New Patient Registration Form

*Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information. 

 

• I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information. 

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 NJ State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 

 

1. Domi Healthcare uses SureScripts, Inc. a prescription system that allows 

prescriptions and related information to be exchanged between my providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs I am currently taking and/or have taken in the past. This information will be used by Domi Healthcare in providing me with health care services. 

2. This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment and/or confidential HIV related information by SureScripts, Inc. to Domi Healthcare.

3. I have the right to revoke this authorization at any time by writing to Domi Healthcare. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 

4. Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan or eligibility to benefits will not be conditioned upon my authorization of this disclosure. 

5. Information disclosed under this authorization might be re-disclosed by the recipient and this re-disclosure may no longer be protected by state and federal law. 

6. THIS AUTHORIZATION DOES NOT AUTHORIZE DOMI HEALTHCARE TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THOSE PERMITTED UNDER APPLICABLE LAW. 

• CONSENT FOR TREATMENT: I do hereby request and authorize Domi Healthcare, its medical practices and providers including physicians, technicians, nurses, and other qualified personnel to perform evaluation and treatment services and procedures as may be necessary in accordance with the judgment of the attending medical practitioner(s). I authorize the physicians of Domi Healthcare to provide myself (or dependent) with reasonable and proper medical care. I acknowledge that no guarantee can be made by anyone concerning the results of treatments, examinations or procedures.
• CONSENT TO TREATMENT USING TELE-CONSULTS: I consent to treatment involving the use of electronic communications to enable health care providers at different locations to share my individual patient medical information for diagnosis, therapy, follow-up, and/or education purposes. I consent to forwarding my information to a third party as needed to receive tele-encounters, and I understand that existing confidentiality protections apply. I acknowledge that while tele-encounters can be used to provide improved access to medical care, as with any medical procedure, there are potential risks and no results can be guaranteed or assured. These risks include, but are not limited to: technical problems with the information transmission; equipment failures that could result in lost information or delays in treatment. I understand that I have a right to withhold or withdraw my consent to the use of tele-encounters in the course of my care at any time, without affecting my right to future treatment and without risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. 
• PRIVACY NOTICE: I acknowledge receipt of the Health Information Privacy Notice for Domi Healthcare on or after 01/15/2020.
• INSURANCE AUTHORIZATION AND ASSIGNMENT: I request that payment of authorized medical benefits is made on my behalf directly to Domi Healthcare, provider of service(s) furnished to me. I authorize Domi Healthcare to release any medical information to my health insurance carrier and/or its legitimate agents that is necessary to process related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards. I authorize payment of service(s), otherwise payable to me under the terms of my private, group employer's or group health insurance plan, directly to Domi Healthcare. I hereby authorize that photocopies of this form to be valid as the original.
• PAYMENT GUARANTEE: I do hereby guarantee payment of all fees and charges related to all services, including tele-encounters, and durable goods provided to me through Domi Healthcare medical practices and providers from my first date of examination or treatment. I understand that I am financially responsible for all non-converted services, copays, deductible and/or coinsurance. I authorize and give consent for my provider to bill me directly from recommended services performed that are not covered under the terms of my health plan. I understand that I am ultimately financially responsible for any balance remaining on the account after insurance has paid or total charges even if the insurance is pending or has been denied. I agree to make full payment immediately upon receipt of a Domi Healthcare billing statement whether it is an interim or final bill. In the event that I fail to make full payment or fail to comply with other payment arrangements made with Domi Healthcare approval, I understand that appropriate collection measures may be initiated. If I am uncovered by any insurance, I agree to pay the self-pay fee for the services I receive. A fee for no show/cancellations may apply.
• I authorize any holder of medical or any other information about me to release to the social security administration and the center for medicare and medicaid services or its intermediaries or carriers, or to the billing agent of this physician. Any information needed for this or a related medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts the assignment.
• I request that payment of authorized medigap benefits be made either to me or on my behalf to the provider of service and (or) supplier for any services furnished to me by the provider of service and (or) supplier. I authorize any holder of medicare information about me to release to: Medigap Insurance HIC#:
• Any information needed to determine these benefits payable for related services.
• ELECTRONIC HEALTH RECORD: Healthcare providers require access to patient medical information whenever or wherever a patient presents for care to assure safety, quality and to coordinate patient care across the provider network, avoiding duplication of services. Domi Healthcare has a system-wide electronic medical record that is available to caregivers on a “need to know" basis, to share information about patient care provided in the hospital, outpatient or physician office settings. Confidentiality of records including those reflecting treatment for behavioral health issues, HIV/AIDS or drug or alcohol problems is maintained per relevant governmental and regulatory standards. Patient care summaries are automatically sent to designated Domi Healthcare, and other community primary care/family/referring physicians, as well as to physicians who are consulted by the attending physician for coordination of care. Domi Healthcare and/or the attending physician can furnish and release to federal and state healthcare oversight agencies, or upon written request, to all insurance companies or their representatives any information with respect to treatment of the patient herein named including copies of the medical record.
• ELECTRONIC PRESCRIBING: I understand that Domi Healthcare medical practices and offices may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my Domi Healthcare providers and my pharmacy. I have been informed and understand that Domi Healthcare providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my Domi Healthcare providers to see this health information.
• IMMUNIZATION REGISTRY: I understand that Domi Healthcare participates in the New Jersey's Dept. of Health's statewide immunization registry that collects vaccination history and information to serve the public health goal of preventing the spread of vaccine preventable diseases. The registry complies with federal health information privacy laws.
• RELEASE OF RESPONSIBILITY FOR PERSONAL VALUABLES: I have been made aware and understand that all Domi Healthcare medical practices and offices provide no facilities for safekeeping of valuables. I do hereby release Domi Healthcare from any responsibility due to loss or damage of any valuables that I, or anyone accompanying me, may bring to a Domi Healthcare medical practice, office or facility.
• PERMISSION TO FAX CHILDHOOD IMMUNIZATION RECORD TO SCHOOLS: I do hereby grant permission for Domi Healthcare to send or fax childhood immunization records to schools, upon request.
• I, or my legal representative, certify that I have read this document and that I understand its contents, and hereby agree to all terms and conditions set forth above and acknowledge the receipt of a copy if requested.