Employer Information

Patient’s / Responsible Party Information

Patient’s Insurance Information

Please have your insurance cards ready for the receptionist

Patient’s Referral Information

Patient’s Primary Medical Doctor

Patient’s Other Medical Doctors

Pharmacy Information

Emergency Contacts

I agree to have my blood tested for HIV, HBV, and HCV, at no charge to me, as part of this facility’s post exposure follow-up procedure as required by OSHA regulations. The results of this blood test will be used only for evaluation purposes and will remain in confidential medical records.

COMPREHENSIVE HISTORY AND PHYSICAL ENDOCRINOLOGY EVALUATION

PAST MEDICAL HISTORY:

PAST HOSPITAL ADMISSIONS & SURGERIES:

FAMILY HEALTH HISTORY

Such as heart disease, high blood pressure, stroke, cancer, diabetes, thyroid disease, mental illness.

PERSONAL AND SOCIAL HISTORY

CHECK ALL THAT APPLY

Osteoporosis: Can It Happen to You?

Osteoporosis is a major public health threat for 44 million Americans. Ten million individuals already have osteoporosis and 34 million more have low bone mass placing them at increased risk for developing osteoporosis and the fractures it causes.
Eighty percent of those affected by osteoporosis are women. Known as “the silent thief,” osteoporosis progresses without symptoms or pain until bones start to break, generally in the hip, spine, or wrist.

Assignment of Benefits – Appointment as Authorized Representative

I hereby acknowledge and confirm that, by signing this Assignment of Benefits (“AOB”), I have requested medical treatment, diagnostics and/or other medical or healthcare services (the “Medical Services”) from Endocrinology Consultants P.C. (“the Practice”) on behalf of myself and/or my dependents. I hereby assign all applicable health insurance benefits and payment (each such payment or benefit, a “Benefit”) and all rights and obligations that I and any of my dependents are entitled to (or have actually received), whether it be from a private insurance payor, government source (including, without limitation, Medicaid and/or Medicare) or any other third-party payor (any of the above payment and benefit sources, an “Insurance Payor”), in connection with the Medical Services to the Practice. This authorization fully applies to any and all fees regardless of whether the Practice is in-network or out-of-network with the Insurance Payor providing such Benefit. I hereby appoint the Practice as my authorized representative (my “Authorized Representative”) with the power to:
File and process medical claims with the Insurance Payor.
File appeals and grievances with the Insurance Payor.
Discuss or divulge any of my personal health information or that of my dependents with any third party, including the Insurance Payor.
Institute and pursue on my behalf any claim, right or cause of action, including any necessary litigation and/or complaints against the Insurance Payor (even to name me as a plaintiff in such action).
Act with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the Medical Services I received from the Practice and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines.

I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from the Practice are paid in full. I also understand that I am financially responsible for any and all fees and payments associated with any and all Medical services rendered to myself and/or to my dependents (the “Fees”), including without limitation, any co-pays, coinsurance and deductibles. I understand that no guarantees have been made by the Practice or any other party in respect of any Medical Services or whether the Fees associated with such Medical Services will be paid for by any Insurance Payor and that I have the right to receive care elsewhere. I understand that I am fully responsible for any Fees due to the Practice in connection with the Medical Services that have not been actually received by the Practice for any reason, including without limitation, due to a nonpayment or claim denial by any Insurance Payor. I agree to assist the practice in its efforts to obtain payment for any Medical Services from any Insurance Payor. However, I fully understand that it is ultimately my responsibility to pay any and all Fees and to obtain any and all required authorizations, referrals and/or precertification(s) for any and all Medical Services. If my insurance plan has a pre-existing conditions clause, or requires an authorization or referral and I do not obtain one for the Medical Services I receive, I understand that I am responsible for all Fees, even if the provisions of my plan stipulate I otherwise wouldn’t be. I understand that this AOB incorporates and supersedes any prior and contemporaneous understandings or agreements between the parties with respect to the subject matter of this AOB.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Endocrinology Consultants, P.C. (the “Practice”), and its staff and providers, may use and disclose my Protected health Information (“PHI”) to carry out treatment, payment and healthcare operations (“TPO”). I understand and acknowledge that the Practice’s Notice of Privacy Practices (the “Notice”) has a more complete description of such uses and disclosures.

I permit the Practice to leave e-mail, telephone and text messages regarding my appointments, prescription renewals, lab results, and all other PHI on voicemail systems, or to provide such information to the person(s) who answer the phone, using the contact information provided.

• I agree that my PHI may be shared with my spouse (if applicable)
• I agree that my PHI may be shared with the following other people:

• I understand that I can change or revoke any of the foregoing agreements, at any time, by giving written notice to the Practice to the attention of the Privacy Officer. I understand and acknowledge that the Practice may decline to provide me with any services should I decline to sign this agreement, or should I later revoke this agreement.
• I agree that my PHI may be shared with my credit card vendor(s) if I contest any credit card charges, so that the practice can submit records to support its charges.
• I agree that the Practice may contact me at any phone numbers or email addresses provided by me regarding both PHI and non-PHI.

FINANCIAL POLIC IES

Registration: Upon scheduling and registration with Endocrinology Consultants, P.C. (the “Practice”), we require you to provide your medical insurance card (if you are utilizing its coverage, it must be brought to every visit), all third-party payor coverage information, photo identification, address, date of birth and phone number. If you receive health benefits through a spouse, partner or parent, we require you to also provide that person’s full address, date of birth, and phone number. For collection purposes, we also require social security numbers. Should you be unable to produce this documentation, you may pay in full at the time of service and submit the claim to your insurance plan for reimbursement. Please notify us of changes to your insurance coverage or contact information, otherwise you may be responsible for charges we were unable to recover.

Medicare: If you have coverage with Medicare (including both original Medicare and commercial Medicare Advantage plans), it is your responsibility to understand the provisions of your health insurance plan and coverage. Every original Medicare beneficiary is responsible for an annual deductible and coinsurance. Medicare Advantage beneficiaries may be responsible for an annual deductible, coinsurance and/or a copayment. Any portion of copayment, coinsurance and deductible which is not covered by a supplemental carrier will be your financial responsibility to pay. You are wholly responsible for your coverage limitation, regardless of whether you are aware of the details. If you have both Medicare coverage and also commercial insurance, you are responsible for providing the correct primary insurance at your visit. If you have supplemental insurance that does not cross over automatically, you will be billed for the deductible and coinsurance, and you may be given a receipt to submit yourself. By signing below, you specifically agree to these terms, and exempt yourself from any protections your insurance plan may offer you regarding these provisions.

Commercial Health Insurance Plans: Although we will advise you whether we believe we participate with your insurance plan, we are not responsible for any verbal assurances made to you regarding whether particular services rendered in this Practice are covered by your plan. You and you alone are responsible to understand the provisions of your insurance plan and coverage. We recommend contacting your plan prior to receiving services in order to verify your financial responsibilities. If your insurance plan, including Medicare, issues payment to you instead of to us, you are responsible to turn the entire payment over to us immediately upon receipt together with the complete explanation of benefits form. You may be responsible for an additional balance, depending on how your insurance plan adjudicates such a claim.

Referrals: You are responsible to obtain all necessary referrals prior to your appointment, if required by your health plan and assure it is presented at the time of your visit. If your plan requires a referral, precertification or authorization that you do not obtain, your appointment may have to be rescheduled. Otherwise, if as a result your health plan refuses to pay for any claim, you explicitly agree to be responsible for our charges for any affected visits, even if the provisions of your plan stipulate you otherwise wouldn’t be (you are waiving that defense). Further, it is also your responsibility to keep track of the number of visits you have used on your referral and the expiration date of your referrals and obtain new ones as needed. We will do our best to ensure you have one if you need one, but the ultimate responsibility is yours.

Cancellation/No Show Policy: If a new patient consultation has to be cancelled or rescheduled, please call the Practice forty-eight hours in advance or there will be a $75 charge. If you miss two appointments there will be a $25 charge.

Copayments, Coinsurance and Deductible: If your plan has a copayment, co-insurance or deductible, it is your responsibility to pay it at the time of service, even if the amount is not printed on your insurance card. Please have your payment ready upon check-in. We are out-of network healthcare providers with some health plans, meaning we have no contract with some health plans to participate in their network of participating providers and in many instances, they do not pay our charges for medical services in full. As a result, we have an obligation to bill our out-of-network patients their ordinary co-insurance, deductibles and cost share amounts as per your insurance agreement. If you fail to pay your coinsurance, deductibles or cost share amounts upon receipt of our invoice, you may be subject to collection activity and may be further responsible for the interest on the balance owed the Practice. However, we recognize that not all of our patients will be able to afford their patient cost share amounts. As a result, we have created a financial hardship policy which legally permits us to reduce, and in some cases, waive your patient cost share responsibility, if you qualify for the waiver. If you believe you might qualify, you may ask our staff for a copy of our financial hardship policy. Accordingly, you agree by signing this document to be responsible for your patient cost share amount, unless you qualify for financial assistance under the Practice’s financial hardship policy.

Non-Payment: Any fees that are due and payable for over thirty (30) days may accrue interest at the monthly rate of thirty percent (30%). I understand that if a balance is unpaid, my account may be referred to an external collection action.

I have read, fully understand and agree with all the above policies. I fully understand and accept my financial responsibility for the charges I, or my dependents, may incur at this office.

PATIENT RESPONSIBILITY FOR FOLLOW-UP CARE PLEDGE

hereby acknowledge and understand that even with the best training, skill and experience, a medically trained professional is not always capable of solving my medical problems. Therefore, I understand it is important that any and all recommendations by doctors are followed completely in order to increase the likelihood of a positive and healthy treatment/outcome. I acknowledge and understand that if any physician in this office prescribes medicine to me that the proper taking of any such medicine shall be my sole responsibility (or my guardian who has attended this consultation). I agree to properly follow the prescribed dosage and frequency amounts of these medicines as recommended by my doctor.

I understand that if a doctor in this office refers me to see another doctor or receive another test including, but not limited to, a blood test, an MRI, or CT Scan, this timely recommendation is important and essential to the ultimate success of my treatment/outcome. I understand that it is not possible for any person in this office to constantly follow-up to ensure that I have followed these recommendations. Therefore, I understand that if I fail to see that specialist or obtain the test for which I was referred immediately, this can risk my current health or increase future health risks.

I understand that it is solely my responsibility to follow any of the medical advice given by any medical person in this office and any bad health outcome from my failure to follow the advice of my doctors should be expected.

NOTE: 1. Patient Demographic Information (N.J.S.A. 45:9-42.46(a)(1)-(4)) a. N.J.S.A. 45:9-42.46(a)(1) requires clinical laboratories to record the race, ethnicity, sexual orientation, and gender identity of each patient who presents with a non-electronic order for testing at a clinical laboratory patient service center. In other words, when a patient presents at a clinical laboratory patient service center, as defined at N.J.A.C. 8:44-2.14(b), with a paper order for a laboratory test, the clinical laboratory must capture the patient’s race, ethnicity, gender identity and sexual orientation.

Please check the Preferred Response