Relationship:

Relationship: Business Phone: Phone:_ RIMARY INSURANCE Jeffrey I. Mechanick, M.D. Elise M. Brettlill. PATIENT INFORMATION Name: j RaN E.-PSit -11•1 Social Security # Street: q EAST - 4- VI 51. Date of Birth: J Pip1 • QC 1 I g 3 City: N State:t4 Zip:LOVZi Sex: F Marital Status: M D W Partnered Spouse's Name: Home Phone: NM a IN I I Cell Phone: Occupation: I44 Employer: Ci& A Al & AL- 12LAS1 Business PhonernilMaill01 Fax: Pharmacy: Phone: Address: Primary Care Physician: Phone: Emergency Contact: Home Phone: Referred by: 1YR_ EVft 41,1bE12---SSe)i Heat m- ?LAN). Late Policy #: Group # Insured TE,Fc--- ge9 e . g13- -i eiti Insurance Co: Ltb..) j.TE b-FP:porbe__Ae Relationship to Patient: se Li:- Address: To -sot i4-4R0 0 Date 9s3 City: PCt.-A ts.1TA State:4A Zip: 10S94- SS# Cep 0 SECONDARY INSURANCE Policy: Group # Insurance Co: Relationship to Patient Address: Date of Birth City: State Zip: SS#: Insured I hereby authorize Jeffrey I. Mechanick, M.D. and Elise M. Brett, M.D. to furnish information concerning my illness and treatment to my insurance carriers. I authorize payment of medical benefits to Jeffrey I. Mechanick, M.D. and Elise M. Brett, MD. I understand that I am responsible for any pan of the charges that are not covered by medical coverage. Signed: (Parent or Guardian if patient is a minor) Date: r/rri AJMISPIPIA:ol )S1P IPR PIP rts EFTA00310781 SAMPLE HIPAA PRIVACY NOTICE IS NOTICE DESCRIBES HOW MEDICAL INFORMATION w sOtIT YOU NIAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I RODLCTION linter' the name of the Practicel understands that yOur medical information ts pm ate and confidential Further. we art required by law to maintain he privacy of "protected health information" "Protected health intormairan includes any individually identifiable information that we obtain from you or others that relates to your past. present or future physical nr menial health. the health care you have recewed, or payment for your health Gait As iequired by law, this notice provides you with information about yes r rights and our legal duties and privacy practices with respect to the pi rya y of protected health information. This name also discusses the oci and disclosures we ti ill make of your protected health information We Must COMply with the provisions of this notice as currently in effect. although we nurse the right to change the terms of this notice from tune to time and to make the revised notice effective for all protected health in format On ..c maintain You cart always request a written copy of our most current privacy notice from the Practice's Privacy Officer or you can access it on our website at . (Note: The reference to the ix ebsite should be included only if the Practice has a act V. I f EEO USES AND DISCLOSURES WC Can use or disclose your protected health information for purposes of tr eatment. pNiplein mid health ra•r operations. For each of these categories of uses and disclosures. we have provided a description and an et amp e below Howe% er, not every particular usc or disclosure in every category rill be listed reelitounil means the provision, coordination or management of your health care, including consultations between health care providers regarding your care and referrals for health care from SAMPLE ACKNOWLEDGMENT Practicel's privacy notice. one health care provider to another. For example, a doctor IlCatin for a broken leg may need to know if you have diabetes be diabetes nay slow the healing process. In addit to n. the doctor may to contact a physical therapist to Create the exert isc regimen mares to your cafe Paisment means the activities vie undertake toobtain reimbursemc the health care provided to you, including billing, collections. c management. determinations of eligibility and COW 3SC and oh, review activities. For example, prior to providing health care set we may need to provide information to your Third Party Patior your medical condition to &leonine whether the proposed cow treatment will be cohered. When we subsequently hill the Third Payer for the services rendered to you. we can provide the Third Payer with information regarding your care if necessary to c payment. Federal or State law may require us to obtain a written from you prior to disclosing certain specially protected information for payment purposes. and we will ask you to sign when necessary under applicable law. Health rare operations means the support functions of our pr related to oectrotur and pcti Wilt. such as quality assurance acts case management. receiving and responding to patient Cornea complaints. physician reviews. compliance programs. audits. by planning, development, management and administrative act.i e ctiiMpIC. we may use your protected health information to et alum performance of our stall' when caring for you We may oho CO health information about many patients to decide what adds services we should offer, what Services ire not needed, and w certain new treatments are effective. In addition, we may ro information that identifies you Rom yOur patient information 1 others can use the dexelentifitd information to study health ea health care delivery without learning who you arc. OTHER USES AND DISCLOSURES OF PROTECTED HE INFORMATION In addition to using and disclosing your information for net payment and health cart operations, we may use your protected health rotor in the following ways. , acknowledge that I have been provided with a copy of 'Insert nai Date. , 200 (Note: As discussed in the Step 7 of the Privacy Guide, the privacy regulations require health care provid with direct treatment relationships to make a good faith effort to obtain an individual's written acknowledgement of his/her receipt of the Practice's privacy notice at the time of the first service deliver) 'p. in emergencies). This sample acknowledgment is included for the Practice's use for this purpose.! 279851 2 et 1001- Garfunkel. wild & Trans. PC £.2'd 6aLLTS212T6:01 L£12 MB 212 OW NDINIzIrlTh 1.q>14•MP:WOJ Cr .r.r • Tn.. EFTA00310782 Data HEALTH HISTORY - please check symptoms you currently have or have had since your last visit here. General Unexplained weight loss! gain Unexplained fatigue / weakness Fall asleep during day when sitting Fever, chills No problems Skin New or change in mole Rash / itching No problems Breast Breast lump / pain / nipple discharge No problems Ears/Nose/Throat Nosebleeds, trouble swallowing Frequent sore throat, hoarseness Hearing loss / ringing in ears No problems Eyes Change in vision / eye pain ! redness No problems Cardiovascular Chest pain / discomfort Palpitations (fast or irregular heartbeat) No problems Respiratory Cough / wheeze Loud snoring / altered breathing during sleep Short of breath with exertion No problems Gastrointestinal Heartburn / reflux! indigestion Blood or change in bowel movement Constipation No problems Genitourinary Leaking urine Blood in urine Nighttime urination or increased frequency Discharge: penis or vagina Concern with sexual function No problems Musculoskeletal Neck pain Back pain Muscle / joint pain No problems Endocrine Heat or cold sensitivity No problems Hematologic/Lymphatic Swollen glands Easy bruising No problems Neurological Headache Memory loss Fainting Dizziness Numbness tingling Unsteady gait Frequent falls No problems Allergitimmune Hay fever / allergies Frequent infections No problems Psychiatric Anxiety stress / irritability Sleep problem Lack of concentration No problems Women only Pre-menstrual symptoms (bloating cramps, irritability) Problem with menstrual periods Hot flashes / night sweats No problems Men only Erection problems Lump in testicle Prostate cancer Enlarged Prostate No Problems To the best of my knowledge, the above information is complete and correct. I understand that is my responsibility to inform my doctor in or my minor child ever have a change in health. I assign directly to Dr. Elise M. Brat and Dr. Jeffrey I. Merhanick at 1192 Park Avenue, all insurances rendered. I understand 1 am financially responsible for all charges. I also authorize the disclosure of medical records to other providers for the management of my care in the extent permitted by law. 1 request payment to be made directly to Dr. Elise M. Brett and Dr. Jeffrey I. Mechanick at 1192 Park Avenue on my behalf Signature Print DOB 2,2'd 6LLLLIS21216:oi L£12 1£8 212 OW NOINFAADA ARMAARP:w0J4 Ac:SI IIRP-RI-iin EFTA00310783