SUFFOLK VASCULAR ASSOCIATES

Patient Name*
DOB*
SS#
Sex
Email
example@example.com
Address*
City/State*
Zip Code*
Home Phone
Cell Phone*
Business Phone
Employment Status:*

Full TimePart TimeRetired
Employer
Marital Status:*

SingleMarriedDivorcedWidowedLife Partner
Emergency Contact*
Contact Phone*
Relationship to Patient*
Primary Care Physician*
Referring Physician
Podiatrist
Neurologist
Nephrologist
OB-GYN
Cardiologist
Dialysis Center
Dialysis Days
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**If your insurance requires an insurance referral to be seen by Specialists, you are responsible to have that referral before your visit or your appointment will need to be rescheduled.

**If your insurance has a Specialist Copay, payment is due at check in for all visits.

***LATE POLICY: If you are 15 minutes late or longer, your appointment will need to be rescheduled.
Patient Signature*

Clear
Date*

MonthDayYear
While Suffolk Vascular Associates is waiting for payment for all of the fees, I agree to provide the office with information and forms regarding any source of potential payment, to assist in any way I can, and:

1.Hereby assign Suffolk Vascular Associates my rights to receive payments from the insurance companies responsible for my claims.

2. I also hereby authorize the direct payment to Suffolk Vascular Associates of any sum I now, or hereafter, owe by any insurance company obligated to make payment to me or you based in whole or in part upon the charge made for your services.

3. You are authorized to release any information including the diagnosis and records of any such treatment to any insurance company to process any claims for reimbursement of charges incurred.

4. I hereby assign and transfer to you the cause of action that exists in my favor, including the right to proceed via state external appeal or Superior Court, against the insurance company responsible for this claim to collect any unpaid bills.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.
Patient Signature*

Clear
Date*

MonthDayYear
Patient Name*
I, {name}, am aware that my insurance company may sendme paymentsfor services rendered bySuffolk Vascular Associates, which includes(Consultation/Surgery/Vascular Lab/FollowUp)
I agree that when I receive any insurance payments for those services, I will:

1. Sign/Endorse the check, and I WILL NOT DEPOSIT or CASH it. (Unless otherwise instructed to do so by the office in the case of a bulk insurance check)

2.Under my signature, I will print the following:"Make Payable Only to Suffolk Vascular Associates"

3.I will enclose the check with the accompanying letters or forms, such as the Explanation of Benefits, in an envelope, and promptly send it to Suffolk Vascular Associates at the address on this letterhead. Or I will bring the check to the office within 5 business days from receipt.

I also understand that in the event that the check is not immediately sent to Suffolk Vascular Associates, I will be responsible to pay the full and entire fee for all services rendered, plus any additional collection fees and legal costs in connection with collecting this debt.

I will be provided a copy of this letter as a reminder as to what is required of me when I receive payment from my insurance company.

By signing below, you are stating you understand the conditions of receiving treatment at Suffolk Vascular Associates and will comply with all the terms above or will be liable for all bills.
Patient Signature*

Clear
Date*

MonthDayYear
Patient Name*
HIPAA Authorization Form:

I, {name}, give the business office of Suffolk Vascular Associates permission to discuss my personal health information with authorized individual(s) listed below.

Please List any Family or Friends we may speak with (not including Doctors): Include: Name, Relationship, Best Phone #

**IF YOU DO NOT WANT TO LIST ANYONE, PLEASE WRITE “N/A” BELOW**
1. Name of Authorized Individual*
Relationship to Self
Phone Number
Please enter a valid phone number.
2. Name of Authorized Individual
Relationship to Self
Phone Number
Please enter a valid phone number.
3. Name of Authorized Individual
Relationship to Self
Phone Number
Please enter a valid phone number.
4. Name of Authorized Individual
Relationship to Self
Phone Number
Please enter a valid phone number.
5. Name of Authorized Individual
Relationship to Self
Phone Number
Please enter a valid phone number.
Patient Signature*

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Date*

MonthDayYear
Patient Release of Health Information Authorization Form:

*For outside Doctors and other medical offices*

I, {name}, hereby authorize SUFFOLK VASCULAR ASSOCIATES to obtain any and all pertinent health information on my behalf, including clinical notes, laboratory results, and imaging results.
Patient Name*
Patient Name*
Patient Signature*

Clear
Date*

MonthDayYear
Should be Empty: