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FORMS

1. Patient Registration Form

Registration Form

  • Patient Appoinment Information

  • Date Format: MM slash DD slash YYYY
  • REGISTRATION FORM

    Instructions: Fill in the blanks.Please replace any incorrect or outdated information.

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Contact Information

  • Guarantor Information

  • Date Format: MM slash DD slash YYYY
  • Physician Information

  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 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.

  • Date Format: MM slash DD slash YYYY
    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

  • Date Format: MM slash DD slash YYYY
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  • We Are Committed To Diversity And Inclusion.
    We Care About Your Health!

2. Medicare Secondary Payer Questionnaire

  • Date Format: MM slash DD slash YYYY
  • Medicare Secondary Payer Questionnaire

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

  • Date Format: MM slash DD slash YYYY
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  • 60 Day Rule

  • Date Format: MM slash DD slash YYYY
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  • Back Lung Benefits

  • Date Format: MM slash DD slash YYYY
  • End Stage Renal Disease Benefits

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    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.
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