ( ) Preferred 0 SSN Date of Birth Gender Marital Status a Single a Married a Divorced a Widowed o Separated a Partner o Other Race Ethnicity Preferred Language Country of Origin Emergency Financially Responsible Contact Party Is patient responsible party/guarantor? OYesONo(lf are the person financially responsible for any charges you you are over may incur the age of 18 and not in the care during your visit) of an institution you are the guarantor as you Name Address City/State/Zip Relationship to Patient Occupation Employer Email Address Date of Birth Home Phone ( ) Preferred 0 Work ( Phone ) Preferred 0 Cell Phone ( ) Preferred 0 Name Relationship to Patient Home Phone ( ) Preferred 0 Work ( Phone ) Preferred 0 Cell Phone ( ) Preferred 0 O IN low 10 as w a. Referring Physician's Name Ph ( •sician Phone/Fax (if known) 1 Physician Address y.° U e a. •-• Primary Care Physician's Name (Check if same as Referring Physician aboveD) Physician ( Phone/Fax (if known) 1 Physician Address c a I Subscriber's a .... e t c 2 i Patient's ... Primary Insurance Company Policy # Group # Patient's Relationship to Insured a Self 0 Spouse 0 Child 0 Other Name of Subscriber (if other than patient) Social Security # Gender Date of Birth Employer of Subscriber Work Phone ( 1 Secondary Insurance Company Policy # Group # Relationship to Insured 0 Self 0 Spouse 0 Child 0 Other Name of Subscriber (if other than patient) Subscriber's Social Security # Gender Date of Birth Employer of Subscriber Work Phone ( ) By signing below. I acknowledge that the information I provided is correct to the best of my ability. Patient Signature: Date: / / Guarantor Signature (if other than patient): Date: / / Form Revised: 3/23/2O17 EFTA00308055 Q JYU Langone MEDICAL CENTER Patient Pre-Visit Worksheet Department of Plastic Surgery 305 East 33rd Street , New York, NY 10016 Tel. 212-263-3030 Fax 212-263.8492 Legal Name: MRN (for office use): Date of Birth: Age: Reason for Visit: Medical History: 0 None Do you have a history of fainting or seizures? 0 NO 0 YES Surgical History — Please list dates, if any: 0 None Allergies — Please list Reactions: 0 None 0 Latex: 0 Other: Social History: Highest Level of Education: Occupation: Marital Status (select one): 0 Si ngle 0 Ma rried 0 Divorced 0 Widowed 0 Partnered Tobacco Use: Alcohol Use: Illicit Drug Use: Family Medical History: Current Medication with Usage: Is it okay to leave you a voicemail with possible confidential information:Q NO 0 YES, PREF # Patient Signature: Date: Name of Person completing this form PI not the patient): Relationship to Patient: Signature: Date: EFTA00308056 /—\ Q. 4Y_U Langone MEDICAL CENTER Hansjerg Wyss Department of Plastic Surgery 305 East 33rd Street New York, NY 10016 Tel. 212.263.3030 Fax 212.263.8492 Thank you for choosing NYU FGP Plastic Surgery Associates for 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 overview of common insurance terms and protocol so that you can better understand what your insurance coverage means. As a patient at our practice, you may be responsible for some out of pocket costs (all non-reimbursed expenses for health care required to be paid by the enrollee or insured person) depending on your insurance coverage. The costs include, your co-payment (co-pay) (a fixed amount that a subscriber pays to the health care provider for a specified service), your co-insurance (a shard cost provision by which covered members of a health plan pay for a percentage of billed services, usually applied after the deductible has been met and in addition to any co-payment), and your deductible (fixed amount that a member pays out of pocket for health care, in addition to premiums, before insurance coverage or reimbursements is calculated). You are expected to pay your copay and any other pertinent payments at the time of your visit. We will 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 be using your in-network benefits. If we do not participate with your insurance, please be sure that your insurance has out of network coverage (benefits for treatment obtained from a non-participating provides). If you do decide to move forward with a surgical procedure with us, we will obtain a pre-certification (an authorization provided by your insurance company after a review of diagnosis and proposed treatment plans prior to treatment). The precertification is not a guarantee of benefits or payment and the procedure must meet the medical necessity guidelines in order for your insurance to cover it. We can provide you with the procedure code(s) 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 code(s) so that they can let you know what their reasonable and customary rate is. This will also allow the insurance company to provide you with an estimate of what your out of pocket responsibility may be based on your insurance benefits. Please note that these codes are not guaranteed to be billed until after the procedure is performed; they might change if the physician deems necessary while performing the procedure. There is also a post op period associated with your procedure. This is a pre-set amount of time in which you will not be charged for any follow up office visits that are related to the procedure performed. • The post-operative period for most minor procedures that are performed in the office is 10 days from the date of service. • The post-operative period for most surgical procedures performed in the hospital is 90 days from the date of service. However, any type of procedure, injection, x-ray, or office visit regarding a separate issue, performed within these 90 days, is billable to your insurance company and a copayment, coinsurance, or deductible may apply once the claim is processed per the insurance. Only post-operative office visits alone are not billable. After the 10 or 90 day period, all visits are billable in full. INTIAL THAT I HAVE READ AND UNDERSTAND ALL ABOVE STATED EFTA00308057 NYU Langone Health I understand that NYU School of Medicine. my treating physicians and their respective designees. will use and disclose my health information for all purposes necessary for treatment, payment and health care operations, including but not limited to release of information requested by my insurance company (or carrier) and any information necessary for discharge planning purposes. • ASSIGNMENT OF INSURANCE: I hereby authorize my insurance benefits to be paid directly to NYU School of Medicine. I understand I am financially responsible for non-covered services. I authorize the release of any medical or other information necessary to process insurance claims on my behalf. • FINANCIAL LIABILITY: I have been provided a copy of the NYU School of Medicine financial policies and agree to the specified terms. I hereby agree to pay all charges due (or to become due) to NYU School of Medicine for care and treatment, including co-payments and deductibles as provided under my plan. Benefits, if any, paid by a third party, will be credited on account. I understand that I will be responsible for any charges if any of the following apply: • My health plan requires prior referral by a Primary Care Physician (PCP) before receiving services at NYU School of Medicine and I have not obtained such a referral or I receive services in excess of the referral, and/or • My health plan determines that the services I receive at NYU School of Medicine are not medically necessary and/or not covered by my Insurance plan. and/or • My health plan coverage has lapsed or expired at the time I receive services at NYU School of Medicine, and/or • I have chosen not to use my health plan coverage, and/or • The physician I see does not participate with my health care plan. • MEDICARE SIGNATURE ON FILE (Medicare Patients Only): I request that payment of authorized Medicare benefits be made either to me or on my behalf to all providers who treat me during my hospital stay or any services furnished to me by those providers. I authorize the holder of medical and other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services. Patient's Medicare Number Patient Signature • ANCILLARY SERVICES: I understand I may receive certain ancillary medical services while I am at NYU School of Medicine; such as, anesthesia, interpretation of cardiac tests, imaging services (e.g., x-rays. MRIs) and pathology specimen examination. I understand that some physicians may not provide services in my presence, but are actively involved in the course of diagnosis and treatment. I hereby authorize payment directly for these services under the policy(s) or plan(s) issued to me by my insurance carrier. I understand that I may incur additional charges as a result of these ancillary services: I agree to pay all charges due with respect to such services to the extent the charge is due after credit is given for benefits paid on my behalf by any third party payor. • CANCELED OR NO-SHOW APPOINTMENTS: I understand that, based on the policy of individual physician offices, I may incur a cancelation fee if I do not provide the required notice of cancelation, or if I do not keep my appointment and have not canceled. I have been provided the Faculty Group Practice Patient Financial Policies. I understand the information listed above which has been fully explained to me. Patient Signature uate uarentor Signatur Form Revised: 9/14/2016 EFTA00308058 C ACULTY GROUP PRACTICE CELL PHONE CONTACT FORM NYU Langone \s- 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, I 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. K I GIVE CONSENT for NYU Langone to contact me regarding bill pay reminders on my cell phone. K 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 emailing my name and date of birth (for verification) to NYUPhysicianServices@nyulmc.org, submitting a message via MyChart, or by providing written notice to: NYU Langone Physician Services, PO Box 415662, Boston, MA 02241 Patient (Parent/Guardian) Signature Date EFTA00308059 , NYU Langone Health HEALTH INFORMATION EXCHANGE, CARE EVERYWHERE AND HEALTHIX CONSENT FORM In this Consent Form, you can choose whether to allow the health care providers listed on the NYU Langone Medical Center Health Information Exchange ("NYUL Health HIE") website http://health-conneamed.nyu.edui ('HIE Participants") and non- NYU health care providers who may request access to your medical records for purposes of current treatment (tare Everywhere Providers") to obtain access to your medical records through a computer network operated by the NYUL Health HIE. In order for a Care Everywhere Provider to know that information may be available through the NYUL Health HIE, you must tell them that you were/are a patient of an HIE Participant and that such information may be available upon request. This can help collect the medical records you have in different places where you get health care, and make them available electronically to the providers treating you. You may also use this Consent Form to decide whether or not to allow employees, agents or members of the medical staff of NYU Hospitals Center to see and obtain access to your electronic health records through Healthix, which is a Health Information Exchange, or Regional Health Information Organization (RHIO), a not-for-profit organization recognized by the state of New York. This can also help collect the medical records you have in different places where you get healthcare, and make them available electronically to the providers treating you. This consent also gives your permission for any NYU Langone Health program in which you are a patient or member, to access your records from your other healthcare providers authorized to disclose information through Healthix. A complete list of current Healthix Information Sources is available from Healthix and can be obtained at any time by checking the Healthix website at http://www.healthix.org or by calling Healthix at 877-695-4749. Upon request, your provider will print this list for you from the Healthix website. YOUR CHOICE WILL NOT AFFECT YOUR ABILITY TO 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 Health HIE and Healthix share information about people's health electronically and securely to improve the quality of health care services. This kind of sharing is called ehealth or health information technology (health IT). To learn more about ehealth in New York State, read the brochure. "Better Information Means Better Care." You can ask your health care provider for it, or go to the website www.ehealth4ny.org. PLEASE CAREFULLY READ THE INFORMATION ON THE FACT SHEET BEFORE MAKING YOUR DECISION. Your Consent Choices. You can fill out this form now or in the future. You have the following choices: Please check one box U below: • • 1. I GIVE CONSENT to ALL of the HIE Participants listed on the NYUL Health HIE website and Care Everywhere Providers to access ALL of my electronic health 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 my electronic health information through HEALTHIX in connection with any of the permitted purposes described in the fact sheet, including providing me any health care services, including emergency care. 2. I DENY CONSENT to ALL of the HIE Participants listed on the NYUL Health HIE website and Care Everywhere Providers to access my electronic health information through the NYUL Health HIE or HEALTHIX for any purpose, even in a medical emergency. 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 emergency as allowed by New York State Law. PRINT Name of Patient Patient Date of Birth Signature of Patient or Patients Legal Representative Date Print Name of Legal Representative (if applicable) Relationship of Legal Representative to Patient (if applicable) EFTA00308060 r's t r YUHL:are NYU Langone Health Notice of Privacy Practices NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT FORM By signing this form, I acknowledge that I have received a copy of NYU Langone Health's Notice of Privacy Practices. Patient Name: Signature: Date: Personal Representative's Name (if applicable): Personal Representative's Authority (e.g., parent, guardian, health care pt-ox Effective as of 11/01/2017. EFTA00308061 BENEFITS OF MYCHART • View your test and lab results • Access your medical records, medications, immunizations, and more • Schedule appointments • Request prescription refills • Send secure messages to your doctor's office • Access your billing statements and make payments SET UP YOUR ACCOUNT Visit mychart.nyulmc.org and click Sign Up Now to create your username and password or download the app from iTunes. MOBILE ACCESS Once you have created your own username and password using a desktop or laptop computer, download the MyChart app on your Apple' or AndroidTM device. Select NYU Langone Medical Center from the list of hospitals, and sign in. SECURITY OF YOUR HEALTH INFORMATION MyChart is password-protected and encrypted. This means your information is safe and secure from unauthorized access. QUESTIONS If you have questions about using MyChart, please call 866.262.6458. t ilYU Langone HEALTH SYSTEM EFTA00308062 Adult MyChart at NYU Langone Proxy Access Request and Authorization Form Requirements and Procedures • Proxy access to the MyChart at NYU Langone record of an adult may be granted by the patient or his/her legal representative. • Both the person requesting access and the patient or his/her legal representative must sign this form. • The proxy must have his/her own MyChart at NYU Langone account because the patient's chart will be accessed through the proxy's MyChart at NYU Langone record. I understand that: • MyChart at NYU Langone is intended as a secure online source of confidential medical information. • MyChart at NYU Langone is not to be used in an emergency. • Use of MyChart at NYU Langone is voluntary and I am not required to authorize proxy access. • I must select a confidential password to maintain my password securely and change my password if I believe it may have been compromised in any way. • If I share my MyChart at NYU Langone ID and password with another person, that person may be able to view my or my child's health information, as well as information about any adult who has authorized me as a MyChart at NYU Langone proxy. • If I have proxy access, I must log in to my own MyChart at NYU Langone account and click on "View Other Records" to access another patient's record. • MyChart at NYU Langone contains selected, limited medical information from a patient's medical record and is not the complete medical record. • My activities 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 Center has the right to deactivate access at any time for any reason. Completing this form will establish a MyChart at NYU Langone 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 5 to 7 business days after completed request and authorization form is received. PROXY: I am requesting access to the medical information available on MyChart at NYU Langone for the patient named below and agree to abide by the above terms and conditions of MyChart at NYU Langone and all other terms and condition viewable online within MyChart at NYU Langone. Name: Date of Birth: Email: Address/Phone #: Proxy Signature Relationship to Patient Date PATIENT OR PATIENT REPRESENTATIVE: I acknowledge that I have read and understand this Request and Authorization Form. I agree to its terms and choose to designate the person named above as my MyChart at NYU Langone Proxy, thereby allowing my proxy to access my MyChart at NYU Langone medical record. Name: Date of Birth: Email: Address/Phone #: Patient or Representative Signature Relationship to Patient Date EFTA00308063 Q‘ mu Langone MEDICAL CENTER 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-prescribing. Patient Name: Please complete the information below if you are interested in e-prescribing. Preferred Pharmacy Name of Pharmacy: Address: City: State: Zip Code: Phone Number: Fax Number: Alternate Pharmacy Name of Pharmacy: Address: City: State: Zip Code: Phone Number: Fax Number: 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. LabCorp Quest Labs NYU Lab Other External Location Please provide name of external location: EFTA00308064 Q IYU Langone MEDICAL CENTER Hansj6rg Wyss Department of Plastic Surgery 305 East 33rd Street New York, NY 10016 Tel. 212-263-3030 Fax 212-263-8492 Patient Name: Date of Birth: Consent for Diagnostic & Treatment Photographs I understand that photographs may be taken in connection with consultation, diagnostic testing, surgical procedures and treatments by the physicians of NYU Plastic Surgery, Drs. Daniel Ceradini, Roberto Flores, Alexes Hazen, Jamie Levine, Eduardo Rodriguez, Pierre Saadeh, Sheel Sharma, David Staffenberg, Vishal Thanik, and Barry tide or the Nurse Practitioners Amanda Young, Kimberly Morrone, Whitney Saia and Nicole Sweeney. I understand that failure to consent to these photographs will give NYU Plastic Surgery the right to decline my treatment. Print Patient/Guardian Name Relationship to Patient Patient/Guardian Signature Date Email / Call Consent Join our online newsletter to receive announcements, news and learn about exciting offers at NYU Plastic Surgery and The Institute of Reconstructive Plastic Surgery. To join, please provide us with your: (Please Print) Name: Email Address: Protecting your privacy is important to NYUPS and the IRPS. We strive to keep your personal information confidential. We will never share your information. If you wish to be called with our exciting offers please provide the best number to call you. Telephone Number: By checking this box, you agree we can leave a message at the number provided about our offers. Best time to call: D 8-10am ID 12pm — 2pm D 4pm-6pm To unsubscribe from our emailing or call list, please send an email to NYUPlasticSurgery@nyumc.org with the words "Unsubscribe Me" on the subject line. Date: Signature: EFTA00308065