Nuclear Medicine Associates

Nuclear Medicine Associates 1 Gustave Levy Place #1141 New York, NY 10029 (212) 241-5998 Patient Last Name: S 1 eod Patient First Name: Date of Birth: RTIT, r4 r o, iqs3 Address: — 1 Social Sec. *: Sex: M Er F L I (i L-7 AS'T 4-1 Sr ST/2 ,- (City: State: N `I lap. I 00 -1 Country LAS Employer Name: /4_114 Q2 NI -112-uS-r Primary Insurance: LM 1 itt 1-4-EAL--n4 c Aga -1 Name of Policyholder: 625-ThW Referring MD: Phone: 39-0 - D7,;Sli Policy ft: Policyholder Date of bIrth:l --r L\)Ar-1 0)0,195;3 Relationship to Policyholder: Self :2 Spouse 0 Child Ej Other Secondly Insurance: Policy*: Name of Policyholder. IL Relationship to Policyholder: 1 Policyholder Date of birth: [1 Self ; 1 Spouse Child 0 Other I request that payment of authorized Medicare or other medical benefits be made on my behalf to the physican practice. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefrts payable for related services. Office use: Patient Signature: ifstr ic,R_ Est Date: 1 Policy Holder Signature: Date: 1)EC .fi) l -+ VA Z abed 9L6Z.68Z-ZLZ FL'S luimW ktiZZ:Ol. CM EL 380 EFTA00313791 S Mount Sinai Doctors AUTHORIZATIONS AND ASSIGNMENTS PLACE LABEL Hair. 1. FINANCIAL AGREEMENTEQUAFtANTEE OF PAYMENT (All Patients) QY No (Please Initial) In ccesideratior o' sets, asegnmerit of benefits and care rendered; I agree that 1 am responsible for any and all cnarges bled by Ore. (the -Physiciane'l with respect to such services snit cam unless the contract between the Physicians and my insuranoo compary provides critervAse. In the event hat the requested services are not epecitfeafly authorized by my insurarce company, I agree to oay for all sermon es agreed upon. unless chewer; provided by law. I authorize payment of mecca benefits to which I am entitled tamely to the Physicens, to cover *he cost of trio care and treatment rendered to myself or my dependents in the cave. Upon receipt of a medical Pe I agree to ImMedistely pay all amau4s not contered by 'menace. It any insurance I have rejects my dem or pays part of the claim. I shad be mappable for payment Of any balance as determined by Mount Sinai Immodiatety upon teaming of such coverage. unless OthelViiS5 provided bylaw. In the event my Insurer denies payment to Ins Physicians for services rendered to me, I hereby ghee my consent to have an authorized representative 01 the Physician * contact my insurer and to provide to my Insure, all information and documentadon regarding the services rendered to me by the Physicians which may be required it order for my hatter to nieva loots Its decision to deny payment for such services. I aohonce this tractics, my treating physician, and ther tespechre designees to use and cisclose my heath information for all necessary treatment, payment and heath care opeations purposes. I acknowledge that my health infonnadon may include Information relating to mental Illness andior AIDS/ARC/HIV and that any such informaton may be doctored (incluidng examlnaton and copying hi ether hard copy or dliltel formal) to Insurers, venous entail agencies ant guarantors solely if needed for payment of the professional charges (no cliniasl infonnetfon wit be disclosed to any CIaIR seseoln. .3.11EDICARE-RELEA E OF RMATI IG F BENEFITS I re - P 8 . ..' es No (Please initial) I certify that the information given by me in applying for payment under Tide XVIII of the Social Security Ad Is cermet. I authorize any holder of medical or other Infcenat On about mete release to the Social Security Administration and Center, for Medcare aid Met scald Services or its internediches or carnal any ariorrnaton One/Wing hformatbn misting to mental Illness ancillor AIDSIARCIHIV) needed kr this or a rested Medicare claim. I request that payntent of authorized benefits be made on my behalf I assign benefits paysble to physician (a) anion the (Mgr organnatons proricling the service (s) ..414NSURANCE NETWORK/PROVIDER NOTICE PURSUANT TQ WS tOUT4F-NETWORK" LA) I understand that the Physlc.ans may be partcipat ng providers in certain hoe th dal retworta. and that a list of the plans that the Physicians panic Pete canbe found on their webs tea can be provided to meupon request. I taiderhand that the Physicians may not PlIft:tipsie In the same teeth pane and ...nee— -. 0— im.np‘tine sea tapIr3Op in thif KAM it 3111W nears Dystem wan tempt, the PI • y bhasnu may ate employee Dy or afelisted with hospitals or facilities in the Mount Sinai Heath System. I understand that I can determine the neakh plans participated to by physicians who are employed or contracted by Mount Sinai to provide hospital services by visiting hfladagnitelinekigiggergemsaegndrulakt ;lobo uraSerste 6 that I can ids° determine the heath plans accepted by hospitals and facilities in the Mount Sinai Heath System by visiting the facility's web portal. I understand that the Physicians charge for their services separately born the tcep lab and facilities in the Most Sinai Heath System, and that any Dila from hoopla* or *den In the Mount Sinai Health System for so-caked 'fealties' or technical' lees viol be sent separiltelY hen the Physicians Iota MO 'Professional' services. i undersiand that it is my rayon/bitty to cher* with the 'physician' arranging for my services regaring: (I) whether the services of any other physicians wig be required tor my care; are (2) whether the services of any other pnyelciare !indicting but not tined to anesthesiologists. pathologists, ardor radiologists) may be reasonably anticipeted to be provided in caries-ton eat my Cana, r bather oxidenrand that I can check win the 'physician' wronging for my services to obtain the called Information and*, health plan partdpabon inter ale., kr any physicians or facility whose services may be needed connection with my care and that I can also contact those physicians d'ectly to obfa n information regrdIng thole health plan participation. in for in I HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE ITEMS. SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE DATED RELATIONSHIP TO PATIENT o WITNESS TO SIGNATURE Please Turn Page Over g 01PC 9L6Z-68Z-aZ leu!S lunct.1 laNZZ:01. LICZ £ ' EFTA00313792 Icahn School of Medicine at Mount Sinai Mount Sinai Doctors Faculty Practice Financial Agreement Welcome to Mount Sinai Doctors Faculty Practice (MSDFP), a division of the Icahn School of Medicine at Mount Sinai. We are committed to providing you with the best possible care and are pleased to explain our professional fees to you at any time. Your clear understanding of our Financial Agreement is important to our professional relationship. Please ask if you have any questions about our fees, our financial policy, or your financial responsibility. PATIENTS MUST FILL OUT PATIENT INFORMATION FORMS PRIOR TO SEEING THE DOCTOR. WE WILL ALSO PHOTOCOPY YOUR INSURANCE CARD(S) FOR YOUR FILE. • REFERRALS - If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, and cannot obtain one at the time of your visit, you will be personally responsible for that day's services. • CO-PAYMENTS — By law we MUST collect your carrier's designated co-pay. This payment is expected at the time of service. Please be prepared to pay the co-pay at each visit. • OUT OF NETWORK PLANS — If your provider does not participate with your plan, payments for any co-insurance, deductible and non-covered amount is expected at the time of service unless prior arrangements have been made with our financial staff. We will send a courtesy bill to your insurance carrier on your behalf. Private Insurance Authorization for Assignment of Benefita/Information Release: I, the undersigned, authorize payment of medical benefits to MSDFP for any services furnished. I understand that I am financially responsible for any amount not covered by my health insurance contract I also authorize any holder of medical information about me to be released to my insurance company (or its agent) concerning health care, advice, treatment or supplies provided to rue. This information will be used for the purpose of evaluating and administering claims for benefits. • SELF-PAY PATIENTS — Payment is expected at the time of service unless other financial arrangements have been made prior to your visit. • MEDICARE — We will submit claims to Medicare. You will be responsible for the deductible and the 20% co-insurance, which can be billed to a secondary insurance if you have one. Medicare Lifetime Signature on File: I request that payment of authorized Medicare benefits be made on my behalf to MSDFP for any services furnished to me. I authorize any holder of medical information about me to release it to the CMS (and its agents) to determine the benefits payable for related services. This information will be used for the purpose of evaluating and administering claims for benefits. • DIVORCED/SEPARATED PARENTS OF MLNOR PATIENTS — The guarantor is responsible for payment for services rendered. MSDFP cannot be involved with separation or divorce disputes. You are responsible for the timely payment of your account. Our financial staff will work closely with you and your carrier to avoid sending any account to an outside agency to collect payment We reserve the right to send delinquent accounts to an outside collection agency. We accept CREDIT CARDS (MASTERCARD, VISA, or AMERICAN EXPRESS), CASH, or CHECKS. Our preferred method of payment is by credit or debit card. THANK YOU for taking the time to review our policies. Please feel free to ask any questions or share _ any special concerns you mayhave with a member of our staff illisbane Mama Pellet SIgniturt Dube at With: L-Tec-tfraa1/4i GP's-rgiA p741.1.ata?3 WIDOW NY, y`l Lets)z- I I Queranbx Nam Of not the patent) Patient ralailantab raTh auarantor stun: Please Please Turn Page Over 0L6Z-682-ZI2 leuS lonow laaRFAL CUR £l Da3 EFTA00313793 Patient Name: TE,Firge \-1 GP..s I G1 Mount Sinai • MRN: INFECTIOUS DISEASES SCREENING TOOL Assigned staff should have ALL patients answer these questions: 1. Have you traveled outside the U.S. in the past 21 days (3 weeks)? • If yes, where PA-RIS, EIZArNie-e: erl'es K Yes c No 2-No Has a dose contact (household member) traveled outside the U.S. in the past 21 days (3 weeks)? If yes, where 2. Have you had close contact with a person with Ebola? o Yes si-No 3. Do you have a fever (Temp more than 100.4°F (38°C)) or feel hot? 0 Yes n-No • 4. DO you have a cough or a sore throat? • o Yes o No 5. Are you vomiting or having diarrhea? o Yes o No 6. Do you have a rash? o Yes o No * During FLU season, think FLU * rnsp MSHS 1FIMavIS S abed 9L62-68Z-Z12 ?us 1unok IANEZ:Ol LLOZ El )90 EFTA00313794 SOUTHERN TRUST COMPANY 6100 RED HOOK QUARTER. 8-3 ST THOMAS VI 00802-CODD UnitedHealthcare P 31412{ >002669 7080107 003082 CPCTCTI/ of IMURAN VI VITUUC VUUU a r$ 0302700CW 0000 0002669 3519116 EFTA00313795 II Pnvinn7114 MUMMMAIP Members: %Vero here to help. Check benefits. view claims. find a cloCtar. ask a quesann alb more. Web, www.myuhc.coM CM are b speak Ems& [email protected] with a Nurse Phone. 800.782-3740 Mental Health. 800.842-2065 Providers: 877-842-3210 or mewt.friteistreeleiciereOnene.corn Medical Claims: P.O. 80X 740803 ATLANTA GA313740300 PR - MkPFRE • PO Sca70297. San !an. PR 009363297 .4 ItittiPlan :MAPFRE rwnay.e. 4', Pharmaclats: 1188-290-5416 Pharmacy Clans: OtitureFte P0 Box 29044 not Stings. AR 71903 0 0 MO DOCIPC.0 004010? 00,01? OOOOOO 01101 EFTA00313796