Sisselman Medical Group - Patient Registration Form

Sisselman Medical Group, PC
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Please fill out either section I OR section II and sign below:
Section 1
A. I, blanks give Sisselman Medical Group, PC, permission to leave information on my voice mail/answering machine or with the following family member(s) or designated representative(s) as noted below:
B. Check All That Applies*

Voice Mail/Answering MachineFamily Members
If Family Members, Please List Their Names:
Please Check All That Can Be Left In A Message or With A Representative:

Test ResultsLab ResultsConfirming AppointmentsMedication ChangesBilling/Insurance ChangesAny Information, Including All of The Above
PLEASE NOTE THAT IF YOU DO NOT CHECK OFF SECTION B, WE WILL NOT LEAVE MESSAGES.
Section 2
I, blanks do not want any information pertaining to all aspects of my medical care left on my answering machine or with anyone other than myself.
CONSENT TO TREAT A MINOR CHILD:
The information I have given this office pertaining to blanks is true and complete to the best of my knowledge. I authorize the doctors and staff of Sisselman Medical Group, PC to administer such procedures and treatment as they deem necessary to my child/ward in my legal custody. The doctors have implied to guarantee of cure.
Signature*
Date*

MonthDayYear
Date
Relationship To Patient*

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I have received this practice’s Notice of Privacy Practices, which provides in detail the uses and disclosures of my protected health information that may be made by this practice, my rights and the practices legal duties with respect to my protected health information. I have been provided to review the Notice of Privacy Practices and understand that I can obtain a copy on request.
Signature*
Date*

MonthDayYear
Date
Relationship To Patient (if patient is a minor or signed by a personal representative:

SISSELMAN MEDICAL GROUP, PC

Stephen G. Sisselman, FACP

Jill C. Sisselman, FAACP
Date*

MonthDayYear
Date
PARTICIPATING INSURANCE
I, blanks* have been informed on this date blank* by Sisselman Medical Group that if my health plan does not cover routine physicals, testing done in conjunction with my physical exam, any type of surgery or any vaccines that I have been given, I (the patient) will be personally responsible for the charges incurred and in the event of non-payment, I would be responsible for any fees incurred in an attempt to collect the balance. You are ultimately responsible for knowing the requirements and coverage limitations of your own insurance policy. I understand that Sisselman Medical Group will bill my insurance company on my behalf.
Responsible Party Signature*
SERVICE FEE FOR NON-CANCELLATION OF APPOINTMENT
I, blanks* am aware that if I have an appointment scheduled at Sisselman Medical Group and I am unable to keep this appointment, I will be charged a service fee of $40.00 if I do not show up for my scheduled appointment and $25 if I cancel my appointment within 24 hours.
I understand that by not calling to cancel my appointment, I am holding an appointment in the doctor’s schedule that could be used for another patient.
Responsible Party Signature*
PRESCRIPTION DATABASE CONSENT FORM
I, blanks* give Sisselman Medical Group permission to access RX HUB (prescription database) to view my prescription history. As of August 27, 2013, consulting the prescription database is a New York State law for both providers and pharmacists. Failure to sign this document could restrict your provider from prescribing certain controlled substances.
Responsible Party Signature*

APPOINTMENT REMINDERS
To make your experience with us even more enjoyable and convenient, Sisselman Medical Group will be utilizing electronic appointment reminders. You can elect to receive text message notification, email notification or automated telephone appointment reminders. Each of these options will allow you to confirm an appointment automatically, or prompt you to call office to reschedule. Please select your preference below:
I would like to use the following for reminders and give my consent to do so:*

Phone CallText MessageEmail
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Name*

First NameLast Name
Signature*

TELEHEALTH CONSENT
I understand that Telehealth is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider. I understand that the laws that protect the privacy and the confidentiality of patient medical information also apply to telehealth services. As always, my insurance carrier will have access to medical records for quality review/audits. I understand that I will be responsible for any copayments of coinsurance that may apply to my telehealth visit. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I may also revoke my consent orally or in writing at any time by contacting Sisselman Medical Group.
Patient Name*

First NameLast Name
Signature*

SISSELMAN MEDICAL GROUP, PC CREDIT CARD AUTHORIZATION FORM
The purpose of this form is to authorize Sisselman Medical Group to retain a valid credit card number on file for you as our patient. All patients are required to complete this form. This form will be kept confidential and only authorized staff will have access to the information. We find it necessary to do this because of changes in health care law and changes to your health plan starting 1/1/2014.

Your supplied credit card will be charged ONLY under the following circumstances:
- To satisfy any balances more than 60 days old, including co-pays and deductibles, for claims processed by your insurance carrier. If you do not send in payment for the balance due after receiving two (2) statements from us, we will charge your credit card for the outstanding balance. We will notify you when the card will be charged.
- To pay any returned check fees (not to exceed $35) in the event your check is returned to us for any reason.
- To pay for any Fee for Service testing, including any procedures not covered by your insurance and offered to you by us. For a list of our Fee for Service costs, please see the front desk.
A receipt will be kept in your chart, unless directed to send the receipt directly to you. This notice serves as your consent to being charged for all current patient balances on your account.
Acknowledged, Agreed & Accepted:

Having read this form and speaking to staff, my signature below acknowledges that I voluntarily give my authorization and consent to providing the requested information for my credit card to be charged accordingly for the conditions listed above.
Patient Signature (or authorized party)*
Date*

MonthDayYear
Date
Name As It Appears On Card*

First NameLast Name
Card Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Card Number*
Expiration Date*

MonthDayYear
Date
Verification Code (3 digits)*

Authorization for Access to Patient Information Through a Health Information Exchange Organization

New York State Department of Health
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
Date
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow Sisselman Medical Group to obtain access to my medical records through the health information exchange organization called Healthix. If I give consent, my medical records from different places where I get health care can be accessed using a statewide computer network. Healthix is a not-for-profit organization that shares information about people’s health electronically to improve the quality of healthcare and meets the privacy and security standards of HIPAA, the requirements of the federal confidentiality laws, 42 CFR Part2, and New York State Law. To learn more visit Healthix’s website at www.healthix.org. The choice I make in this form will NOT affect my ability to get medical care.

The choice I make in this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.
My Consent Choice.

ONE box is checked to the left of my choice.

I can fill out this form now or in the future.

I can also change my decision at any time by completing a new form.
My Consent Choice

I GIVE CONSENT for Sisselman Medical Group to access ALL of my electronic health information through Healthix to provide health care.I DENY CONSENT for Sisselman Medical Group to access my electronic health information through Healthix for any purpose.
If I want to deny consent for all Provider Organizations and Health Plans participating in Healthix to access my electronic health information through Healthix, I may do so by visiting Healthix’s website at www.healthix.org or calling Healthix at 877-695-4749.

My questions about this form have been answered and I have been provided a copy of this form.
Signature of Patient or Patient’s Legal Representative
Date

MonthDayYear
Date
Name of Legal Representative (if applicable)

First NameLast Name
Relationship of Legal Representative to Patient (if applicable)

Details about the information accessed through Healthix and the consent process:

1. How Your Information May be Used. Your electronic health information will be used only for the following healthcare services:
- Treatment Services. Provide you with medical treatment and related services.
- Insurance Eligibility Verification. Check whether you have health insurance and what it covers.
- Care Management Activities. These include assisting you in obtaining appropriate medical care, improving the quality of services provided to you, coordinating the provision of multiple health care services provided to you, or supporting you in following a plan of medical care.
- Quality Improvement Activities. Evaluate and improve the quality of medical care provided to you and all patients.
2. What Types of Information about You Are Included. If you give consent, the Provider Organization listed may access ALL of your electronic health information available through Healthix. This includes information created before and after the date this form is signed. Your health records may include a history of illnesses or injuries you have had (like diabetes or a broken bone), test results (like X-rays or blood tests), and lists of medicines you have taken. This information may include sensitive health conditions, including but not limited to:
- Alcohol or drug use problems
- Birth control and abortion (family planning)
- Genetic (inherited) diseases or tests
- HIV/AIDS
- Mental health conditions
- Sexually transmitted diseases
- Medication and Dosages
- Diagnostic Information
- Allergies
- Substance use history summaries
- Clinical notes
- Discharge summary
- Employment Information
- Living Situation
- Social Supports
- Claims Encounter Data
- Lab Test
3. Where Health Information About You Comes From. Information about you comes from places that have provided you with medical care or health insurance. These may include hospitals, physicians, pharmacies, clinical laboratories, health insurers, the Medicaid program, and other organizations that exchange health information electronically. A complete, current list is available from Healthix. You can obtain an updated list at any time by Healthix’s website at www.healthix.org or by calling 877-695-4749.

4. Who May Access Information About You, If You Give Consent. Only doctors and other staff members of the Organization(s) you have given consent to access who carry out activities permitted by this form as described above in paragraph one.

5. Public Health and Organ Procurement Organization Access. Federal, state or local public health agencies and certain organ procurement organizations are authorized by law to access health information without a patient’s consent for certain public health and organ transplant purposes. These entities may access your information through Healthix for these purposes without regard to whether you give consent, deny consent or do not fill out a consent form.

6. Penalties for Improper Access to or Use of Your Information. There are penalties for inappropriate access to or use of your electronic health information. If at any time you suspect that someone who should not have seen or gotten access to information about you has done so, call Sisselman Medical Group at (516) 308-4040; or visit Healthix’s website: www.healthix.org; or call the NYS Department of Health at 518-474-4987; or follow the complaint process of the federal Office for Civil Rights at the following link:http://www.hhs.gov/ocr/privacy/hipaa/complaints/.

7. Re-disclosure of Information. Any organization(s) you have given consent to access health information about you may re-disclose your health information, but only to the extent permitted by state and federal laws and regulations. Alcohol/drug treatment-related information or confidential HIV-related information may only be accessed and may only be re-disclosed if accompanied by the required statements regarding prohibition of re-disclosure.

8.Effective Period. This Consent Form will remain in effect until the day you change your consent choice, death or until such time as Healthix ceases operation. If Healthix merges with another Qualified Entity your consent choices will remain effective with the newly merged entity.

9.Changing Your Consent Choice. You can change your consent choice at any time and for any Provider Organization or Health Plan by submitting a new Consent Form with your new choice. Organizations that access your health information through Healthix while your consent is in effect may copy or include your information in their own medical records. Even if you later decide to change your consent decision they are not required to return your information or remove it from their records.

10. Copy of Form. You are entitled to get a copy of this Consent Form.
The New York State Immunization Information System (NYSIIS) is a confidential, computerizred system that contains immunization records and allows authorized users access to a person's shot record. Strict federal and state laws protect the privacy of your personal information in the system. The benfits of participating in NYSIIS include:
- Your health care provider can use NYSIIS to be sure that you receive the needed immunizations and proper medical treatment is received when needed.
- There will be a permanent and easily accessible record of your immunizations.
Participation in NYSIIS for people 19 years of age or older is voluntary, so your consent is needed. If you want to participate, please carefully read the consent below and sign in the space provided. For additional information about this consent, please call (518) 473-2839.
I give my consent for blanks (name of doctor or organization) to release my immunization(s) and identifying information to the New York State Immunization Information System (NYSIIS). I understand the purpose of NYSIIS is to assist in my medical care and to record the immunizations that I have had or will receive in the future. My immunization information may potentially be used by the Department of Health for quality improvement purposes, epidemiologic research and disease control purposes. Information used for quality improvement or any research purposes will have my personal identifying information removed.

The immunization information in NYSIIS may be released to the following: myself, my health insurance plan, the state and local health departments, the school that I am registered to attend, and authorized medical providers that deliver my medical care.

I understand that there will be no effect on my treatment, payment, or enrollment for benefits if I choose nor to enroll in NYSIIS. This consent may be withdrawn at any time by using the form provided. Information about immunizations received by NYSSIS with my consent will remain in NYSIIS if I later choose to withdraw my consent. However, future immunizations will not be recorded in NYSIIS.
Name

First NameLast Name
DOB

MonthDayYear
Date
Signature
Date

MonthDayYear
Date

Sisselman Medical Group Preventive Physical Exam Policy
An annual preventive exam done at Sisselman Medical Group may include the following procedures, tests and services:
- Preventive Exam (CPT codes: 99393 - 99397 for established patients, 99383 – 99387 for new patients. For Medicare-age patients, CPT codes are G0438, G0439 or G0402.)
- Electrocardiogram (CPT code 93000)
- Otoacoustic emissions or hearing test (CPT 92587)
- TB skin test (CPT 86580)
- Spirometry or pulmonary function test (CPT 94010)
- Blood draw (36415)
- Urinalysis (81002)
In addition, there are several immunizations that are recommended:
- Tetanus, diphtheria and pertussis vaccine (90715)
- Influenza vaccine (90688)
- Pneumococcal or Prevnar vaccine (90732 or 90670)
These services are done or recommended in the best interest of the patient – especially in consideration of a patient’s chronic conditions, family history and medications taken. Please understand that any of the above mentioned tests or services done with your physical exam may NOT be considered preventive by your insurance plan and therefore may apply to a copay, deductible or coinsurance and you will be billed for those fees. If a service is simply considered not covered, we reserve the option to reduce the fee to our self-pay rate and bill the patient (usually $25 per non-covered test; vaccines will be billed at our cost.)

It is in the patient’s best interest to know his/her insurance policy and coverage guidelines as to which of these services are covered benefits, either for preventive care or for standard medical care. We try our best to check insurance eligibility and benefit information, but not all information is made available to us. Some policy provisions are not made known to us until a claim has been submitted and processed.

Please note that at the time of your wellness visit, if you present with sick or acute complaints that are considered outside the scope of the preventive exam, an Office Visit may be charged and a balance may be due from you.

I have read and understand that I may be financially responsible for balances due for those services performed during a preventive exam by Sisselman Medical Group.
Patient Name*

First NameLast Name
DOB*

MonthDayYear
Date
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Rows	Not At All	Several Days	More Than Half The Days	Nearly Every Day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed? Or the opposite – being so dgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better o dead or of hurting yourself in some way

Sisselman Medical Group - Patient Registration Form

Patient Demographics

Emergency Contact

Primary Insurance Information

Sceondary Insurance Information

Employment and Responsible Party

Guarantor/Responsible Party Full Name (if different from patient or if patient is a minor)

Pharmacy Information

Sisselman Medical Group, PC

Please fill out either section I OR section II and sign below:

Section 1

Section 2

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

PARTICIPATING INSURANCE

SERVICE FEE FOR NON-CANCELLATION OF APPOINTMENT

PRESCRIPTION DATABASE CONSENT FORM

APPOINTMENT REMINDERS

TELEHEALTH CONSENT

Patient Medical History

SISSELMAN MEDICAL GROUP, PC CREDIT CARD AUTHORIZATION FORM

Authorization for Access to Patient Information Through a Health Information Exchange Organization

Patient Health Questionnaire (PHQ-9)

Sisselman Medical Group Preventive Physical Exam Policy