EFTA00313611.pdf

S Mount Sinai Doctors AUTHORIZATIONS AND ASSIGNMENTS 1. FN AGREEMENT/GUARANTEE PAYMENT (All Dents E.T- i Yes I No (Please initial) considerabon of serne-05, assignment of benefits and care rendered; I agree that I am responsible for any and ail charges tilled by Ors. (the •Pnysioare) with respect to such services and tare unless the contract between the Physicians and my insurance company provides otherwise In the event that the requested services are not specifically authorized by my insurance company, I agree to pay for all services as agreed upon, unless ' otherwise provided by law. I authorize payment of medical Denefits to which :am entitled directly to the Physicians, to cover the cost of the care and treatrrent rendered to myself or my dependents in the GTE°. Upon receipt of a medical till I agree to immedimey pay al arnountS not covered by insurance. If ary insurarkm L nave elects my claim or pays part of the dein, I shall be responsible for payment of any balance as starred by Mount Sinai immediately upon reaming of such coverage, unless otherwise provided bylaw 2. RELEASE OF INFORMATION No (Please inkial) In the event my insurer denies payment to the Pnyseans for services rendered me, thereby to give my consent to have an authorized representative of the Physician to contact my Ensurer and to provide to my insurer all in'orrnahon and documentation regarding the services rendered to me by the Physicians which may be required in order for my insurer to reevaluate its decison deny to payment for such services. I authOn20 this practice. my beating physic-an. and their espective desigrees to use and enclose my health ireomxation for all necessary treatment, payment and health care operations purposes. 1 aCoMvAedge that my health information may nclude information relating to mental Uness and/or AIDS/ARC/HIV and that any such informabon may be disclosed (inducing examination and copying in either hard copy or digital format) to nsurent, venous credit agencies and guarantors solely if needed for payment of the professional charges (no dines: information wig be disclosed to any credit aliens* 3.MEDICARE.RELEASE OF INFORMATION & ASSIGNMENT OF BENEFITS (Medicare only - Part B Drayton) catty that the information given by me in appirag for payment under Title XVIII of the ET, Yes El No (Please initial) Social Security Act is coned. I authorize any holder of medal or other information about me to release to the Social Secunty Adrnmstration and Centers for Medicare and Medicaid Services or its intermediaries or carers any information (ididing infabnaton relating to 'rents illness ander AIDS/ARC/HIV needed ) for irks er a related Medicare darn I request that payment of authon2ed benefits be made on my behalf. I assign benefits payable to physician (slander the (s) or ordarlizatIohs providing the service (s) 4.INSURANCE NETWORK/PROVIDER NOTICE PURSUANT TO NYS "OUT-OF-NETWORK" LAW I understand that the Physicians may be participatirg providers in certain health plan networks. and Mat a list of the ;Lars that the Physicians participate in can be found on thew website or can be provided to me upon request. I uncerstand that the Physicians may not participate in the same health plans and networks as the hospitals and factities in the Mount Sena Health System even though the Physicians may be employed ic or affiliated with hospitals y a facihties in to Mount Sine Health System. I understand that I can determine the heath plans participated in by physicans who are employed pr contracted by Mount Sinai to provide nosPeal services by visiting reex://www.rrountstraitcro/Dabent-caryLfin ; lase understard that I can also determine the health plans accepted by hospitals Mount Sinai Health System by visiting the facilites web portal. and facilities ll are I understand Vial the Physicians charge for their services separately from the hospitals and facilities in the Mount Sinai Health System, and that any bills from hospitals or facilities in the Mount Sinai Health System for so-called iseilitiest or ',actinic:if fees will be sent separately horn the Phys cans bills for their *protases:mat services. t uncerstand that it is my responstedy to check wth the 'physician- arrargrg !or my services regarding: (1) whether the services of any other ph/shows will be required for my taro. and (2) whether the services of any other physicians (including but not I m ted to anestrestologists pathologists. and/or radiotogism) may be easo.nably amides:6-d to be proviced in connection with my care. I urderstadri that I can check with the *physician' arranPng for my services :o obtain the contact information and/or health plan participation information for any phythc.ians or faulty whose services may be needed in connecbon watt my care, and that I can alSO contact those PrlySiciars drectly to obtain information regarding they health plan participation. I HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE ITEMS. -Tecp ga\I I>) Sia_c SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE DATED RELATIONSHIP TO PATIENT WITNESS TO S EFTA00313611