WC package -combined

NYC Medical & Neurological Offices, PC 91-31 Queens Blvd, #601, Elmhurst, NY 11373 Tel. 718-454-2222 Fax: 718-264-0257
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WCB CASE NO. (F)
CARRIER CASE NO.
NATURE OF INSURY OR ILLNESS*
HIS/HER USUAL AND CUSTOMARY FEES FOR SERVICES RENDERED TO THE ABOVE NAMED CLAIMANT
SIGNATURE*

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IF SIGNED BY OTHER THAN CLAIMANT, PRINT BELOW: NAME, ADDRESS, AND RELATIONSHIP OF SIGNED
NAME AND ADDRESS
RELATIONSHIP

INDIVIDUAL PATIENT'S AUTHORIZATION
NYC Medical & Neurological Offices, P.C. 91-31 Queens Blvd Suite 601 Elmhurst, NY 11373 Tel: 718-593-8000 Fax: 718-651-7489
THIS FORM IS TO CONFIRM YOUR AUTHORIZATION TO USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION FOR A SPECIAL PURPOSE.
I give my authorization to use or disclose my protected health information as described in Section 2 below. I give this authorization voluntarily.
Type a question
Type a question
INDIVIDUAL PATIENT'S AUTHORIZATION
Describe each purpose for which you are authorizing your protected health information to be used and/or disclosed.
Select one of the following two choices.

This authorization will end on the following date: This authorization will end when the following event happens. The event must relate to the individual or the purpose of the authorized use and/or disclosure. Describe the event below:
4. CHANGING YOUR MIND ABOUT TillS AUTIIORlZATION

I understand that I may revoke this authorization al 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 il 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.

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 health 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.

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*

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Personal Representative's Name:
Name
Signature

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

YOU HAVE A RIGHT TO HAVE A COPY OF THIS FORM AFTER YOU SIGN IT.

NYC Medical & Neurological Offices, P.C. 91-31 Queens Blvd Suite 601 Elmhurst, NY 11373 Tel: 718-593-8000 Fax: 718-651-7489
AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION
Kindly furnish my insurance company or their representatives all information you may have regarding my condition while under your treatment or observation, including the history obtained, X-ray and physical findings. diagnosis and proguosis. You are authorized to provide this information in accordance with the New York State sutomobile reparations act, (No-fauk law I hereby authorize my insurance carrier to release my medical records to my provider or it's representative.
PROVIDER'S LIEN
I hereby authorize the above provider to furnish you, my attorney, with full report of his/her examination and test results, or myself in regard to injuries I sustained in the above mentioned accident. I also authorize and direct you, my attorney to pay directly to said provider such sums as may be due and owing him/ber for professional services rendered me both by reason of this accident and by reason of any other bills that are due his/her office and to withhold such sums from any settlement, judgementa verdict as may be necessary adequately to protect said provider. 1 hereby furhter give a lien on my case to said prov ider against any and all proceeds of any settlement, judgement or verdict which may be paid to you, my attorney or myself as the result to the injuries for which I have been tested or injuries in connection therewith.

I fully understand that should I cause the discontinuance of payment of benefits by my insurance carrier to said provider, as a result of my failure to fulfill one or more of the conditions set forth in my contract with my insurance carrier, or should I in any way defauk on my agreement with my attorney, I will assume full responsibility for all moneys owed to said provider for his/her medical services.
PATIENT/GUARDIAN SIGNATURE

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
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 bealth information described below includes any of these types of information, and I initial the line on the box in Item 9a, 1 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 212480-2493 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. 1 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 eligibilityfor 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.
Intials*
Signature of patient or representative authorized by law.*

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Signature of patient or representative authorized by law. Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could Human identify someone as having HIV symptoms or infection and information regarding a person's contacts.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Signature of Patient or representative authorized by law.*

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THE NOTICE OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF
(Signature of Patient or Parent or Legal Guardian)

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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.
, 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.
Should be Empty:

	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.

HIS/HER USUAL AND CUSTOMARY FEES FOR SERVICES RENDERED TO THE ABOVE NAMED CLAIMANT

IF SIGNED BY OTHER THAN CLAIMANT, PRINT BELOW: NAME, ADDRESS, AND RELATIONSHIP OF SIGNED

INDIVIDUAL PATIENT'S AUTHORIZATION

INDIVIDUAL PATIENT'S AUTHORIZATION

AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION

PROVIDER'S LIEN

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

Signature of patient or representative authorized by law. Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could Human identify someone as having HIV symptoms or infection and information regarding a person's contacts.