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PATIENT REGISTRATION (Academic medical center at State University of New York at Stony Brook)

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BROWSE ACADEMIC MEDICAL CENTER AT STATE UNIVERSITY OF NEW YORK AT STONY BROOK FORMS

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PATIENT REGISTRATION
PATIENT INFORMATION
Name: (Last, First, MI)
Address:
City:
State/Province:
Zip:
Country:
Mailing Address (if different from above):
Home Phone:
Mobile:
Email:
SSN:
Birth Date:
Sex: M □ F □
Marital Status:
Single □
Married □
Divorced □
Separated □
Widowed □
Unknown □
Race:
White □
Hispanic □
Black/African American □
Other Pacific Islander □
Other □
Asian □
Native Hawaiian □
American Indian □
Ethnicity:
Hispanic/Latino □
Not Hispanic/Latino □
Other □
Language:
Contact Preferred:
Home □
Work □
Mobile □
Leave Message: Yes □ No □
Allow Appointment Reminder: If Yes, please choose one method Call □ Text □ No □
Primary Care Physician:
Referring Physician:
Pharmacy Name/Address/Phone:
EMPLOYER INFORMATION
Employer Name:
Phone Number:
Address:
City:
State/Province:
Zip:
Country:
EMERGENCY CONTACT INFORMATION
Name:
Relationship to Patient:
Phone:
Email:
POLICY INFORMATION
Patient is the Insured:
Yes □
No □
(if no complete the Insured fields below)
Insured Name:
Relationship to Patient:
Insured Address:
City:
State:
Zip:
Country:
Insured Home Phone:
Work:
Mobile:
Insured Birth Date:
Insured Sex: M □ F □
Insured SSN:
Insured Employer Name:
Insured Employer Phone Number:
Insured Employer Address:
City:
State:
Zip:
Country:
Primary Insurance
Policy Number:
Insurance Company Group Name:
Effective Date:
Expiration Date:
Policy Copay:
Secondary Insurance
Policy Number:
Insurance Company Group Name:
Effective Date:
Expiration Date:
Policy Copay:
Tertiary Insurance
Policy Number:
Insurance Company Group Name:
Effective Date:
Expiration Date:
Policy Copay:
NOTICE OF PRIVACY PRACTICES
Purpose of this notice: To describe how your medical information is used, whom it is disclosed to and how you gain access to it.
Stony Brook Community Medical as a healthcare provider is permitted by law to collect, use and disclose your “protected health information”
or medical record for the purpose of treatment, payment, internal business operations or as required by law for reporting purposes.
You have certain rights including access to your information and some control over who has access to your information.
Stony Brook Community Medical, PC agrees to abide by the terms of this notice but reserves the right to change the terms at any time. Should
we do so, we will notify you in writing.
Use and Disclosure of Protected Health Information (PHI): When you sign a consent form to be treated, your protected health information is
used to treat you, to bill you or your insurance company for your care and to make decisions on how to provide healthcare services for you,
your family and the community we take care of. Your physician, office staff and others outside of Stony Brook Community Medical i.e. your
insurer are allowed access to this information.
Some examples of uses and disclosures of your protected health information are for:
• Treatment by your doctor
• Reporting health risks
• Law enforcement
• Response to legal proceedings
• Workers compensation
• Organ or tissue donation
• Appointment reminders
• Coroners, funeral directors
• Payment for your treatment by you or your
insurance
• Stony Brook Community Medical to determine if we
meet the needs of our patients
• Reporting adverse events of medication or medical
devices to the FDA
Any other uses and disclosures not specified require an authorization, including for marketing purposes and disclosures that constitutes the
sale of PHI.
Patient Rights:
A. You have the right to inspect and to obtain a copy of your protected health information for as long as the group maintains your record.
*We are permitted by NYS law to charge you a fee of 75 cents per page
B. You have the right to restrict or to limit the use of your protected health information that we use for treatment, payment or operations.
*Stony Brook Community Medical reserves the right to deny you treatment should you restrict the use of your protected health information for treatment,
payment or operations, unless the requested restriction relates to disclosures to a health plan and the Protected Health Information relates to a health care
service or item which you have paid for in full and out of pocket.
C. You can restrict the release of your health information to family or friends unless they have your written or verbal permission.
D. You have the right to request an accounting of disclosures made of your health information.
*Your request must be submitted in writing, specifying dates and time periods as far back as six years from today, as long as the events in question happened
after April 12, 2003.
E. You have the right to amend your protected health information.
*To amend your health information, your request must be given in writing along with a reason for doing so. Your request can be denied if the information
originated outside Stony Brook Community Medical, PC.
F. You have the right to request confidential communications as long as it is done in writing
*For example, you can specify that we only contact you at work, at home or by mail, etc.
G. You have the right to receive notifications whenever a breach of your unsecured PHI occurs.
If you feel your privacy rights have been violated, you may file a complaint, which will be forwarded to our Compliance Officer.
Acknowledgement of Receipt of
Stony Brook Community Medical’s Privacy Practices
I, the undersigned, acknowledge that I have received a copy of Stony Brook Community Medical’s
Notice of Privacy Practices. Should I have any questions about the policy, I will discuss them with
my Physician or the group’s Compliance Officer.
Print Name: ____________________________ Date of Birth: ________________
Signature: ______________________________ Date: ______________________
-------------------------------------------------------------------------------------------------------------------------------
Authorization for the Release of Patient Health Information to a Second Party
I authorize the release of my Patient Health Information to my
(Fill in name(s) of all that apply.)
Spouse, _____________________________________________
Family Member, ______________________________________
Friend, ______________________________________________
School/College Health Services, __________________________
Other, ______________________________________________
By signing below, I acknowledge that this authorization is valid until it is revoked by me.
Patient Signature: ___________________________ Date: ________________
Parent/Guardian Signature (if patient a minor): ________________________________
Print name of Parent/Guardian: ____________________________________________
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G
roup #______________: Patient Name:________________________ MR#:______________ Date:___________
CLINICAL PRACTICE MANAGEMENT PLAN
P
atient’s Name: ___________________________________________________________________________
Last First Middle
RELEASE OF INFORMATION
I hereby authorize and direct Stony Brook Internists, University Faculty Practice Corporations having treated me, to release to
governmental agencies, insurance carriers, or others who are financially liable for my medical care, all information needed to
substantiate payment for such medical care and to permit representatives thereof to examine and make copies of all records
relating to such care and treatment.
X
_______________________________________________________________ ___________________________
Signature of Patient or Authorized Representative Date
UNIFORM ASSIGNMENT
I
hereby assign, transfer and set over to Stony Brook Internists, University Faculty Practice Corporations sufficient monies and/or
benefits to which I may be entitled from governmental agencies, insurance carriers, or others who are financially liable for my medical
care, to cover the cost of care and treatment rendered to myself or my dependent.
In
addition, I also assign, transfer and set over to all of the other University Faculty Practice Corporations from which I may require
medical care, sufficient monies and/or benefits to which I may be entitled. These other University Faculty Practice Corporations are as
follows: Stony Brook Anaesthesiology, Stony Brook Dermatology, Stony Brook Family Medical Group, Stony Brook Internists, New
York Spine and Brain Surgery, Neurology Associates of Stony Brook, University Associates of Obstetrics and Gynecology, Stony Brook
Preventative Medicine Services, Stony Brook Ophthalmology, Stony Brook Orthopaedic Associates., Stony Brook Children’s Services,
Stony Brook Psychiatric Associates., Stony Brook Radiation Oncology, Stony Brook Radiology, Stony Brook Surgical Associates,
and Stony Brook Urology.
X
_______________________________________________________________ ___________________________
Signature of Patient or Authorized Representative Date
A
ccount Representative: _____________________________________
PA
6a
(4/13-eb)
G
roup #:__________ Name:________________________ MR#:____________ Date:___________
Stony Brook Internists
P.O. Box 417978
Boston, MA 02241-7978
GUARANTEE OF PAYMENT
Many insurance companies, including managed care organizations, require prior written
authorization for treatment and follow-up visits. It is your responsibility as a patient to obtain all
necessary authorizations from your insurance company prior to receiving medical services. If you
have not received prior approval for the service or authorization has been denied, you are fully
responsible for all charges if your insurance company does not agree to pay. In addition, you will
be responsible for all deductibles, co-insurance, co-payments, any service that is not covered by
your insurance plan, and any service that your insurance company has determined not to be
“medically necessary”.
I have read and understand this information. I understand that my insurance company may deny
coverage and request that Stony Brook Internists perform this medical service anyway. I agree
to be personally and fully responsible for all charges. I understand that the provider named above
is relying on this promise and is rendering services without requiring payment at the time of service
based on such reliance.
____
_____________________________ __________________________ ___________________
Signature of Patient or Print Name Date
Legally Authorized
Representative
____________________________
__ _______________________ ________________
Witness Print Name Date
MCGOP 3/14
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PATIENT REGISTRATION (Academic medical center at State University of New York at Stony Brook)

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Completed 27 August 2020

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