EFTA00313913.pdf

NYU Langone Health FACULTY GROUP PRACTICE FINANCIAL POLICIES AND PATIENT RESPONSIBIL1 I understand that NYU School of Me3rane, my treating physicians and their respective designees, will use and disclose my health information for all purposes necessary ice treatment payme nt and healthcare operations. including but not limited to release of information requested by my insurance compa ny ter carrier) and any information necessary for discharge plannin purposes g • ASSIGNMENT OF INSURANCE I hereby authcn ze my insurance benefits to be pad directly to NYU School of Medici uncerstard I am financa.y responsible for non-covered ne I services. I authorize the release of any medical Or other informa necessary to process insurance clams on my tehm tion • FINANCIAL LIABILITY: I have been provided a copy of the NYU School of Medicine financia policies and agree to the specified terms. I hereby agree to pay an charges due (cc to become due) to NYU School of Meicine for care and treatment including co-payments and dedix,trbles as provided under my plan Benefits, 4 any, paid by a third party, will be created on account I understand that I will be responsible for any charges if any of the foovnag apply • My health plan requires prior referral by a Pnmary Care Physic ian (PCP) before recaving services at NYU School of Medicine and I have not obtained such a referral or I receive services in excess of the referral. ancitor • My health plan *stemmas that the senaces I receive at NYU School of Medicine are not medically necessary anctior not covered by my Insurance plan. andior • My health plan coverage has lapsed or expired at the time I receive services at NYU School of Medicine. and • I have cr.osen not to use my health plan coverage, andeor • The physician I see does not participate with my health care plan • MEDICARE SIGNATURE ON FILE (Medicare Patients Only): I re0uest that payment of authorized Medcare benefits be made either to me or on my behalf to all pro-Mews who treat me during my hospital stay or any services furnished to me those providers I authonze the holder of medical and other by information about me to release :o Medcare and its agents arty information needed to determine related seMces. Patients Medicare N lent Signature • ANCILLARY SERVICES: I understand I may receive certain ancaary medical services We I am at NYU School of Medicine. Such as. anesthesia, interpretation of cardiac tests imaging services (e.g.. x-rays. MR's) and pathology specim examination. I understand that some phystians en may not provide services In my presence, but are actvely involve course of diagnosis and treatment. I hereby authorize payment d in the directly for these services under tne policy(s) or plen(s) issued to me by my insurance canes' I understand that I may incur additional charges as a resit of these ancillary I agree to pay air charges duo with respect to such service services. s to the extent the Marge is due after credit is green for benefit paid on my behalf by any third party payor s • CANCELED OR NGSHOW APPOINTMENTS: I unders tand that, based on the policy of individual physics') mmoue a cancelation fee glib not provide the re:It:re offices. I may d notice of cancelabon. or if I do not keep my aPcon canceled. tment and have not I have been provided the Faculty Group Practic e Patient Financial Policies. I understand the Information listed above which has bean fully explained to me. Wit Signature I I- Guarantor Signature bate Form Rz..r.o.t1 9/t4/2016 EFTA00313913