Mandatory Patient Paperwork

• Failure to provide this information may result in an insurance denial and make you responsible for full payment.
• I authorize payment of benefits on my behalf to HPSA for service provided to me. I also authorize any holder of medical information about me to release to those parties who are financially liable for my medical care any information needed to determine these benefits and the benefits for any related services.

Please check all that apply in the following:

The Release of Information will remain in effect until terminated by me in writing.

 

Messages

STEVEN I. CURTISS, M.D.
SCOTT F. ROSEN, M.D.
JEFFRY ZAVOTSKY, M.D.

ELIZABETH NORTHFIELD, M.D.

MEDICAL RECORDS RELEASE

 

New Jersey Department of Banking and Insurance

NOTICE OF REVOCATION OF CONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS AND OF AUTHORIZATION TO RELEASE OF MEDICAL RECORDS
 
 

APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS

You have the right to ask your insurer, HMO or other company providing your health benefits (carrier) to change its utilization management (UM) decision if the carrier determines that a service or treatment covered under your health benefits plan is or was not medically necessary.[1]  This is called a UM appeal.  You also have the right to allow a doctor, hospital or other health care provider to make a UM appeal for you.  

There are three appeal stages if you are covered under a health benefits plan issued in New Jersey.  Stage 1:  the carrier reviews your case using a different health care professional from the one who first reviewed your case.  Stage 2:  the carrier reviews your case using a panel that includes medical professionals trained in cases like yours.  Stage 3:  your case will be reviewed through the Independent Health Care Appeals Program of the New Jersey Department of Banking and Insurance (DOBI) using an Independent Utilization Review Organization (IURO) that contracts with medical professionals whose practices include cases like yours.  The health care provider is required to attempt to send you a letter telling you it intends to file an appeal before filing at each stage.  

At Stage 3, the health care provider will share your personal and medical information with DOBI, the IURO, and the IURO’s contracted medical professionals.  Everyone is required by law to keep your information confidential.  DOBI must report data about IURO decisions, but no personal information is ever included in these reports.

You have the right to cancel (revoke) your consent at any time.  Your financial obligation, IF ANY, does not change because you choose to give consent to representation, or later revoke your consent.  Your consent to representation and release of information for appeal of a UM determination will end 24 months after the date you sign the consent.

INDEPENDENT ARBITRATION OF CLAIMS

Your health care provider has the right to take certain claims to an independent claims arbitration process through the DOBI.  To arbitrate the claim(s), the health care provider may share some of your personal and medical information with the DOBI, the arbitration organization, and the arbitration professional(s).  Everyone is required to keep your information confidential.  The DOBI reports data about the arbitration outcomes, but no personal information will be in the reports.  Your consent to the release of information for the arbitration process will end 24 months after the date you sign the consent.

CONSENT TO REPRESENTATION IN UM APPEALS AND AUTHORIZATION TO RELEASE OF INFORMATION IN UM APPEALS AND ARBITRATION OF CLAIMS

I agree to representation by Highland Park Surgical Associates and Vein Treatment Access Care  in an appeal of an adverse UM determination as allowed by N.J.S.A. 26:2S-11, and release of personal health information to DOBI, its contractors for the Independent Health Care Appeals Program, and independent contractors reviewing the appeal.   My consent to representation and authorization of release of information expires in 24 months, but I may revoke both sooner.

  I agree to release of personal health information to DOBI, its contractors for the Independent Claims Arbitration Program or the Chapter 32 Independent Arbitration System, and any independent contractors that may be required to perform the arbitration process.  My authorization of release of information for purposes of claims arbitration will expire in 24 months.

 

New Jersey Department of Banking and Insurance

NOTICE OF REVOCATION OF CONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS AND OF AUTHORIZATION TO RELEASE OF MEDICAL RECORDS
 
 

You may, at any time, revoke the consent you gave allowing a health care provider to represent you in an appeal of a UM determination and allowing the release of your medical records to the DOBI, the IURO and medical professionals that contract with the IURO.  You may use this form to revoke your consent, or you may submit some other written evidence of your intent to revoke consent, if you prefer.  Either way, if you have not yet received a Stage 2 UM determination from the carrier, send the written and signed revocation to the carrier at the address indicated in the carrier’s written notice to you regarding the carrier’s initial UM determination.  If you have received a Stage 2 UM determination, then your revocation should be sent to:

New Jersey Department of Banking and Insurance

Consumer Protection Services

Office of Managed Care – Attn:  IHCAP

P.O. Box 329

Trenton, NJ 08625-0329

OR for courier service to: 

20 West State Street       OR by fax to:  (609) 633-0807 

You may also want to send a copy of your notice of revocation to the health care provider.

ASSIGNMENT OF BENEFITS

I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to Highland Park Surgical Associates and/or Vein Treatment Access Care LLC., for any medical services provided to me by that organization. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, the Department of Banking and Insurance, my insurance carrier or other medical entity.

A copy of this authorization will be sent to the Department of Banking  and Insurance, my insurance company or other entity, if requested. The original will be kept on file by the organization. I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form, I am accepting financial responsibility as explained above for all payment for products and services received.

Appointments: Our standard office hours are Monday through Thursday 8:30am – 5pm and Friday 9 am to 4 pm however our staff understands that your needs don’t always fall within our regular availability and thus we make every effort to accommodate you physical and time needs.
We understand your time is important thus every effort is made for the doctor to start examining you at your scheduled time. In order to achieve this, we need to enlist your assistance. Please visit www.surgicalaffiliatesnj.com and access and complete the appropriate forms in the comfort of your home. We request that all forms be completed prior to arriving at our office.
If you are a new patient please come in 20 minutes before your appointment time IF you have not completed the new patient paperwork. If you are an existing patient please come in 10 minutes before your scheduled time. This will allow our staff to complete all necessary administrative tasks so that we can bring the doctor in at your scheduled time.
Although every effort is made to maintain a timely schedule at times delays are inevitable either due to a patient emergency or due to the complexity of a patient’s condition. Our staff is committed to communicate delays to our patients as soon we are aware. We therefore request that you provide our office with a number that you can be advised of such instances so that you may be able to adjust your schedule accordingly.
Cancelling of Appointments: If you are unable to keep your appointment, please call at least 24 hours in advance of your scheduled time.
No Show Policy: For patients who do not show for a scheduled appointment, a no-show fee will be charged directly to you in the amount of $50 for office visits and $250 for surgeries. This charge will not be billed to your insurance company as it is not a covered benefit.
Medications: Please bring a medication list with all prescriptions, over the counter medications, vitamins and supplements you are currently taking to each visit.
In an effort to facilitate a smooth patient flow routine prescription refills will be handled at the time of your scheduled appointment. Please make sure to advise the staff/doctor at the time of your visit that you will require a refill.
Workers’ Compensation: All patients receiving treatment under Workers’ Compensation must have authorization from the Workers’ Compensation insurance company prior to receiving treatment. Failure to obtain authorization or advise our office of treatment being related to a work injury, will result in being billed directly for all medical services rendered by our office
Automobile Insurance: All services related to a motor vehicle accident must be authorized by the automobile insurance unless the automobile policy stipulated health insurance is primary. In order to verify this, we need you to provide a copy of the policy declaration page as well as your health insurance information. Any services applied to the automobile insurance deductible and co-insurance will be billed to the health insurance company if one is available however any outstanding balance related to a motor vehicle accident will be your financial responsibility. Our office does not bill attorneys, we do not accept letters of protection and we do not wait for cases to be settled.
Medical/Record Requests: We hold patient information as confidential and follow our office policy regarding communication with you, family and friends involved in your caregiving. We honor your written restrictions indicated in our “Confidentiality Notice and Release” form which is included in our new patient packet.
At your request, medical records will be forwarded directly to any healthcare provider’s office at no charge. Every other medical record request will be honored within 30 days at a cost for records retrieval and postage in the amount of $10 plus $1 per page not to exceed $100.
Itemized statements other than for insurance billing purposes will be provided at a fee of $5. 

Medical Form Completion: Medical forms will be completed within 48 hours of receipt by our office at a fee of $5-$25, depending on the complexity of the form.
Insurance Claims/Billing: If you are unsure as to what your benefits are, please contact our knowledgeable staff who will gladly assist you in determining your benefits and financial responsibility. Please remember, insurance is a contract between you and your insurance company. In order to properly bill your insurance company, we require a copy of all your insurance cards. Any services not covered by your insurance company is your responsibility, however our staff is knowledgeable regarding insurance coverage and policy benefits and will work closely with you to ensure your carrier meets their responsibility to you in accordance to your contract with them. We need YOU to notify our office whenever there is a change in your coverage as this may result in a change in the amount your insurance company will cover. It is the responsibility of the patient to inform the office of any insurance changes. If you fail to provide updated insurance information you will be billed for your medical services directly.
Referrals/Pre-authorizations: Our staff will contact your insurance company for any pre-certification of procedures or tests that we refer and recommend. If you are given a prescription for an MRI, CT Scan or any other procedure performed at a hospital or diagnostic facility, DO NOT schedule the appointment until you are notified by our office to do so as this will require in our office contacting the insurance company and at times the notes are required. Please understand that if you fail to wait for our notification of authorization, you may be held responsible for the bill in its entirety.
Self-Pay and Patient Balance Accounts: It is important to keep the doctor patient relationship uninfluenced by financial issues. The doctor’s role is that of caregiver, he does not handle any financial issues. It is the responsibility of the office manager and billing staff to handle all financial issues directly with the patient. If you are having financial difficulty, please speak with the office manager or the billing staff who will work with you to make payment arrangements. Our office will send out one statement at no charge to the patient. Failure to issue timely payment or to contact the office to make payment arrangements within 20 days of receipt of the statement, a $5 surcharge for each additional statement.
If you do not have insurance your account is considered self-pay. Liability cases are also considered self-pay.
Our office does not accept attorney letters of protection or contingency payments. Extended payment arrangements are available if needed. Please ask to speak with the office manager to discuss a mutually agreeable payment plan. It is never our intention to cause you hardship, only to provide you with the best care possible at the least amount of stress.
Returned Checks: The charge for a returned check is $30 payable by credit card, cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may also be placed on a cash only basis following any returned checks.
Outstanding Balance Policy: Upon receiving notification of claims processing by your insurance company, a statement will be generated and mailed to you. Timely payment is expected. Our policy is to issue two statements, and a pre-collection notice. If we do not receive payment or contact from you to make payment arrangements, the account may be transferred to a collection agency, or referred to an attorney. In the event your account is referred to our collection agency or attorney, you will be responsible for all collection costs including attorney fees and court costs. Remember, we are here to work with you. Upon receipt of our statement, please contact our office to avoid the added financial expense.
Our patients and their needs are our priority. In order for our office to complete each patients request in a timely manner, it is important to streamline the multitude of tasks that are imposed by the healthcare climate. the various administrative needs in a timely fashion, it is important for you to allow enough time for the completion of the various items.
This financial policy helps assure your needs are handled promptly. Today’s healthcare climate places ever increasing demands on medical practices by insurance companies and governmental agency regulation requiring the streamlining of duties to assure all your needs are handled promptly. The above helps you understand what to expect in our handling of your requests. If you have any questions or need clarification of any of the above, please feel free to contact us.

By signing below, I acknowledge receipt and review of the above office policies.