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Includes insurance authorization and assignment language for Medicare/other insurers, laboratory billing authorization options, and acknowledgement of privacy practices under HIPAA. The document specifies how protected health information may be used or disclosed for treatment, payment, and health care operations, and lists effective-date and contact information for the privacy 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insurers for related claims.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the LABORATORY TESTING section affect billing for lab services?",{"text":118,"@type":110},"Patients must choose whether the laboratory may bill their insurance or whether billing goes directly to the patient; the choice determines who is responsible for payment of lab 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PATIENT INFORMATION                                \n\nAge:        \nBirth Date:            \n                                  SS\\#:               \nName:  \nMI  \nFirst  \n[]Divorced  \n[]Widowed  \nMarital Status:[]Single []Married  \nSex:_          \n[]Non-Hispanic  \nEthnicity:[]Hispanic  \nRace:[]White[]Asian:_                    _________(Specify,if known-e.g.,Chinese)[jBlackIAfrican American[]Natlve Hawailan or Pacific Islander[jAmerican Indian or Alaskan Native[jOther:_         (Please describe)  \nWork Phone (r cJ  \nPhone(co  __    -_—  \n\n| Address:  \u003Cbr>Street   |  | Zp  \u003Cbr>State  \u003Cbr>City   |  |\n| --- | --- | --- | --- |\n| Nam—  \u003Cbr>Emergency Contact Person:   |  | Rolatuonship  \u003Cbr>Phone   |  |\n| Patient's Employer:____   |  | Occupation::   |  |\n| Employer's Address:  \u003Cbr>street   |  | Stale  \u003Cbr>Zp  \u003Cbr>cClly   |  |\n\nAll professional services are charged to the patient.Necessary forms will be completed to help expedite insurance carrier payments.Please be advised that we will submit to your primary and secondary.Any remaining balance afer receipt of explanation of benefits fromyour primary and secondary insurance carrier willbe billed to you.  \n# INSURANCE AUTHORIZATION AND ASSIGNMENT                     \n\nNAME OF POLICY HOLDER:                                                                                \nIrequest that payment of authorized Medicarel other insurance company benefits be made either to me on my behalf or to the DigestiveHeaith Center of Huntington for any services furnished me by that third party who accepts assignment/physician.Regulations pertainingto Medicare assignment of benefits apply.  \nI authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care FinancingAdministration or Its intermediaries or carriers and information needed for this or a related Medicare claim/other nsurance companyclaim.I permit a copy of this authorization to be used inplace of the original,and request payment of medical insurance benefits either tomyself or to the party who accepts assignment.I understand it is mandatory to notify the health care provider of any other party who maybe responsible for paying for my treatment.(Section1128B of the Social Security Act and 31 U.S.C 3801-3812 provides penalties forwithholding this information).  \nSlgnature ofPatlent or Responsible Party  \nDate  \nLABORATORY TESTING                                    \nDuring the course of your procedureit may be necessary for your physician to obtain and send tisue samples,blood samples,or requestother laboratory testing.The State of New York now requires clinical laboratories to directly bill patients for their testing services,or thatperson's legal representative.Therefore,it is necessary for the Digestive Health Center of Huntington to receive authorization from thepatient in order for us to allow the laboratory to bill your insurance company for you.If you do not want the laboratory to bill yourinsurance company,then billing for the services will go directly to you as the patient.Please complete and sign below so that we may direct this issue in the proper manner.Thank you for your cooperation with this matter.  \n[]Yes,I am giving the laboratory permission to bill my insurance company.  \n[]No,I do not give the laboratory permission tobill my insurance company.I am aware that lam responsible for payment ofservices directly to the laboratory  \nDigestive Health Center of Huntington,Inc.  \nTHIS NOTICE DESCRIBES HOW MEDICALINFORMATOINABOUT YOU MAY BE USED ANDDISCLOSED AND HOWYOU CAN GET ACCESS TO THIS INFORMATION,PLEASE REVIEW ITCAREFULLY  \nEffective April 14,2003  \nThe privacy of your medical information is important to us.You may be aware that U.S.government regulatorsestablished privacy rule(\"HIPAA\")governing protected health information.This notice tells you about how ","cbCaivOOApQJPwEj","https://ap.wps.com/l/cbCaivOOApQJPwEj","pdf",6357255,"English","# PATIENT INFORMATION\n## INSURANCE AUTHORIZATION AND ASSIGNMENT\n## LABORATORY TESTING\n# NOTICE OF PRIVACY PRACTICES (HIPAA)\n## Effective April 14, 2003","[{\"question\":\"What information is requested in the PATIENT INFORMATION section?\",\"answer\":\"The form requests age, birth date, SS#, name and initials, marital status, sex, ethnicity, race, work/phone contacts, address, emergency contact details, and employer/occupation information.\"},{\"question\":\"What does the INSURANCE AUTHORIZATION AND ASSIGNMENT section allow?\",\"answer\":\"It authorizes payment of authorized benefits for Medicare or other insurance to the patient or the Digestive Health Center of Huntington and allows release of necessary medical information to government agencies and insurers for related claims.\"},{\"question\":\"How does the LABORATORY TESTING section affect billing for lab services?\",\"answer\":\"Patients must choose whether the laboratory may bill their insurance or whether billing goes directly to the patient; the choice determines who is responsible for payment of lab services.\"}]","DHC-Registration-Forms-rev-202006 | PDF"]