New Patient Registration Form

Patient Details:

Assignments of Insurance Benefits                                   

I hereby authorize direct payment of surgical/medical benefits to Dr. Kalitenko. For services rendered by him in person or under his supervision. I understand that I am financially responsible for any balance not covered by my insurance.

   Authorization to Release Information

I hereby authorize Dr. Kalitenko to release any medical information that may be necessary for either medical care or in processing applications for financial benefits.

  Signature on File

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Kalitenko for services furnished to me by provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information acceded to determine these benefits payable for related services.

   Internet Options

I give my permission to Dr. Kalitenko Medical office to send promotional materials to my mailing address, e-mail address and to my phone through text messaging. I agree not to use e-mail and office e-mail address for emergency or medical problems and questions.

I am aware that the only phone numbners to contact Dr Kalitenko's office are 718 382 9200 in Brooklyn and 561 464 2500 in POalm Beach Gardens.

I am also aware that Dr Kalitenko does not suport email and cell phones and any recording devices are prohibited in the office especially in examining rooms and I agree to comply.

A photocopy of these assignments shall be valid as the original

Patient Name : {fullName3}     Date: {date}

Name: {fullName3}

This consent provides us with your permission to perform reasonable and necessary medical examinations and testing and treatment. By signing below, you certify that:
(1) you agree that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office. The consent will remain fully in effect until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.

I voluntarily request Sergey Kalitenko MD, and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

I also understand that no guarantee or assurance has been made as to the results that may be obtained.

 

Release of Medical Record:  In order to ensure proper follow-up and continuity of care. I agree that a copy of my medical record may be released to my physician, a designated referral physician, and/or the provider, if any, who referred me here.

 

Insurance Authorization: I request that payment of authorized benefits be made to the above-named Doctor(s) on my behalf, for any services provided to me. I authorize any holder of medical and other information about me to release to Medicare and to its agents, any insurance company, any other third party payer, state medical assistant agency, or any other governmental or private payer responsible for paying such benefits, any information needed to determine these benefits for related services. I agree to pay for a l charges not covered by a third-party payer. I authorize a copy of this authorization to be used in place of the original.

Patient Name: {fullName3}     Date: {date}

Patient or person authorize to consent for patient

By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the hospital and the facilities listed at the beginning of this Notice, and how I may obtain access to and control this information. I also acknowledge and understand that I may request copies of separate written explanations of special privacy protections that apply to HIV related information and mental health information.

Name: {fullName3}     Date: {date}