Full Patient Form

REGISTRATION FORM

Central Park Endocrinology PC

Dr. Gregory Dodell MD

Raya Galibov, PA

Dr. Jimmy Vol MD

Richard Neufeld MD Robert Romanoff MD. PC
Today's Date

MonthDayYear
Primary MD name: If You Are Being Referred
Referring Provider Information

Street Address

Street Address Line 2

CityState

Zip Code
Tel
Format: (000) 000-0000.
Fax
Format: (000) 000-0000.

PATIENT INFORMATION
First Name*
Middle
Last Name*
DOB*

MonthDayYear
MF
S.O./G.I.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Email Address*
Home Phone #
Format: (000) 000-0000.
Cell Phone #*
Format: (000) 000-0000.
Occupation
Employer
Employer Phone #
Format: (000) 000-0000.
Pharmacy's Name*
Pharmacy's Tel #*
Format: (000) 000-0000.

INSURANCE INFORMATION

(Please give your Insurance card and ID to the receptionist)
Primary Insurance Name*
Subscriber's Name*
Subscriber's SS #
Date Of Birth*

MonthDayYear
Policy #*
Group*
Patient's Relationship To Subscriber*
Please Upload The Front of Your Insurance Card*

Cancelof
Please Upload The Back of Your Insurance Card*

Cancelof
YesNo
SECONDARY INSURANCE
Name*
Subscriber's Name*
Subscriber's Policy # / Group #*
Birth Date*

MonthDayYear
Patient's Relationship To Subscriber*
Please Upload The Front of the Secondary Insurance Card*

Cancelof
Please Upload The Back of the Secondary Insurance Card*

Cancelof

IN CASE OF EMERGENCY
Name Of Local Friend Or Relative
Relationship To Patient
Home Phone #
Format: (000) 000-0000.
Work Phone #
Format: (000) 000-0000.
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims.
Signature*
Date

MonthDayYear

Referral Policy:

For all patients of our Primary Care Practice, if a referral is required for your plan, Please Contact our office 48 hours prior to your appointment or immediately after making the appointment at the specialist office.

We retain the right to refuse any referral to specialist if the patient has not adhered to our office policy. (Please discuss any and all medical issues with PCP first before scheduling appointments with a specialist office)

Financial Policy:
- Patients are ultimately responsible for the balance on account for professional services rendered in our office. This may include services not covered by your insurance policy. We can give you an estimate, not a guarantee of what percentage will be covered by your insurance company.
- Patients are responsible for updating your insurance information at each visit. If you fail to inform us of such changes, you will be responsible for the full fee on the treatment given. As a courtesy, we will help you by filing the claim.
- Patients should be fully aware of your insurance co-payments and limitations. If you have any questions about your insurance, you should contact the member services line listed on your insurance card.
- Patients are responsible for keeping scheduled appointments. If 24 hour advance notice is not given, then a fee of 80.00 will be charged for the missed appointment.
- I understand the above-mentioned information and agree to all the terms. I agree that all amounts are due upon request and are payable Central Park Endocrinology, PC or alt practice.
- If my account is not paid within 60 days of the date of service, I shall pay the reasonable legal fees or collection expenses to Central Park Endocrinology, PC.
- The duration of this authorization is indefinite and continues until revoked in writing. I understand that by not signing this release of information, I am responsible for payment of services in full before the services are rendered. Deposit of 150.00 shall be required for service rendered on date of service for all Deductible plans.
Date

MonthDayYear
Date
Signature*

NEW PATIENT FORM
Name*
Date of Birth*

MonthDayYear
Why are you here today? *
How did you hear about our practice?
List any medical problems and/or chronic conditions:*
List any previous surgeries, if any:*
List any medications that you are taking:*
Are you allergic to any medications?*

For Women
Age When Period Began:
Date of Last Period:

MonthDayYear
Age at Menopause:

Where Were You Born (Country)?
What is Your Occupation? If Retired, What Was Your Occupation?
YesNo

Family History
Father
Mother
Siblings
For Diabetic Patients
Last Eye Exam Date

MonthDayYear
Name of Eye Doctor
Last Dental Exam Date

MonthDayYear
Name of Dentist
Last Foot Exam Date

MonthDayYear
Name of Doctor

YesNo
PATIENT AUTHORIZATION to ACCESS MOUNT SINAI MEDICAL RECORDS via CARELINK
Patient's Last Name:*
Patient's First Name:*
Patient's Middle Name:
Date of Birth

MonthDayYear
Date
Tel No.:*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
I authorize my provider Central Park Endocrinology, PC to access my Mount Sinai medical records through Carelink

I understand my HIV, Alcohol and Drug Use, Psychiatric/Mental Health and Genetic information may be included.

I understand that this authorization is valid as long as I am under the care of the above noted healthcare provider and may be revoked by me at any time except to the extent that action has been taken based on my authorization.

Central Park Endocrinology, PC will not condition treatment or payment on whether you sign this authorization.

SPECIFIC UNDERSTANDINGS

I understand that this consent may include disclosure of Alcohol and Drug Abuse records and/or Psychiatric records and or HIV-related information (indicating that I have had an HIV-related test, or have HIV infection, HIVrelated illness or AIDS, or that could indicate that I have been potentially exposed to HIV).

If I am authorizing the release of HIV/AIDS, Alcohol or Drug treatment, or mental health treatment related information the recipient(s) is prohibited from redisclosing the information without my authorization unless permitted to do so under federal and state law. I also have a right to request a list of people who may receive or use my HIV-related information without authorization. If you experience discrimination because of the release or disclosure of HIV-related information, you may contact the New York State Division of Human Rights at (800) 523-2437 / (212) 480-2493 or the New York City Commission on Human Rights at (212) 306-7450.
By signing this authorization form, I am authorizing the use or disclosure of my protected health information as described above. This information may be redisclosed if the recipient(s)as described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations.
Patient's Signature
Date

MonthDayYear
Personal Representative Signature
Print Name:
Authority:
Tel No.:
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date

MonthDayYear
Date
(Personal Representative to sign only if patient is a minor or unable to sign on his/her own behalf)

To request records or to revoke authorization, send a written request to:

Central Park Endocrinology, PC
115 Central Park West, Suite 14, NY, NY. 10023
Fax: 212-873-9311

NOTICE OF PRIVACY PRACTICES
Central Park Endocrinology, PC

Richard R. Neufeld MD

Robert M Romanoff MD, PC
This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully.
Protected health information (PHI), about you, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future physical or mental health condition and related healthcare services.

Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.

Your Rights Under The Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices - We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location within the practice, and if such is maintained by the practice, on it’s web site.

You have the right to authorize other use and disclosure - This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about medical matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.

You have the right to inspect and copy your PHI - This means you may inspect, and obtain a copy of your complete health record. If your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines.

You have the right to request a restriction of your PHI - This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your health plan regarding a specific treatment or service that you, or someone on your behalf, has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction.

You may have the right to request an amendment to your protected health information - This means you may request an amendment of your PHI for as long as we maintain this information. In certain cases, we may deny your request.

You have the right to request a disclosure accountability - This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office.

You have the right to receive a privacy breach notice - You have the right to receive written notification if the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.

If you have questions regarding your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided on the following page under Privacy Complaints.

How We May Use or Disclose Protected Health Information.
Following are examples of uses and disclosures of your protected health information that we are permitted to make. These examples are not meant to be exhaustive, but to describe possible types of uses and disclosures.

Treatment - We may use and disclose your PHI to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party that is involved in your care and treatment. For example, we would disclose your PHI, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment.

Special Notices - We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health-related benefits and services offered by our office, for fund-raising activities, or with respect to a group health plan, to disclose information to the health plan sponsor. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out.

Payment - Your PHI will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the healthcare services we recommend for you such as, making a determination of eligibility or coverage for insurance benefits.

Healthcare Operations - We may use or disclose, as needed, your PHI in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment and improvement, medical review, legal services, auditing functions and patient safety activities.

Health Information Organization - The practice may elect to use a health information organization, or other such organization to facilitate the electronic exchange of information for the purposes of treatment, payment, or healthcare operations.

To Others Involved in Your Healthcare - Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, that you identify, your PHI that directly relates to that person’s involvement in your healthcare. If you are unable to agree or object to such a disclosure, we may disclose such information as neceesary if we determine that it is in your best interest based on our professional judgment. We may use or disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your healthcare provider may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the PHI that is necessary will be disclosed.

Other Permitted and Required Uses and Disclosures - We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities; health oversight activities; in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; military activity; national security; worker’s compensation; when an inmate in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of the Privacy Rule.

Privacy Complaints
You have the right to complain to us, or directly to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Manager at:

(212) 877-2100

We will not retaliate against you for filing a complaint.

Effective Date: 08/07/2015 - CONTINUOUS Publication Date: 08/07/2015
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PATIENT INFORMATION

INSURANCE INFORMATION

SECONDARY INSURANCE

IN CASE OF EMERGENCY

NEW PATIENT FORM

For Women

Family History

For Diabetic Patients

PATIENT AUTHORIZATION to ACCESS MOUNT SINAI MEDICAL RECORDS via CARELINK

NOTICE OF PRIVACY PRACTICES