Intake Forms with IDs

Patient Intake Form
Today's Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender

FemaleMale
Phone Number
Please enter a valid phone number.
Email
example@example.com
I consent to receive text message/call reminders

YesNo
I consent to receive email reminders

YesNo
Insurance Information
Group #
ID #
Upload the front of Health Insurance ID here

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Upload the back of Health Insurance ID here

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Upload the Driver's License here

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Patient Attestation Conservative Vein Care
I , First Name Last Name hereby certify to The Provider's name and its licensed healthcare providers, (“Provider”), as well as my health insurance carrier or administrator, with the intent that my provider and insurer rely upon this attestation, the following:

1. That I currently wear/or have previously attempted to wear (in the recent past) medical grade compression stockings for the treatment of venous reflux and/or associated lower extremity conditions

2. Medical grade (not over the counter) compression stockings have been worn by me for a minimum of 3 months in the relatively recent past.

3. Medical grade (not over the counter) compression stockings were attempted by me in the recent past. I was not able to tolerate stocking usage despite knowing the benefit.

4. I have communicated this to the Surgeon evaluating me and he has answered all of my questions in this regard. I authorize disclosure of this information to my insurer listed above.

Signature
Indigency Policy & Agreement
Our indigency discount is no different than all PPO discounts from BCBS or all other commercial insurers in compliance with all applicable federal and state laws with respect to indigency assistance without any routine waiver of cost sharing, advertising, or solicitation, for underinsured or uninsured patients. Once indigency is determined, collection is no longer undertaken with regard to the patient for the forgiven amount without waiving any patient financial and legal obligation or responsibility to the provider’s actual total charges AND patient’s right and eligibility, assigned to the provider, to claim for reimbursement, under the health plan coverage, based on the provider’s actual total and reasonable charges in accordance with Provider’s Corporate Indigency Policy, as the Indigency determination itself is a good effort to collect, and hospitals or doctors are NOT required under any federal or state laws, Medicare, ERISA & PPACA, to take low-income, medically indigent, uninsured or underinsured patients to court, garnish their wages, or seize their homes, or send claims out to a collection agency when those patients don’t or can’t pay their hospital or doctor bills.

In consideration of my particular medical needs and care expenses to be incurred solely based on such medical needs, and my financial ability to pay for such recommended medical services without or even with applicable insurance coverage, and with understanding and agreement that I am personally financially and legally obligated to and responsible for any and all professional actual total charges regardless of any applicable insurance coverage, I hereby declare that I have financial difficulty to pay for part or all expenses because of the following:

Please check the applicable circle below:

Low or a fixed incomee   Without any or applicable insurance for treatment at this clinic   With applicable insurance but still medically indigent (see below)

More importantly, I declare that without following indigent assistance, seeking for and continuing with medically appropriate and important health care would be impossible for me or would make indigent if I were forced to pay full charges for my medically necessary care expenses. I also declare that I personally requested for such indigent assistance only after I was fully informed of my important medical treatment options and necessity solely based on my particular medical needs and availability of this provider Indigency Policy:

“Nothing in the Centers for Medicare & Medicaid Services’ (CMS’) regulations, Provider reimbursement Manual, or Program Instructions prohibit a healthcare provider from waiving collection of charges to any patients, Medicare or non-Medicare, including low-income, uninsured or medically indigent individuals, if it is done as part of the healthcare provider indigency policy.”

“By “indigency policy,” we mean a policy developed and utilized by a healthcare provider to determine patients’ financial ability to pay for services. By “medically indigent,” we mean patients whose health insurance coverage, if any, does not provide full coverage for all of their medical expenses and that their medical expenses, in relationship to their income, would make them indigent if they were forced to pay full charges for their medical expenses.”

I specifically request under this provider indigency policy for the following indigent discount assistance for the specific time periods from   Date  to   Date

Please check the applicable boxes below:

Waiving collection of my deductible

Waiving collection of co-pays/encounter fees

Waiving collection of co-insurance

Waiving collection of out-of-pocket fees/costs

Waiving collection of partial*

First Name   Last Name

Signature
New Jersey Department of Banking and Insurance

CONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS AND AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS IN UM APPEALS AND INDEPENDENT ARBITRATION OF CLAIMS
APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS

You have the right to ask your insurer, HMO or other company providing your health benefits (carrier) to change its utilization management (UM) decision if the carrier determines that a service or treatment covered under your health benefits plan is or was not medically necessary.[1] This is called a UM appeal. You also have the right to allow a doctor, hospital or other health care provider to make a UM appeal for you.

There are three appeal stages if you are covered under a health benefits plan issued in New Jersey. Stage 1: the carrier reviews your case using a different health care professional from the one who first reviewed your case. Stage 2: the carrier reviews your case using a panel that includes medical professionals trained in cases like yours. Stage 3: your case will be reviewed through the Independent Health Care Appeals Program of the New Jersey Department of Banking and Insurance (DOBI) using an Independent Utilization Review Organization (IURO) that contracts with medical professionals whose practices include cases like yours. The health care provider is required to attempt to send you a letter telling you it intends to file an appeal before filing at each stage.

At Stage 3, the health care provider will share your personal and medical information with DOBI, the IURO, and the IURO’s contracted medical professionals. Everyone is required by law to keep your information confidential. DOBI must report data about IURO decisions, but no personal information is ever included in these reports.

You have the right to cancel (revoke) your consent at any time. Your financial obligation, IF ANY, does not change because you choose to give consent to representation, or later revoke your consent. Your consent to representation and release of information for appeal of a UM determination will end 24 months after the date you sign the consent.

INDEPENDENT ARBITRATION OF CLAIMS

Your health care provider has the right to take certain claims to an independent claims arbitration process through the DOBI. To arbitrate the claim(s), the health care provider may share some of your personal and medical information with the DOBI, the arbitration organization, and the arbitration professional(s). Everyone is required to keep your information confidential. The DOBI reports data about the arbitration outcomes, but no personal information will be in the reports. Your consent to the release of information for the arbitration process will end 24 months after the date you sign the consent.

CONSENT TO REPRESENTATION IN UM APPEALS AND AUTHORIZATION TO RELEASE OF INFORMATION IN UM APPEALS AND ARBITRATION OF CLAIMS

I,    First Name   Last Name ,by marking  (√)   (or  x ) and signing below, agree to:

      Provider's name   & Billing Affiliates representation by   Provider's name   & Billing Affiliate in an appeal of an adverse UM determination as allowed by N.J.S.A. 26:2S-11, and release of personal health information to DOBI, its contractors for the Independent Health Care Appeals Program, and independent contractors reviewing the appeal.  My consent to representation and authorization of release of information expires in 24 months, but I may revoke both sooner.

     Provider's name   & Billing Affiliates   release of personal health information to DOBI, its contractors for the Independent Claims Arbitration Program or the Chapter 32 Independent Arbitration System, and any independent contractors that may be required to perform the arbitration process. My authorization of release of information for purposes of claims arbitration will expire in 24 months.

Signature:    Signature    Ins. ID#:

Date:    Date

Relationship to Patient:     I am the Patient    2 I am the Personal Representative

*If the patient is a minor, or unable to read and complete this form due to mental or physical incapacity, a personal representative of the patient may complete the form.
New Jersey Department of Banking and Insurance

NOTICE OF REVOCATION OF CONSENT TO REPRESENTATION IN APPEALS OF UTILIZATION MANAGEMENT DETERMINATIONS AND OF AUTHORIZATION TO RELEASE OF MEDICAL RECORDS
You may, at any time, revoke the consent you gave allowing a health care provider to represent you in an appeal of a UM determination and allowing the release of your medical records to the DOBI, the IURO and medical professionals that contract with the IURO. You may use this form to revoke your consent, or you may submit some other written evidence of your intent to revoke consent, if you prefer. Either way, if you have not yet received a Stage 2 UM determination from the carrier, send the written and signed revocation to the carrier at the address indicated in the carrier’s written notice to you regarding the carrier’s initial UM determination. If you have received a Stage 2 UM determination, then your revocation should be sent to:

New Jersey Department of Banking and Insurance

Consumer Protection Services

Office of Managed Care – Attn: IHCAP

P.O. Box 329

Trenton, NJ 08625-0329

OR for courier service to: 20 West State Street      OR by fax to: (609) 633-0807

You may also want to send a copy of your notice of revocation to the health care provider.

ONLY COMPLETE AND SEND THIS IN WHEN AND IF YOU WISH TO REVOKE YOUR CONSENT!

REVOCATION OF CONSENT TO REPRESENTATION AND RELEASE OF MEDICAL RECORDS IN UM DETERMINATION APPEALS

    I hereby revoke my consent to representation by     and my authorization to the release of medical information in an appeal of an adverse UM determination. I understand that by revoking consent, the UM appeal may not be pursued further by my health care provider. I understand that this revocation may occur after my personal and medical information has already been shared with the DOBI, the IUROs and medical professionals with whom the IUROs contract, but that no further distribution of records in this matter will occur based on my authorization, and that all of my medical and personal information is required to be maintained as confidential by all parties.

Signature:    Signature         Ins. ID#   Type a label
Date:   Date
Relationship to Patient:     I am the Patient 1   I am the Personal Representative

Contact Information of Personal Representative

Please provide the following contact information IF it is different from the patient’s contact information:

PRINT NAME:   First Name   Last Name

ADDRESS:   Street Address   Address Line 2   City   State   Zip


PHONE:   Area Code   Phone Number    FAX:   Area Code   Phone Number   EMAIL:   Email
Assignment of Benefits
I hereby authorize payment of medical insurance benefits otherwise payable to me, be made directly to     Provider's name   & Billing Affiliates.

I authorize the release of any medical or other pertinent information necessary to determine these benefits for payable services rendered by     Provider's name   & Billing Affiliates.

I authorize     Provider's name   & Billing Affiliates to submit appeals on my behalf for any denied benefits to my medical insurance carrier.

I also authorize    Provider's name   & Billing Affiliates to pursue all legal remedies available for the collection of any and all fees and cost due and owing on account of professional services rendered to me. By this authorization I expressly confer upon    Provider's name   & Billing Affiliates the right to file suite against any party who may be responsible for paying any fees and costs incurred on account of professional services rendered to me, and to exercise the same rights and remedies which I have to collect all such sums, without limitations, including costs of suit and reasonable attorney’s fees.

Patient Name:   First Name   Last Name
D.O.B.   Date
Relationship if other than patient:
Signature:   Signature*   Date:   Date*
Lower Extremity Screening Assessment

Please answer the following questions about your symptoms. Keep in mind how it affects your daily life.
1. Does the appearance of your legs bother you?

YesNo
2. Do you have spider veins and/or varicose veins?

YesNo
3. Do you have lower back pain, leg pain or cramping in your legs?

YesNo
4. Do you have hip pain?

YesNo
5. Do you have back pain?

YesNo
6. Do you have Numbness or Tingling in your Legs, Feet or Hands?

YesNo
7. Do you develop numbness in your legs when you sit or stand?

YesNo
8. Do you have a history of sciatic nerve pain?

YesNo
9. Do you have a shooting burning pain in your legs or lower back?

YesNo
10. Do your legs ever ache or become swollen when you stand or walk?

YesNo
11. Have you developed any discoloration or color changes in your legs?

YesNo
12. Do you notice that the skin on your legs is dry, scaly, shiny?

YesNo
13. Do you bruise easily on your legs?

YesNo
14. Have you ever worn compression stockings?

YesNo
14. Have you ever worn compression stockings?

YesNo
If yes for how long?No. of Years Years No of Months Months
15. Have you ever been diagnosed with venous disease or insufficiency?

YesNo
16. Have you had any previous vein treatments in the past?

YesNo
Vein treatments:

Laser AblationSclerotherapy InjectionsVein StrippingPhlebectomy
General History

Do you have any of the following?
Diabetes?

YesNo
Heart Disease

YesNo
High Blood Pressure

YesNo
Liver Problems

YesNo
Arthritis

YesNo
Problems with Kidneys

YesNo
Back Pain

YesNo
Glaucoma

YesNo
Headaches

YesNo
Difficulty Sleeping

YesNo
Frequent Bleeding

YesNo
Difficulty Walking

YesNo
Lung Disease

YesNo
Shortness of Breath

YesNo
Do you have blood thinning medications?

YesNo
Do you have allergies? If yes, what medications?

YesNo
If yes, what medications?
Are you taking any medication? If yes, please list medication and dosage per day
Should be Empty:

Patient Intake Form

Insurance Information

Patient Attestation Conservative Vein Care

Indigency Policy & Agreement

New Jersey Department of Banking and Insurance

New Jersey Department of Banking and Insurance

Assignment of Benefits

Lower Extremity Screening Assessment

General History