EFTA00304446.pdf

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Patient Signature: Guarantor Sicatt (dote than (Sr et_ J ii 1 IR pito e Ite: / c. Fete Rrand 12110I EFTA00304446  el Langone Defieftment of Nestle tot It Miry Welt , hew York OS MEDICAL CENTER 10011 rei 212.10-1030 fa 212 20-4 1C Patient Pre-Visit Worksheet 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 dote s. if any 0 HOMY Parefes -.Plea list Rea ctions: O hone 0 Later 0 Other. Social History-. Highest Lent of Educatio n.. 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 • ~ema il with possible confidential informitINI:O NO 0 TESS. Patient Signature _ -4-11-15? blame of Person cOro011i thre this form Neat Mar be taltro Sgnature. DARR: -9 [(3 EFTA00304447  QIVUtri:iLancs.gone HMO% wins Oncost of Man surl Mt tag Mistime New York NY 10016 ily Tel 212461-3010 ta. na2634 492 Thank you for choosing NYU FGP Plastic Surgery Associates patient and intend to be as availab fax your healthcare needs. We le and informative to you thro appreciate you as a providing you with an env-view ughout your entire experience of common insurance terms and with us We are what your insurance coverage mea protocol so that you can better ns. understand As a patient at out practice. you may be responsible for same out of health care required to be paid by the pocket costs (all n0fl reimbursed cep enrollee or insured person) depending outsfor meiotic, your in-payment (co- nay on your insurance coverage. The cos ) (a fixed amount that a subscriber ts service), your co-Insurance (a Au pays to the beakh cart posies foe a ra cox prooston by *hick cowed ma wafted savXes usually applied after the dniuctdr tters of a bath plan pay forapreemro k has been met and in addaion ill any geof billed amoutit that a mambo' pays out of pock co payment). and your deduct et for health care, in asifitien topremi ible (fixed calculated) You arc expected to pay ums before insuraixe enrage or your copal and any other rom bursements n pertinent payments at the tim We sill inform you when you e of your Ash. make your appointment with us wh not. If we participate wit ether we participate with your h your insurance. you will he usin insurance or participate with your insurance, ple g you r in-network benefits li we do not ase be sure that your insuran matrix-tit rewind born a mon par ce has out of net work cm ticipategprenettr) -crate (bent/asfor II you do decide to move forward with a surgical procedure with authors-Wien provided by your insurance us, we will obtain a pre -certif company after a Mire Ofdiagnosis and ication (an The precertification is not a gua propose,I trearmou plans prior to trea rantee of benefits or payment and tment ) necessity guidelines in order for the procedure must. IMO the med your insurance to cover it. ical We can provide you with the pro cedure code(%) that corresponds to performed before your procedure the procedure that is anticipate takes place You can contact you d to be Services number located on the r insurance company (by using the back of your insurance card) and Member can let you know what their provide them with the cade(s) so reasonable anti customary rate is that they provide you with an MIRIAM of This will also allow the insurance com what your nut of pocket resp pany to benefits. Please note t hat these onsibility may be based on your codes are nix guaranteed to be bill insu ran ce performed; they might change ed until after the procedure is U the physician deems necessary while perromiing the procedure . There is also a post op period associated with your procedure Thi mall not be charged for any follow s is a pre-set amount or time in up office visits that are related to which you • The postoperative period for the procedure performed most minor procedures that arc perform the date of service. ed in the office is 10 days from • The post operative period for most swim:alprocedure.. date of service. no-formed in the hospital P. 90 clays from the However, any type of preeed ure, injection. x ray, or office visit these 90days, is billable to your insu regarding a separate issue, perform rance company and a Copayrnent, ed within once the claim is processed per the coinsurance, or deductible may apply insurance. Only past -operative 10 or 90 day period, all visits art bill office visits alone are not billable. able in full. After the INITIAL THAT I HAVE READ AND UNDERSTAND All ABOV E STATED EFTA00304448  I understand that NYUSCM W of *Declare. my Metro phy healthnorintibm for all papoos sicians end then re e necessary to vestment. I, _tr. a-3 metre my orate of inkonnation mount ed by my insurance consortParfroft Int Mph ell', &orations. rtr-kar39 bre net limed to purposes (ce UMW) and any anlorrna lon nasality for chichirso bion nbip • ASSIGNMENT OF INSURA NCE: I terry autncrue my tmoentans I em francs/ay macrame benefits to be pact orectty resoonsfse to non-onred rwoes to NYU School of Median. I necessary to process mance I auncna the release of Plain on my NNW any medical Cr other intorma ti0n • FINANCIAL MERLIN: I In bean pros ded a copy of eroded bre thereof agre the NYU School of Molione Syn e to pay al °woe du (ot to bec od policies and agree to the tnealthert Marc co-paym ome an) to NYU School of ents and CleilattiMes es provided lamk:Me ice care and creditol do loccult. I rdersta uncle( my peen Safes R ers nd thalweg be reeponabe ter any , pod by. thed patty, charges W any of the Wrong *My • My tsar planmare rot referral by • Primary Care Physicia Of Medicine amt hie not obta n (PCP) before tearing..ta ined tsch a referral or e. at NYU School • My troth pan der sermes El excess oftener. nees that the swam I receive * andfor woof not coveted by my Insu at NYU Sara Cl Modern are not rance Alen, andlce leleclitielly necessary • My heath plan coverage has betted cc expired at Me erne • I hive chosen not to We my ho I receive annoys DI NYU Sch ar plan coverage, worm ool of Metkine, antr • The physician I see doe an s d pewee, with my health can plan • MEDICARE SIGNATURE ON FILE (Medicare Pares male eat to me or on my Only): I NOW to Y prat* who reams Mum* flan PaYforc of aurcond Unica, tea bs tote powders I ailtionze *ay my hospital say or any sa s the holder of medic.* and other ns lurrad to me by information needed to debentu micanabon wbeiRar to rdsase d re themPoeta or benefits for Medicare and Rs agents any (OS iier/oes Patient's Medicare NumberO 10 ' 'H 33d6 patent signature • ANCILLARY SERVICES: I understand I may mere cotton Ileficinfr such as rester ancaary medical sown wry* I allevPlatetii30 ofmew tett rac am et NYU Bacot of etaminebon. I understand ing services (0 g., ■lays. MIM Mel scow "iodine nay net pro I) and penology soodmen carted calpseis and Pestrae w* services Si my presence. but rt I hereby auditor) psyment Chre mooch* mordnth issued to me by my InituranCe cann cdy for rem errs under the er. I undenNand that I may was mecy(s) of pate) I agree to ploy all Charges asestionel charges as a realtch due let raped 10 WO elowes ntee ancelary SOS pod on my behalf by any rued pon to the Mtn the dope re due NW y payer ant is even for beret • CANCELED OR NO-SHOW APPOINTMENTS: I unSeett incur a cenceismon tee d 1 do and that based on tan pop of inc not pew& the mound rows ivial phyran oncost may centre of antelabon or Aldo not kee p my aporement any have not I nave been provided the F acuity Group Practice Patient F listed above whichhas • n fully al Policies I one.no land the Info espial rmation Gas n rm+irantorSpnatun inn Revised 9111rtOl• EFTA00304449  TraTirmaryarrygrzywrma I m! NYU Langone Health I understand that as a service to its patients, NYU Langone )faculty Group Practic pay reminders to patien e) provides bill ts that may be placed usin g a prerecorded message By providing my cell phone or text message number to NYU Langone and receive these calls or text signing below, I am giving consent to messages at the number mainta record. i understand that if ine d in my NYU Lan gon e medical my cell phone num ber is updated at NYU Langon the calls or text messages e, t will receive to the new number, unless I have opted out as describ also understand that this ed below I consent will apply to any NY office that may use this service U Lan gon e Fac ulty Gro up Practice . 0 t GIVE CONSENT for NYU Langone to contact me regarding bill phone. pay reminders on my cell CI I DENY CONSENT for NY U Langone to contact me reg phone. arding bill pay reminders on my cell I understand that I can opt -out at any time by emading my name and date of birth (for verification) to NYUPthiniiren Servicestpnyulnic ort submitting providing written notice to: a message via MyChart. or by NYU Langone Physician Service 02241 s, PO Box 415662, Boston, MA EFTA00304450  IIBUr HEALTH INFORMATIO N EXCHANGE. CARE EVERYWHERE AND HEALTHIX In this Consent EOM, CONSENT FORM you can choose *tether to Heath Informabon Exc allow the heath care prov hange (NYUL Noah HIFI iders lusted on the NYU NYU heath ewe prov **bate Mteihtlath-C Langone MeiScat Getter iders who may request acc alnect fried 'iv CHIE ParticiPeltal and Evermshere Provides') b ess to your medal records non- obtain access to your med for purposes of current HE In order for a Car ical records Waugh a COM treatment (Care e Evernihehe Provider Oute r network Operated by the must the them that you to know tom Scansion Pug NYUL Hest we sere a patient of an HE be irealtabla through the NYU This can hip coin Parecipant and put such L Heal HE. you the medical records you info rmation may be avarLabb sassed* electronically to have N deleibrit places where upon request Vie prodders resting you get health care you and make them You may LSO use this Consent Form to tepee whe NYU Homatais Center eler Ce not to ithOw &motor to see and obtain access s-es, agents or members of information Exchange. Or Reg to yaw electronic heath reco the mai4cal Hatt or ional Health Information rds through Heat- state of New York TM can Organization iRHIO, whoth a a Health aiKi he mewl Si. med nct-fororctit orgarazabon make them mutable ical records you haven diffe recognized by the electonically to the provider rent traces Where you get Langone Heath proverb in s twang you This con healthcare and Sill you at a patent sent also gores your per Pr0sedels eteh0rted to disd or member, to access you nmnion for any NYU oee infonneicm through Hee r records from your othe avibiebie born Heart end lhat A carpets list or curr r healthcare Mt be obtained at any ere ent Heath's Information Pang Heeithia•Bn405-4 by checking the Hearn **b Sources is 7411 Upon riga your provider win print this hst yte at t O thwiw hegehut rig for you from the Heather or by YOUR CHOICE WILL NO webtfe T AFFECT YOUR ABILITY YOUR CHOICE TO GIVE OR 70 GET MEDICAL CAR TO DENY CONSENT MA E OR HEALTH INSURANCE Y NOT BE THE BASIS FOR COVERAGE DENIAL OF HEALTH SER The NYUL Heat HIE VICES. and Hulett share Horn Of health care services This ation about geodes health elec kind of slump is celled tronically and securely about *heath n New Yor sheath or health inforrnabon to improve ire k State read the brochure technology (health IT) To prodder for it or go to -Better ink/anew Means learn more the waste wewenealtrany Beeer Care • You can ask on) your heath care PLEASE CAREFULLY READ THE INFORMATION Your Consent Choices You ON THE FACT SHEET BEF can NI out tin form now or in ORE MAKING YOUR DEC the future You have the Wo ISION. wing Voices check one boa Er below I. I GIVE CONSENT to ALL of the HIE Par Care Everywhere Provide tecipancs listed on the NYU rs to access ALL of my L Health HIE **baste HIE and I GIVE CONSE aleatoric hewn information and II NT to ALL employees, age through the NYUL Hea Center to access ALL of nts and members of the lth ni) eleaorsc health medical staff of NYU Hos permitted b.:fp:Es:es des inforrriebOw through HEALTHIX pitals crIbeC En the fact sheet n comealon wit any of tie rnefir^cy care including provkling me any hea rt can, services, educing a 2 1 DENY CONSENT Care Everywhere Provide HEALT MIX ice x- y p-Er to ALL of the HIE Par rs to access my ee;trcr. pose then in a rnecbca:rt, ticipants hated on the NYUL Health HIE watisite and rl:,,rnat]on through the NYUL Health HIE or crgenCY NOTE. UNLESS YOU CHE CK THE "I DENY CONSEN emergency to get access T' BOX. New York State law to your medical records. incl allows the people treating you IF YOU DON'T MAKE A uding records that are ava in an CHOICE, the records will ilable through the NYUL Hea SW. LAW. not be shared except In an lth HIE. as allowed by Now York Tt : PRINT Name of Patent irJ u- 1953 Patent Date of Birth Signature fraiH raterirs L -4- - I- IY Date Pnnt Nemo of Legal Represe ntarom of applicable) Relationship of Legal REX esentatne to Patent (rf applicable) EFTA00304451  NYU Langone N... Health NYU Langone Health Notice of Privacy Practices NOTICE OF PRIVACY PR ACTICES ACKNOWLEDG MENT FORM Bs signing this form, I acknoss ledge that I has c reccisal a copy of NYU La Notice of Prism." Practic e.. nese Health's Patient Name: Signature: Dale: —4- - I I- I? Personal Represenotis e's Name (it Applicable Personal Representatise's Au thorits tc.g., parent, guardia n, health ran prosy): Effectist as of 1110112017. EFTA00304452  ACCESS YOUR HEALTH INFORMATION ONLINE IIENEFrf S OF MYCHART • View your test and lab res ults • Access your medical record s, medications, immunizations. and mom • Schedule appointments • Request prescription refills • Send secure messages to you r doctor's office • Access your billing statement s and make payments Ai UP YOUR ACCOUNT SECURITY OF YOUR NEALT I4 visit MytilitinJIrdra C.Oll 31116 INFORMATION click Sligo Up Now to create your usemarne and password or Wain is password-protected download the app from guises. and encrypted. This means you r information is safe and secure Fran unauthorized access. MOISRA ACCESS QUESTIONS Once you have created smir If you have questions about usi own username and password ng using a desktop or laptop My Chart. please call 866.262.6458. computer, download the MyChart app on your Apple' or Android"' device. Select NYU Ungone Medical Center from the list of hospitals, and sign In. N.... WALT'S!Int EFTA00304453  Adult SIsChart at Ni 1. Langone Prtis s terns Rennes; and tuthurrration Form Requirements and Procedures • Proxy access to the MyChan at NYU Langone record of an ink* may be gran representative. ted by the patient or his her legal • Roth the paints requesting access and the patient or hillier legal temm • The proxy must have hish cntatise must sign this form. er own MyChart at NYU Langone acco through the proxy's MyChart at NYU unt beca use the patient's chart will he accessed Langone record. I aaderstaad that: • My Chart at NYU Langone is intended as a secure online source of conf • MyChart at NYC Langone is not idential medical information. to be used is an emergency. • Use of MyChart at NYU Langone is volun tary and I am not required to autho • I mum select a confidential password r tic proxy access. to maintain my password securely and may have been compromised in any way. change my, password if 1 believe it • If I share my MyChart at NYU Lang one If) and password with another perso my or my child's heath information, n. that person may be able to stew as well as information about any adult at NYU Langone proxy. who has authorized me as • MyChart • If I have proxy access. I MST log in to my own MyChart at NYU Langone account Records" to ace= another patient's record. and click on - View Other • MyChart at NYU Langone contains selec ted. limited medical information from a not the complete medical record. patient's medical recast and is My milsdies within MyChart at NYU Langone may be tracked by computer become part of the medical record. audit and entries I make may • Access to MyChart at NYU Langone is provided by NYU Langone :Medical patients and that NYU Langone Medical Center as a convenience to its 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 patie completed forms to your provider's offic nt and proxy. Return e or to If you already have a MyChart at NYU Lang one account. you will receive a MyChart access to the additional patient's record is at NYU Langone message when available. typically S to 7 business days atter authorization fora is received. completed request and PROXY: lam requesting access to the med ical incarnation available on MyChart at NYU named below and agree to abide by the abov Langone for the patient e teats and conditions of MyChan at NYU condition viewable online within MyC Langone and all other tans and han at NYU Langone. cpsert Nam: "Tap;Reic Dale or Binh: /*- 0 -53_ Email: cLeck-ion2)9frnil • CO" AckfresaPhone ems-r FIST ST nittjq PioI / _2 -+.50-98Ss- a? - c3s - 3