NF Package -combined

NYC Medical & Neurological Offices, P.C.

91-31 Queens Blvd Suite 601 Elmhurst NY 11373

Tel: 718-454-2222 Fax: 718-264-0257
Date

MonthDayYear
Date
Personal & No fault Information
Name*

First NameLast Name
Address*
City*
State*
Zip Code*
Telephone #*
Please enter a valid phone number.
Work #
Please enter a valid phone number.
Other #
Your E Mail Address
example@example.com
Your Patient Account Number
Date of Birth*

MonthDayYear
Date
Soc. Sec. #
Emergency Contact Name*
Emergency Phone#*
Please enter a valid phone number.
Sex*

FEMALEMALE
Marital Status*

DIVORCEDMARRIEDSINGLEWIDOW
Referring Physician
Referring Physician Name
Address
Telephone #
Please enter a valid phone number.
Date of Accident*

MonthDayYear
Date
No Fault Insurance Information:
Name of Insurance Carrier*
Street Address
City
State
Zip Code
Adjuster Name
Tel #
Please enter a valid phone number.
Fax #
Please enter a valid phone number.
Claim #
Policy #
Attorney Information
Attorney Name
Street Address
City
State
Zip Code
Tel#
Fax#
Attorney Email
Employer Information
Employer Name
Street Address
City
State
Zip Code
Tel #
Please enter a valid phone number.
Fax #
Please enter a valid phone number.
Pharmacy Information
Pharmacy Name
Pharmacy Name
Pharmacy Address
Pharmacy City
Pharmacy Zip code
Pharmacy State

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM

(For Accidents occurring on and after 3/1/02)

I hereby assign to NYC Medical & Neurological Offices all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law.

The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle accident which occurred on, notwithstanding any other agreement (Print accident date)
(Print accident date)

MonthDayYear
Date
This agreement may be revoked by the assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
(Signature of Patient)*

Clear
Parent/Legal Guardian Name
Parent/Legal Guardian Signature

Clear

INDIVIDUAL PATIENT'S AUTHORIZATION

THIS FORM IS TO CONFIRM YOUR AUTHORIZATION TO USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR A SPECIAL PURPOSE.
Check here if this authorization is for psychotherapy notes.
If this authorization is for psychotherapy notes, it may not authorize the use or disclosure of any other type of protected health in formation.

1. INDIVIDUAL PATIENT (OR PERSONAL REPRESENTATIVE) CONFIRMING THE AUTHORIZATION

I give my authorization to use or disclose my protected health information as described in Section 2 below. I give this authorization voluntarily.
2. THE USE AND/OR DISCLOSURE AUTHORIZED
Select one of the following 2 choices

Option 1: This authorization will end on the following dateOption 2: This authorization will end when the following event happens. The event must relate to the individual or the purpose of the authorized use and/disclosure.
Option1: This authorization will end on the following date. Enter the date

MonthDayYear
Date
Option 2: This authorization will end when the following event happens. The event must relate to the individual or the purpose of the authorized use and/disclosure. Describe the event below:
4. CHANGING YOUR MIND ABOUT THIS AUTHORIZATION

Iunderstand that I may revoke this authorization at any time by giving written notice to the Privacy Officer at your office. However, I understand that I may not revoke this authorization for any actions taken before receipt of my written notice to revoke this authorization. In addition, I understand that if I am giving this authorization as a condition of obtaining insurance coverage, and I revoke this authorization, the insurance company has a right to contest my claims under the insurance policy.

5. SIGNING THIS AUTHORIZATION IS NOT A CONDITION OF TREATMENT

I understand that under most circumstances a healthcare provider may not condition treatment, payment, enrollment, or eligibility for benefits on my signing this authorization. However, I understand that signing an authorization that permits the use and/or disclosure of my protected health information for research purposes may be a condition of my treatment if I am undergoing research-related treatment. Also, I may be required to sign an authorization if my treatment is provided solely for the purpose of creating protected information for disclosure to a third party. And under some circumstances, a health plan may condition my enrollment in a health plan or my eligibility for benefits on my providing an authorization permitting the health plan to make enrollment and eligibility determinations.

6. INDIVIDUAL PATIENT'S SIGNATURE

I have had the chance to read and think about the content of this authorization form and I agree with all statements made in this authorization. I understand that, by signing this form, I am confirming my authorization for use and/or disclosure of the protected health information described in this form with the people and/or organizations named in this form.
Signature*

Clear
Date

MonthDayYear
Date
If this authorization form is signed by a personal representative for the individual patient:
Personal- Representative's Name
Signature

Clear
Relationship to Individual Patient
YOU HAVE A RIGHT TO HAVE A COPY OF THIS FORM AFTER YOU SIGN IT.

Submit the authorization to the Privacy Official and include a copy in the individual patient's medical record.

LIEN ASSIGNMENT AGREEMENT
I hereby enter into the following agreement with NYC Medical & Neurological Offices, P.C. hereinafter known as "the provider" in order to guarantee payment for services rendered by "the provider" to me. I understand that I am directly and fully responsible to "the provider" for all medical bills for services rendered to me. I understand that I am directly and fully responsible to "the provider" for any remaining balance on all medical bills for services rendered to me that were submitted on my behalf to the responsible insurance carrier as applicable. This document further serves to acknowledge my responsibility to repay all remaining balances subsequent to all applicable insurance payments. I agree to make myself available to appear or correspond with "the provider" as often as may be necessary for any collections effort that is undertaken. I have been made aware of the charges for the services rendered under this lien assignment and acknowledge responsibility for the repayment of all outstanding balances. I further direct that my attorney shall not subsequently dispute these amounts and will contact this office to arrange for full payment at the time a settlement, trial or motion proceed becomes ready for disbursement.

To the extent applicable, I agree to comply with all Insurance Company regulations including, but not limited to examinations under oath and independent medical examinations. I understand that any failure on my part to comply with any condition precedent to insurance coverage, may, at the election of the medical provider, serve to revoke any assignment of No-Fault benefits. The patient herein further acknowledges their responsibility to file a timely notice of claim to the applicable insurance carrier and that any subsequent No Fault claim denied based on the failure to provide a timely notice, at the election of the provider, may result in recovery efforts in reliance of this lien.

The Provider agrees to seek compensation from the appropriate insurance carrier prior to invoking the terms of this lien based on the accuracy of the information the patient has provided and to the extent applicable. The patient shall provide all necessary insurance information, police reports, and any additional documentation or information deemed necessary by the provider for the submission of the aforementioned insurance claim as applicable. Failure to provide accurate insurance information leading to a viable source of coverage may serve to invalidate any executed assignment of No-Fault benefits and result in the reliance on this lien for reimbursement purposes.

I hereby give and grant this lien on my case to "the provider" against any and all proceeds of any settlement, judgment, verdict, or other disposition of any litigation filed or contemplated on my behalf that may be paid to me or my ATTORNEY as a result of the injuries for which I have been treated. I grant "the provider" the aforesaid lien against such sums of the aforesaid settlement, judgment, verdict, or other disposition of any litigation filed or contemplated on my behalf as may be necessary to adequately reimburse "the provider" for services rendered to me and towards all outstanding balances. I hereby agree to provide accurate contact information for the attorney pursuing any litigation on my behalf.
I hereby direct and authorize direct payment to "the provider", such sums as may be due and owing for medical services rendered to me. I further direct my ATTORNEY to honor the aforesaid lien and to withhold such sums from any settlement, judgment, verdict, or other disposition of any litigation filed or contemplated on my behalf as may be necessary to adequately reimburse "the provider" for services rendered to me towards all outstanding balances.

I understand that this document may not be rescinded and that my ATTORNEY shall not honor any such rescission. I hereby instruct that in the event another ATTORNEY is substituted in my case, I direct the substituted attorney to provide the incoming ATTORNEY with a copy of this lien and that I direct any incoming ATTORNEY to honor this lien as inherent to the settlement, judgment, verdict, or other disposition of any litigation filed or contemplated on my behalf and enforceable upon the case as if it were executed by him/her. I hereby direct and authorize my attorney, on demand, to provide the status of such litigation to "the provider" or his attorney engaged in any collection efforts. Furthermore, I direct my attorney to contact "the provider" or the attorney representing the provider prior to disbursement of any funds to ascertain any outstanding balances due to NYC Medical & Neurological Offices, P.C.
Date

MonthDayYear
Date
Patient Signature*

Clear
Patient's Attorney's Signature

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

[This form has been approved by the New York State Department of Health)
I, or my authorized representative, request that health information regarding my care and treatment be released 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 HIPAA, 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 initials on the appropriate line in Item 9a 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 9a, I specifically authorize release of such information to the persons indicated in Item 8.

2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing 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 information 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 that I 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 redisclosed by the recipient except as noted above in Item 2, and this redisclosure may no longer be protected by federal or state law.

6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 b

7. Name and address of health provider or entity to release this information:

NYC Medical & Neurological Office PC: Dr. Mehrdad Golzad 91-31 Queens Blvd, Suite 601, Elmhurst, NY 11373
8. Name and address of person(s) or category of person to whom this information will be sent
9 (a) Specific information to be released:

Medical Record
from (insert date)

MonthDayYear
Date
to (insert date)

MonthDayYear
Date
Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.

Including:*

	Indicate by Initializing
Alcohol/Drug Treatment
Mental Health Information
HIV Related Information
Generic Testing

Other
Describe Other Information that will be released
Authorization to Discuss Health Information
(b) By Initializing here Initials I authorizeName of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: Attorney/ Firm Name or Governmental Agency Name
10. Reason for release of information:

At request of individualOther
11. Date or event on which this authorization will expire

MonthDayYear
Date
12. If not the patient, name of person signing form
Authority to sign on behalf of patient:
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.
Signature of patient or representative authorized by law.*

Clear
Date

MonthDayYear
Date

PATIENT ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION
Date

MonthDayYear
Date
I acknowledge that I have either received a copy of this office's NOTICE OF PRIVACY PRACTICES or that this Offices NOTICE OF PRIVACY PRACTICES was made available to me to receive. I consent to the use and disclosure of my personal health information by your office for Treatment, Billing / Payment, and Health care Operations as outlined in the NOTICE OF PRIVACY PRACTICES.
(Signature of Patient or Parent or Legal Guardian)*

Clear

NYC Medical & Neurological Offices, PC 91-31 Queens Blvd, #601, Elmhurst, NY 11373

Tel. 718-454-2222 Fax: 718-264-0257

Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

You have the right to: Get a copy of your paper or electronic medical record Correct your paper or electronic medical record Request confidential communication

Ask us to limit the information we share Get a list of those with whom we've shared

your information Get a copy of this privacy notice Choose someone to act for you File a complaint if you believe your privacy rights have been violated

You have some choices in the way that we use and share information as we:

Tell family and friends about your condition

Include you in a hospital directory

more information on these choices and how to exercise them

Market our services and sell your information

We may use and share your information as we: Treat you Run our organization Bill for your services Help with public health and safety issues

Comply with the law Respond to organ and tissue donation requests

See pages 3 and 4 for more information on these uses and disclosures

Work with a medical examiner or funeral director

Address workers' compensation, law enforcement, and other government requests Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information

You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on page 1. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/ privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care

Share information in a disaster relief situation

Include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

share your information unless you give us written permission:

Marketing purposes Sale of your information Most sharing of psychotherapy notes

We may contact you for fundraising efforts, but you can tell us not to contact you again.

How do we typically use or share your health information? We typically use or share your health information in the following ways.

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

We can use and share your health information to run our practice, improve your care, and contact you when necessary. :

Example: We use health information :about you to manage your treatment and : : services.

We can use and share your health information to bill and get payment from health plans or other entities.

: Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information? We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues

We can share health information about you for certain situations such as: Preventing disease Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Preventing or reducing a serious threat to anyone's health or safety

We can use or share your information for health research.

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

compensation, law enforcement, and other government requests

We can use or share health information about you: For workers' compensation claims For law enforcement purposes or with a law enforcement official With health oversight agencies for activities authorized by law For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a courtor administrative order, or in response to a subpoena.

Instruction C: Insert any special notes that apply to your entity's practices such as "we do not create or manage a hospital directory" or "we do not create or maintain psychotherapy notes at this practice." Instruction D: The Privacy Rule requires you to describe any state or other laws that require greater limits on disclosures. For example, "We will never share any substance abuse treatment records without your written permission. Insert this type of information here. If no laws with greater limits apply to your entity, no information needs to be added.

Instruction E: If your entity provides patients with access to their health information via the Blue Button protocol, you may want to insert a reference to it here.

To leave this section blank, add a word space to delete the instructions.
We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Instruction F: Insert Effective Date of Notice here.

This Notice of Privacy Practices applies to the following organizations. Instruction G: If your entity is part of an OHCA (organized health care arrangement) that has agreed to a joint notice, use this space to inform your patients of how you share information within the OHCA (such as for treatment, payment, and operations related to the OHCA Also, describe the other entities covered by this notice and their service locations. For example, "This notice applies to Grace Community Hospitals and Emergency Services Incorporated which operate the emergency services within all Grace hospitals in the greater Dayton area.'

Instruction H: Insert name or title of the privacy official (or other privacy contact) and his/her email address and phone number.
Should be Empty:

	YES	NO
WERE YOU THE DRIVER OF THE MOTOR VEHICLE?
WERE YOU A PASSANGER IN THE MOTOR VEHICLE?
WERE YOU A PEDESTIAN?
WERE YOU A MEMBER OF OUR POLICY HOLDERS HOUSEHOLD?
DO YOU OR A RELAITIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE?

	Employer 1	Employer 2	Employer 3
Name
Address
Occupation
From date (MM/YYYY)
To date (MM/YYYY)

	YES	SOMEWHAT	NO
Because of my headaches I feel disabled.
Because of my headaches I feel restricted in performing my routine daily activities.
No one understands the effect my headaches have on my life.
I restrict my recreational activities (eg, sports, hobbies) because of my headaches.
My headaches make me angry.
Sometimes 1 feel that I am going to lose control because of my headaches.
Because of my headaches I am less likely to socialize.
My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.
My headaches are so bad that I feel that I am going to go insane.
My outlook on the world is affected by my headaches.
I am afraid to go outside when I feel that a headaches is starting.
I feel desperate because of my headaches.
I am concerned that I am paying penalties at work or at home because of my headaches.
My headaches place stress on my relationships with family or friends.
I avoid being around people when I have a headache.
I believe my headaches am making it difficult for me to achieve my goals in life.
I am unable to think clearly because of my headaches.
I get tense (eg, muscle tension) because of my headaches.
I do not enjoy social gatherings because of my headaches.
I feel irritable because of my headaches.
I avoid traveling because of my headaches.
My headaches make me feel confused.
My headaches make me feel frustrated.
I find it difficult to road because of my headaches.
I find it difficult to focus my attention away from my headaches and on other things.

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS

THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY

(IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP)

PATIENT ACKNOWLEDGEMENT OF THE NOTICE OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION