EFTA00313791.pdf

Nuclear Medicine Associates 1 Gustave Levy Place #1141 New York, NY 10029 (212) 241-59 98 Patient Last Name: S 1 eod — 1 Social Sec. *: Patient First Name: Date of Birth: RTIT, r4 r o, iqs3 Sex: M Er F L Address: I (i L-7 AS'T 4-1 Sr ST/2 ,- Referring MD: (City: State: N `I l ap. I 00 -1 Country LAS Employer Name: /4_114 Q2 NI -112-uS-r Phone: 39 -0 - D7,;Sli Primary Insurance: 1 LM itt 1-4-EAL--n4 c Aga Policy ft: -1 Name of Policyholder: 625-ThW Policyholder Date of bIrth:l --r Relationship to L\)Ar-1 0)0,195;3 Policyholder: Self :2 Spouse 0 Child Ej Other Secondly Insurance: Policy*: Name of Policyholder. IL 1 Policyholder Date of birth: Relationship to Policyholder: [1 Self ; 1 Spouse Child Other 0 I request that payment of authorized Med icare or other medical benefits the physican practice. I authorize be made on my behalf to any holder of medical informati Health Care Financing Administratio on about me to release to the n and its agents any information benefrts payable for related services. needed to determine these Office use: Patient Signature: Date:1 ifstr ic ,R_ Est 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 PLACE LABEL Hair. Doctors AUTHORIZATIONS AND ASSIGNMENTS 1. FINANCIAL AGREEMENTEQUAFtANTE E OF PAYMENT (All Patients) In ccesideratior o' sets, asegn QY No (Please Initial) merit of benefits and care rendered; I (the -Physiciane'l with respect to such servic agree that 1 am responsible for any es snit cam unless the contract betwe and all cnarges bled by Ore. the event hat the requested servic en the Physicians and my insuranoo es are not epecitfeafly authorized by my compary provides critervAse. In chewer; provided by insurarce company, I agree to oay for all law. sermon es agreed upon. unles s I authorize payment of mecca benef its to which I am entitled tamely to the my dependents in the cave. Physicens, to cover *he cost of trio care and treatment rendered to myself or Upon receipt of a medical Pe I agree to ImMedistely pay all amau4s not conter claim. I shad be mappable for paym ed by 'menace. It any insurance I have ent Of any balance as determined rejects my dem or pays part of the provided bylaw. by Mount Sinai Immodiatety upon teami ng of such coverage. unless OthelV iiS5 In the event my Insurer denies paym ent to Ins Physicians for services rende the Physician * contact my insure red to me, I hereby ghee my conse r and to provide to my Insure, all nt to have an authorized representa Physicians which may be required it order information and documentadon regarding tive 01 for my hatter to nieva loots Its decis the services rendered to me ion to deny payment for such services. by the I aohonce this tractics, my treatin g physic payment and heath care opeations purpoian, and ther tespechre designees to ses. I acknowledge that my health infonn use and cisclose my heath inform ation for AIDS/ARC/HIV and that any such informaton may be doctored (incluidng adon may include Information relating all necessary treatment, venous entail agencies ant guarantors examlnaton and copying hi ether hard to mental Illness andior solely if needed for payment of the copy or dliltel formal) to Insurers, seseoln. professional charges (no cliniasl infonn etfon wit be disclosed to any CIaIR .3.11EDICARE-RELEA E OF RMATI IG F BENEFITS I re -P 8 . ..' I certify that the information given by me in apply es No (Please initial) ing for payment under Tide XVIII of other Infcenat On about mete release to the Social the Social Security Ad Is cerme I t. authorize any ariorrnaton One/Wing hformatbn Security Administration and Cente any holder of medical or r, for Medcare aid Met scald Services misting to mental Illness ancillor AIDSIARC or its internediches or carnal of authorized benefits be made on IHIV) needed kr this or a rested Medic my behalf I assign benefits paysble to are claim. I request that payntent physician (a) anion the (Mgr organnaton s proricling the service (s) ..414NSURANCE NETWORK/PR OVIDER NOTICE PURSUANT I understand that the Physlc.ans may be partcipat TQWS tOUT4F-NETWORK" LA) canbe found on their webs tea can be ng providers in certain hoe th dal retwo provided to meupon request. rta. and that a list of the plans that the Physicians panic Pete in I taiderhand that the Physicians may wan tempt, the PI • y bhasn not PlIft:tipsieIn the same teeth pane and ...nee— -. 0— im.np‘tine sea u may ate employee Dy tapIr3Op in th if KAM determine the neakh plans participated or afelisted with hospitals or facilities it 3111W nears Dyste m to by physicians who are employed in the Mount Sinai Heath System. hfladagnitelinekigiggergemsaeg or contracted by Mount Sinai to I understand that I can ndrulakt;lobo uraSerste 6 that I provide hospital services by Mount Sinai Heath System by visitin g the facility's web portal. can ids° determine the heath plans accepted by hospitals and facilitiesvisitin in the g I understand that the Physicians charge for their services separately born from hoopla* or *den In the Moun the tcep lab and facilities in the Mos t Sinai Health System for so-caked 'fealt t Sinai Heath System, and that MO 'Professional' services. ies' or technical' lees viol be sent any Dila separiltelY hen the Physicians Iota for i undersiand that it is my rayon/bit ty to cher* with the 'physician' wig be required tor my care; are arranging for my services rega (2) whether the services of any ring: (I) whether the services of tined to anesthesiologists. any radiologists) may be reasonably antici other pnyelciare !indicting but not other physicians peted to be provided in caries-ton eat my pathologists, ardor for my services to obtain the calle Cana, r bather oxide nrand that I can check win the d Information and*, health plan partd 'physician' wronging connection with my care and that I pabon inter ale., kr any physicians can also contact those physicians d'ect or facility whose services may be needed in ly to obfa n information regrdIng thole health plan participation. I HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE ITEM S. SIGNATURE OF PATIENT OR AUTHOR IZED REPRESENTATIVE o DATED RELATIONSHIP TO PATIENT 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 unders tanding 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 INFORMATI ON FORMS PRIOR TO SEEING THE DOCTOR. WE WILL ALSO PHOTOCOPY YOUR INSUR ANCE CARD(S) FOR YOUR FILE. • REFERRALS - If your plan requires a referral fr om 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/Inf ormation 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 release d to my insurance company (or its agent) concerning health care, advice, treatment or supplies provid ed 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 insuran if ce 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 author ize 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 admin istering claims for benefits. • DIVORCED/SEPARATED PARENTS OF MLNOR PATIE NTS — 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 AMER ICAN 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 4/i GP's-rgiA p741.1.ata?3 WIDOW NY, y`l Lets)z- I I Queranbx Nam Of not the patent) ralailantab raTh auarantor stun Patient : Please Turn Page Over 0L6Z-682-ZI2 leuS lonow laaRFAL CUR £l Da3 EFTA00313793  Patient Name: TE,Firge \-1 GP..s I G1 Mount • MRN: Sinai INFECTIOUS DISEASES SCREENING TOOL Assigned staff should have ALL patients answer thes e 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 c No Has a dose contact (household member) traveled outside the U.S. in the past 21 days (3 weeks)? If yes, where ❑ Yes 2-No 2. Have you had close contact with a person with Ebol a? o Yes si-No 3. Do you have a fever (Temp more than 100.4°F (38°C )) 0 or feel hot? 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  EFTA00313795 SOUTHERN TRUST COMPANY 6100 RED HOOK QUARTER. 8-3 ST THOMAS VI 00802-CODD UnitedHealthcare P 31412{ >002669 7080107 003082 CPCTCTI/ a of IMURAN VI VITUUC VUUU r$ 0302700CW 0000 0002669 3519116  Pnvinn7114 II MUMMMAIP Members: %Vero here to help. Check a cloCtar. ask a quesann alb more. benefits. view claims. find Web, www.myuhc.coM CM are Ems& b speak AdvoCatertme@uhc.COm 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 00936329 7 :MAPFRE .4 ItittiPlan 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