FORMS

1. Patient Registration Form

Registration Form

  • Patient Appoinment Information

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  • REGISTRATION FORM

    Instructions: Fill in the blanks.Please replace any incorrect or outdated information.

  • Patient Information

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  • Contact Information

  • Guarantor Information

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  • Physician Information

  • Insurance Information

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  • ASSIGNMENT OF BENEFITS AND AUTHORIZATION TO RELEASE MEDICAL INFORMATION

    I certify that all information above is true and correct. I authorize and direct Northwell Health Physician Partners, having treated me, to release to governmental agencies, insurance carriers or others who are financially liable for my medical care, all information needed to substantiate payment for such medical care and permit representative thereof to examine and make copies of all records relating to such care and treatment. I hereby assign, transfer and set over to Northwell Health Physician Partners sufficient monies and or benefits to which I may be entitled from governmental agencies, insurance carriers or others who are financially liable for my medical care to cover the costs of the care and treatment rendered to myself or my dependents. I request that payment of authorized benefits be made on my behalf, and I understand I am responsible for charges not covered by policy or plan. (Medicare) I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the SS Administration and HCFA or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician furnishing the services or authorize such physician to submit a claim to Medicare for payment to me.

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    Race: Ethnicity
  • 5. I Agree That The Email Address I Have Provided May Be Used To Generate A Patient Portal Account With Northwell Health. The Patient Portal Will Give You Access To A Clinical Summary From Your Last Visit.

  • 6. Pharmacy Information :
    • If you have a separate RX Benefit card, please hand lt to the receptionist to copy.
    • If you wish to change your pharmacy preference, please let the staff know so that your prescriptions will continue to be directed to your pharmacy of choice.
  • Authorization for Access to Patient Information - Healthix

  • Details about the information accessed through Healthix and the consent process:
    1. How Your Information May be Used. Your electronic health information will be used only for the following healthcare services:

    • Treatment Services. Provide you with medical treatment and related services.
    • Insurance Eligibility Verification. Check whether you hace health insurance and what it covers.
    • Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care.
    • Quality Improvement Activities. Evaluate and Improve the quality of medical care provided to you and all patients.
  • 2. What Types of Information about You Are Included. If you give consent, the Provider Organization(s) listed may access ALL of your electronic health information available through Healthix. This includes information created before and after the date fhis form issigned. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may include sensitive health conditions, including but not limited to:

    • Alcohol or drug use problems & diagnoses
    • Birth control and abortion (family planning)
    • Medication and Dosages
    • Genetic (inherited) diseases or tests
    • HIV/AIDS
    • Mental health conditions
    • Sexually transmitted diseases
    • Diagnostic information
    • Allergies
    • Substance use history summaries
    • Clinical notes
    • Discharge summary
    • Employment Information
    • Living Situation
    • Social Supports
    • Claims Encounler Data
    • Lab Test
    • Trauma history summary
  • 3. Where Health Information About You Comes From. Information about you comes from places that have provided you with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other organizations lhat exchange health information electronically. A complete, current list is available from Healthix. You can obtain an updated list at any time by checking Healthix’s website at www.heaIthix.org or by calling (877) 695-4749.

    4. Who May Access Information About You, If You Give Consent. Only doctors and other staff members of the Organization(s) you have given consent to access who carry out activities permitted by this form as described above in paragraph one.

    5. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient's consent for certain public health and organ transplant purposes. These entities may access your information through Healthix for these purposes wilhoul regard to whether you give consent, deny consent or do not fill out a consent form.

    6. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call Provider Organization at: (800) 894-3226; or visit Healthix’s website: www.heaIthix.org; or call the NYS Department of Health at (518) 474-4987; or follow the complaint process of the federal Office for Civil Righls at the following link: http://www.hhs.gov/ocr/privacy/hipaa/complaints/.

    7. Re-disclosure of Information. Any organization(s) you have given consent to access health information about you may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.

    8. Effective Period. This Consent Form will remain in effect until the day you change your consent choice, death or until such time as Healthix ceases operation. If Healthix merges with another Qualified Entity your consent choices will remain effective with the newly merged entity.

    9. Changing Your Consent Choice. You can change your consent choice at any time and for any Provider Organization or Health Plan by submitting a new Consent Form with your new choice. Organizations that access your health information through Healthix while your consent is in effect may copy or include your information in their own medical records. Even if you later decide to change your consent decision they are not required to return your information or remove it from their records.

    10. Copy of Form. You are entitled to get a copy of this Consent Form.

  • Sexual Orientation/Gender Identity (SOGI) Supplemental Registration Information

    We are asking for the following information because we want to understand your individual needs and improve your care. All answers are strictly confidential

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  • We Are Committed To Diversity And Inclusion.
    We Care About Your Health!

2. Medicare Secondary Payer Questionnaire

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  • Medicare Secondary Payer Questionnaire

    In order to serve you hetter, please PRINT and complete all applicable information

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  • 60 Day Rule

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  • Back Lung Benefits

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  • End Stage Renal Disease Benefits

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    Race: Ethnicity
  • 6. Pharmacy Information :

    • If you have a separate RX Benefit card, please hand it to the receptionist to copy.
    • If you wish to change your pharmacy preference, please let the staff know so that Daur prescriptions will continue to be directed to your pharmacy of choice.

Authorization for Release of Health Information Pursuant To HIPAA

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  • I, or my authorized representative, request that health Information regarding my care and treatment be accessed, used and/or disclosed 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 (HIPM), 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 inltlals on the appropriate line in Item 8(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 8(a), I specifically authorize release of such Information to the person(s) indicated in Item 7.

  • 2. If I am authorizing the release of HIV-related, alcohol, drug treatment, or mental health related treatment information, the recipient is prohibited from rediscioslng 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 !,formation without authorization. If I 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 thatI 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 redlsclosed by the recipient (except as noted above In Item 2), and this redisclosure may no longer be protected by federal or state law.

  • 6. Name and address of health care provider or entity to release this Information:

  • 6a. If you are requesting only laboratory results directly from North Shore-LIJ Laboratories, enter "North Shore-LIJ Laboratories" above. Provide the following Information and then go directly to Sections 7, 9, 10, 11 and 12 and sign as Indicated below item 12.

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  • The laboratory CANNOT answer any questions in reference to interpretation, diagnosis or treatment of laboratory results. All questions regarding testing and the results will be answered by the PATIENT'S PHYSICIAN ONLY. Reports will generally be available 4 days after ALL laboratory test result are complete.

  • Copy 1 - Patient Medical Record Copy 2 - Patient or Patient1s Personal Representative

  • Authorization for Release of Health Information Pursuant To HIPAA

  • Include: (Indicate by initialing) Alcohol/Drug Treatment Mental Health Related Information HIV-Related Information

  • 8. (b).Authorlzatlon to Discuss Health Information

  • 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.

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  • The signature of the patient must be obtained unless the patient Is an unemanclpaled minor under the age of 18 or Is otherwise lncapablo of signing.

  • Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or Infection and information regarding a person 1s contacts.

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Authorization for Access to Patient Information - Healthix

Permission to Send Information Requested by Unencrypted E-mail

  • lf you are requesting health Information (pursuant to the attached Authorization Form# VD001) be released via unencrypted E-mail, Northwell Health asks that you acknowledge and consent to the following:

  • Unless l request otherwise, E-mails containing health information sent to me from Northwell Health are encrypted to keep lhem secure dur'1ng transmission. I understand that most personal E-mail se1Vfces do not encrypt or otherwise protect E-malls and, therefore, I understand that E-mail sent unencrypted means others may be able to access the information and read it once it ls transmitted over the Internet. Despfte this rlsk, I authorize my provider to transmit the information I have requested by unencrypted E-mail.

  • l further acknowledge that E-malls may be inadvertently sent to the wrong address and may be subject to technlcal maJfunct!ons, Therefore1 l understand that E-mail delivery is not guaranteed and potentially subject to unauthorized disclosure to third parties,

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  • *The signature of the patient must be obtained unless the patient is an unemancfpated minor under the age of 18 or lacks capacity to make medical decisions, ln these cases the Agent1 Surrogate or Guardian should sign. Onfy for use when interpreter services are utrll:zed for the completion of this form:

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  • **For consent regarding on-going electronlc communications not related to the release of medical records, please use the "Northwell Health Consent to E-mail and Text Communications" (Form# VD032),

  • Informed Consent forTelehealth Services During a Public Health l:emergency
    By virtue of my participation in this telehealth vls!t1 J om consenting to receive care through telchealth. Telehealth is the use of electronic Information .ind communlc(ltlon technologfes by providers to del!ver health earn to patients at a distance.
    I understand that any care provided to me through Northwell Health lnc.1 s tclehealth application ("the Northwell app11) will Incorporate security protocols to protect the privacy and security of my health information. If any other oppllcation ls used to provide care to me,! understand that the technology may not contain appropriate security protocols to protect the privacy and security of my health information. My provider has
    explaJned to me the risks assocfated with the technology platforms that he or she is using to provide care to me. I Dcknow/edge that there are potential risks associated with any technology used while obtaining care through telehealth, including, but not llmlted to, connectlvely Interruptions, other tcchnlcil! difficulties, and unauthorized access by a third party to one's health Information. Despite these risks, I agree to participate In the telehealth encounter.
    ! understand and agree that I or my healthcare provider may termlnilte a telehealth encounter at any time In the event of a technical mDlfunctlon,
    I also understand that my location determlnes where medicine Is being prnct!ced. As a result, I wlll Inform my provlder where! am located at the time of my telehealth visit,
    I understand that there may be costs associated with a telehea/th visit, f agree that I am responsible for any fees associated with the telehealth services that I receive.
    This Informed Consent for Tele.health Servlcos During a Publlc Health Emergency wlll remain In effect solely during the term of the public hC?a[th emergency.
    By signing below I certify that:
    I have read or hild this form read and/or had this form explained to me;
    J fully understand the contents of this docum ent1 Including the risks and benefits of recerv!ng te!ehealth services; and
    I hrivc been given ample opportunity to discuss any questions I may have regarding the te/ehea/th services and that all of my questions have been answered to my satisfaction,

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  • "The srgnature of the patient must be obtained unless the patient Is an unemanc1pated minor under the age of 18 or lacks capacity to make medical decisions. ln these cases the Agent, Surrogate or Guardian should sign.

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Colorectal Intake Form