If required fields are not applicable, please add 000 to the designated area.
The NSPC doctor I am scheduled to see is Dr. Last Name.
I, blanks, "Assignor" hereby assign to blank , ("Assignee") all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance LawThe Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for the injuries sustained due to the motor vehicle accident which occurred on blanks, not withstanding any other agreement to the contrary.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
In the event I fail to prosecute the claim for Workers' Compensation for this illness or condition or it is _____ by the Workers' Compensation Board that the illness or condition is not a result of a compensable Workers' Compensation case, I hereby agree to pay, (MD NAME blanks) his usual and ___ fees for service rendered to the above named claimant in the avove identified case. I authorize the provider to release any information to ____
I agree to allow NSPC to contact me using the following methods regarding my personal health information, evaluation and treatment. I authorize/do not authorize NSPC to leave messages for me when I am unavailable as indicated below.
I authorize NSPC and medical staff to discuss my personal health information with the individuals listed below. I understand that by leaving spaces blank, I am indicating my choice that I do not want my information shared with or released to anyone else.
By my signature below, I hereby acknowledge that I have read and understand the information provided on this Consent Form. I understand the rrisk associated with different methods of communication, especially email, and consent to the communications outlined in this Consent.
I, or my authorized representative, request that health information regarding my care and treatment be released by Neurological Surgery, P.C. as set forth on this form.
In accordance with applicable law, I understand that:
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 indentify someone as having HIV symptoms or infection and information regarding a person's contacts.
NSPC Brain & Spine Surgery 100 Merrick Road, Suite 128W - Rockville Centre, NY 11570 Phone (516) 255-9031 Fax (516) 255-6010 ADMITTING CONSENT AND FINANCIAL RESPONSIBILITY FORM
Consent for Medical Treatment. I give consent to NSPC Brain & Spine Surgery (the "Practice"), its staff, physicians and other practitioners to provide and perform such health care, tests, procedures, and other services that are deemed necessary or beneficial by the Practice for my health and well being. Payment of Insurance Benefits. I, and/or my dependents, hereby authorize payment to the Practice of all monies an/or benefits to which I and/or my dependents may be entitled from government agencies, insurance carriers or others who are financially liable for my, and/or dependents', medical care and treatment to cover the costs of care and treatment. I also certify that I and/or my dependent(s) authorize the Practice to pursue any and all appeals or legal remedies necessary to recover payment for services rendered to me and/or my dependent(s), by the Practice, including, but not limited to, internal or external appeals of benefits denials, and litigation in any appropriate court. ERISA Designation of Authorized Representative. I hearby designate, authorize, and convey to the Practice, to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan, as my authorized representative, and I convey to the Practice: (1) the right and ability to act on my behalf in connection with any claim, fight, or cause in action that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right to act on my behalf in respect to a benefit plan governed by the provisions of ERISA. as provided in 29 C.F.R. §2560.5031(b)(4)) with respect to any healthcare expense incurred as a result of the services I received from the Practice and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. Signature on File (For Medicare patients). I certify that the information given to me in applying for payment under Medicare is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and/or The Center for Medicare and Medicaid Services, or its intermediaries or carriers, any information needed for this or a related Medicare claim I request that the payment or authorized benefits be made to me or on my behalf to the Practice for services provided by the Practice. Authorized for Release of Information. By signing below, I authorize the Practice to release my health information: (1) to any requesting health care provider for my further diagnosis, care of treatment or for that provider's payment or health care operation purposes; (2) to any person or entity that may be responsible for billing/collection of claims for medical services or products; (3) to any person or entity which is, or may be liable to the Practice or me for all or part of the Practice' charges, including but not limited to, insurers, MCOs or other benefit plans or third party payers; (4) to any goverment agency or other organization. responsible for oversight of the Practice; (5) for the Practice's health care operations. I authorize the Practice to allow the individuals listed above to access such information through any medium including over the Internet and through the Practice's electronic medical record system. Acknowledgement of Notice of Privacy Notice. I have received a copy of the Practice' Notice of Privacy Practices, and have the opportunity to receive assistance in the understanding and exercising these rights. Signature. I have carefully read and fully understand this financial responsibility form and have had all my questions answered.
By signing below you acknowledge that you agree to and accept these terms. A copy will be emailed to you
I, 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 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 in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in 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. IfI experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. 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 THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
Authorization to discuss Health Information(b) By initialing here Initials* I authorize Name of individual health care provider* to discuss my health information with my attorney, ora government agency, listed here: (Attorney/Firm Name or Government Agency Name)*
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided acopy of the form.