Manhattan Pain Medicine, PLLC and its affiliated providers are not contracted with your insurance. We remain out-of-network so that we may provide a higher of level of service for our patients, including shorter wait times, longer appointments, and direct access to the providers.
Insurance policies are complex and we will make every effort to help you understand your benefits and financial responsibilities. Manhattan Pain Medicine, PLLC will submit claims to your insurance on your behalf, and we will accept the amount that your insurance determines is appropriate (the assigned amount). Your financial cost share, depending on co-insurance and/or deductible, may be higher than with a contracted provider. Billed charges are based on the usual and customary rates as published on FairHealthConsumer.org.
Our first goal is to deliver the highest quality and most appropriate care to provide for your best possible recovery. If this ever results in undue financial hardship, please ask us to discuss options for economic hardship.
Patients with insurance plans that reimburse them directly must leave a credit card on file. We will not charge any card without prior notification. Unexcused cancellations within 24 hours, no-shows, and tardiness of 20 minutes incur a $150 fee which is not covered by insurance.
I hereby assign all applicable health insurance benefits and all rights and obligations that I and my dependents have under my health plan to the Provider and the providers representatives (hereinafter, “My Authorized Representatives”) and I appoint them as my authorized representative with the power to:• File medical claims with the health plan• File appeals and grievances with the health plan• Institute any necessary litigation and/or complaints against my health plan NAMING ME AS PLAINTIFF IN SUCH LAWSUITS AND ACTIONS IF NECESSARY (or me as guardian of the patient if the patient is a minor)• Discuss or divulge any of my personal health information or that of my dependents with any third party including the health planI certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated.I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles.
I hereby authorize My Authorized Representatives to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.
I hereby designate, authorize, and convey to My Authorized Representatives to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act as my Authorized Representative in connection with any claim, right, or cause of action including litigation against my health plan (even to name me as a plaintiff in such action) that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act as my Authorized Representative to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. I authorize communication with the Provider and his authorized representatives by email.
A photocopy of this Assignment/Authorization shall be as effective and valid as the original.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
NOTICE OF PRIVACY PRACTICES PURSUANT TO 45 C.F.R. S 164.520
2. YOUR COMPLAINTSYou may complain to us and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. You may file a complaint with us by sending a certified letter addressed to “Privacy Officer” at our current address, stating what Protected Health Information you believe has been used or disclosed improperly. You will not be retaliated against for making a complaint. For further information you may contact our Privacy Officer, at telephone number (646) 580-3538.
3. DESCRIPTION AND EXAMPLES OF USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATIONHere are some examples of how we may use or disclose your Protected Health Information. In connection with treatment, we will, for example, allow a physician associated with us to use your medical history, symptoms, injuries or diseases to treat your current condition. In connection with payment, we will, for example, send your Protected Health Information to your insurer or to a federal program, such as Medicare, that pays for your treatment. This allows us to obtain payment for the services we rendered on your behalf. In connection with health care operations, we will for example, allow our auditors, consultants, or attorney’s access to your Protected Health Information to determine if we billed you accurately for the services we provided to you.
4. USES AND DISCLOSURES WHICH REQUIRE YOUR WRITTEN AUTHORIZATIONUses and disclosures other than those involving treatment, payment, and health care operations, as well as those described in the following sections of this Notice, will only be made by obtaining a written authorization from you. You may revoke this authorization in writing at any time, except to the extent that we have taken action in reliance upon your authorization.
5. USES AND DISCLOSURES NOT REQUIRING YOUR WRITTEN AUTHORIZATIONThe privacy regulations give us the right to use and disclose your Protected Health Information if: (i) You are an inmate in a correctional institution; (ii) we have a direct or indirect treatment relationship with you, (iii) we are so required or authorized by law.The purposes for which might use your Protected Health Information would be to carry out treatment, payment, and health care operations similar to those described in Paragraph I.
6. USES OF PROTECTED HEALTH INFORMATION TO CONTACT YOUWe may use your Protected Health Information to contact you regarding appointment reminders or to contact you with information about treatment alternatives or other health-related benefits and Services that, in our opinion, may be of interest to you. We may use your Protected Health Information to contact you in an effort to raise funds for our operations.
7. DISCLOSURES OF PROTECTED HEALTH INFORMATION FOR BILLING PURPOSESWe may disclose your billing information to any person that calls our billing staff or agents the billing questions after we verify the identity of the person by requesting information such as your social security number or health plan number.
8. DISCLOSURES FOR DIRECTORY AND NOTIFICATION PURPOSESIf you are incapacitated or not present at the time, we may disclose your Protected Health Information (a) for use in a facility directory, (b) to notify family or other appropriate persons your location or condition, and (e) to inform family, friends or caregivers of information relevant to their involvement in your ease or payment for your treatment. If you are present and not incapacitated. we will make the above disclosures, as well as disclose any other information to anyone you have identified, only upon your signed consent, your verbal agreement, or the reasonable belief that you would not object to such disclosure(s).
9. INDIVIDUAL RIGHTS(i) You may request us to restrict the uses and disclosures of your Protected Health Information , but we do not have to agree. (ii) You have the right to request that we communicate with you regarding your Protected Health Information in a confidential manner or Pursuant to an alternative means, such as by a sealed envelope rather than a postcard or by communicating to a specific phone number, or by sending mail to a specific address. We are required to accommodate all reasonable requests in this regard. (iii) You have the right to request that you be allowed to inspect and copy your Protected Health Information as long as it is kept as a designated record set, and as long as you pay in advance for the administrative time and costs hi make arrangements to have the records inspected and copied. Certain records are exempt from inspection and cannot be inspected or copied, so each request will be reviewed in accordance with the standards published in 45 C.F.R S 164.524. (iv) You have the right to amend your Protected Health Information for as long as the Protected Health Information is maintained in the designated record set. We may deny your request for an amendment if the Protected Health Information was not created by us, or is not part of the designated record set, or would not be available for inspection as described under section 45 C.F.R. S 164.524, or if the Protected Health Information is already accurate and complete without regard to the amendment. (v) You have the right to request, and thereafter receive an accounting of the disclosures of your Protected Health Information for six years before the date on which you request the accounting. Exceptions to this accounting are those disclosures not allowed by law pursuant to section 164.528. Each request for an accounting will be reviewed pursuant to the rules of section 164.528. (vi) You also have a right to receive a copy of this Notice upon request.
10. EFFECTIVE DATEThe effective date of this Notice is January 1, 2014.I acknowledge receipt of Manhattan Pain Medicine, PLLC Notice of Privacy Practices.
I am engaging in email communication with my physician realizing that, because there is no way to absolutely secure any electronic exchange of information, the probability of compromise of confidentiality of personal medical information is substantially increased compared to face-to-face information exchange. As such, email communication on personal medical matters should be as limited as possible and reserved for situations not practically allowing for face-to-face communication, but in which the failure to timely inform the patient or their agent on personal medical issues could significantly compromise the patient’s best interests and outcome. No guarantee is made for the timely receipt of email communication, and no guarantee of response is made.
Notwithstanding the above, email communication should, as much as possible, avoid discussion of highly sensitive medical matters that could be, in the event of an information leak, deleterious personally or publicly to the patient and/or their agents. Such topics best avoided are medical disability, sexually transmitted diseases, substance abuse, psychiatric conditions, prognoses (medical outcomes), end-of-life conditions or prognostications, disclosure of demise of an individual, and any other matter that reason could suggest might result in unpredictable emotional distress or reaction in the recipient and possibly lead to behavior harmful to the recipient or others. In a word, remote communicating is a minimally controlled circumstance. Language used should be careful, deliberate, and avoid “emotionally charged” terms.
Email medical communication is a temporary convenience and intervention, not a substitute for proper face-to-face medical encounters. Habitual, ongoing use of email for communicating medical information is discouraged in the best interests of medical professionals and patients and their agents.
By signature, I indicate I have read the above content and policy of my healthcare provider and I agree to abide by the principles and spirit set forth in this document. I further understand the risks and limitations of transmission of medical information communication electronically, and so release from all and any liability my healthcare provider for any unauthorized disclosure or leak of such information inadvertently to parties outside the intended senders and recipients of such communications. I will not hold responsible the sender of medical information by email for any delays in receiving such communications and resulting harm from such delays. I am aware that when communicating from the workplace some companies consider email “at work company property”, and such messages may be monitored and read by the company’s officials. Furthermore, email sent to your home may be intercepted by others. Email sent to your doctor’s office, though directed to a specific individual, may be read by other than the designated recipient since all incoming messages in a medical facility must be reviewed timely, including when a staff member is absent for any reason. Finally, communicating by email always exposes both parties to the risk of computer software virus invasion which can jeopardize and destroy databases and software. By signing this, I release from any liability for damage from computer viruses my healthcare providers and their staff.
I also release my healthcare provider with whom I am communicating voluntarily in medical matters by email from any adverse effects such information has on me or my agents that might have been otherwise avoided or lessened by exchange of such information in face-to-face encounters. Taking all of the above into consideration, I wish to engage in email communications regarding my personal medical information or that for which I am a responsible agent. I have had an opportunity to ask questions on all the aforementioned and provide my consent freely.
Due to the out-of-pocket expense as outlined by your insurance plan, we require that you leave a credit card on file to be charged for services rendered.
Unexcused no-shows, tardiness of more than 20 minutes, and cancellation within 24 hours will be charged at $150 per incident.
This authorization will remain in effect until cancelled. You may cancel this authorization at any time after the services rendered are paid for. The information supplied below will be considered private and confidential and is protected under the Health Insurance Portability and Accountability Act.