MMP New Patient Form

Dear Patient:
Enclosed please find an information packet consisting of a welcome registration form, health history questionnaires, notice of our privacy practices, privacy practice acknowledgment form, authorization form to leave messages, and financial agreements. Please review and complete these forms. Please bring this packet with you to your initial evaluation appointment. Bringing these forms will allow you to save time on your appointment day.

There are a few things to remember when coming to your appointment. Please bring your insurance card(s), driver’s license (or any photo identification), a script from your referring physician, tests or x-rays / reports that you have in your possession, and a list of your current medications.

A special note to patients, it is the policy of Premier Med Group that acceptance of a patient for an initial evaluation does not in any way constitute an obligation to continue any previously prescribed treatments meant for the treatment of pain. If you are concerned about this, please make sure that your current physician discusses your case ahead of time with Dr. Das.

We appreciate your time in completing these forms. If possible return these forms prior to your appointment date. It will cut down the waiting time the day of your appointment. If not please bring them with you the day of your initial appointment. We look forward to seeing you.

Your appointment is scheduled for _________________ at ____________ AM / PM. If you cannot make this appointment, please contact the office at least 24 hours in advance. Please review the Cancellation Policy. Call our office for directions.

With kind regards,
The Staff at Premier Med Group
Office# (908)904-1900
Fax# (908)-904-1908

Thank you for choosing us as your Pain Management provider. We are committed to providing you with quality and affordable healthcare. Because some of our patients may have questions regarding patient and insurance responsibility for services rendered, we have developed this payment policy. Please read it, ask us any questions you may have and sign in the space provided. A copy of this policy can be provided to you upon request.

1. Insurance Plans. We are participating providers with Medicare, Cigna, and Horizon. If you are not insured by a plan we do business with, payment in full is expected at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions that you may have regarding your coverage.
2. Co-payments. All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company. Please help us in upholding your agreement by paying your co-payment at each visit.
3. Non-covered Services. Please be aware that some of the services you receive may be non-covered or not considered necessary by your insurance, even though your physician feels that it is essential to your care. If they decide not to pay for a service, then we ask that you submit payment for that item.
4. Claims Submission. If we participate with your insurance carrier, we will submit your claim and assist you in any way to help get your claims paid.
5. Coverage Changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. We will also need to have a copy of your new insurance card.
6. Non-Payment. If your account is over 60 days past due, you will received a letter from our billing department. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid we will refer your account to collection.
7. Medicinal Marijuana Program Administration Fee. A flat fee will be charged for administration involved in qualifying the patient for the program. This fee includes registering patient/caregivers, verifying and uploading the documentation and patient/caregivers pictures.

Our practice is committed to providing the best treatment to our patients. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.

Medicare

I request the payment of authorized Medicare insurance benefits to be made on my behalf to Premier Med Group. I authorize Premier Med Group to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits payable.

I understand my signature requests that payment be made and authorizes the release of medical information necessary to pay the claims. Premier Med Group agrees to accept the charge determination of the CMS or its agents as the full charge. The patient is responsible for the deductible, co-insurance and non-covered services. Co-insurance and deductible are based upon the charge determination of CMS or its agent.

Medicare Supplemental/Coordination Of Benfits

Insurance

I request that payment of authorized insurance benefits be made on my behalf to Premier Med Group for any services furnished to me by Dr. Vivek T. Das. I authorize release of any medical information deemed necessary to determine these benefits payable.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the claim form is completed, my signature authorizes releasing of the information to the same insurance company(ies) or its agents.

Premier Med Group agrees to accept the contracted fee schedule with those insurance companies with which Premier Med Group holds a current contract. The patient is responsible for all deductibles, co-insurance, and non-covered services. If we do not participate with your insurance, the patient is responsible for all deductibles, co-insurance, and non-covered services.

It is the patient’s responsibility to check with their insurance as to benefits and covered services. Insurance coverage is a contract between the insured (Patient) and the insurance company.

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.

Your health information is contained in a medical record maintained by PREMIER MED GROUP, which medical record is the physical property of PREMIER MED GROUP.

PREMIER MED GROUP uses and/or discloses your health information to carry out your treatment, to obtain payment for such treatment, for health care operations and for other purposes either permitted or required by law. This Notice of Privacy describes how we may use and/or disclose your health information in connection with providing you with medical treatment or services and describes your rights to obtain access to your health information.

HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

Following Uses and Disclosures Do Not Require Your Authorization

For Treatment – We will use and/or disclose your health information to provide you with medical treatment and related services, including coordination or management of your care with a third party that is also involved in your treatment. For example, we may disclose your health information to another health care provider, such as a specialist to whom you are referred by your physician, or to a laboratory performing tests related to your medical care.

For Payment – We will use and/or disclose your health information to others, as necessary, to obtain payment for the treatment or services you receive. For example, a bill, containing information that both identifies you and your diagnosis or treatment, may be sent to you or directly to your insurance company, health plan or other third-party payer. We may also use your health information for the purpose of determining your eligibility or coverage under a certain health plan.

For Health Care Operations – We may also use and/or disclose your health information as necessary to run our business operations and to support the core functions of treatment and payment. These activities include: quality assessment and improvement activities; employee evaluation activities; conducting medical review; legal and auditing services; business planning and development activities; and business management and general administrative activities. We will share your health information, as necessary, with certain “business associates” that provide certain services on our behalf, such as billing or transcription services. Whenever we have an arrangement with a “business associate” involving your health information, we will have that party execute a written contract containing terms that will protect the privacy of your health information.

As Required by Law – We may use and/or disclose your health information as and to the extent required to comply with applicable law. PREMIER MED GROUP may, for example, disclose information in the course of a judicial or administrative proceeding in response to a court order, subpoena or other lawful process, or may be required in certain instances to report certain information to law enforcement officials or other governmental authorities.

Public Health Activities – We may use and/or disclose your health information for public health activity purposes to a public health agency that is permitted to collect such information for the purpose of controlling disease, injury, disability or other health oversight activities.

Disclosure to Coroners, Funeral Directors and for Organ Donations – We may disclose your health information to a coroner or medical examiner for identification purposes, to ascertain the cause of death or to carry out other purposes authorized by law. PREMIER MED GROUP may also disclose health information to a funeral director, as authorized by law, to permit the funeral director to perform his/her duties. Further, protected information may be used for organ, eye or tissue donation and transplant purposes.

Research – We may disclose your health information to researchers when the institutional review board that has reviewed the research proposal has established protocols to ensure the privacy of your health information.

Workers Compensation – We may use and/or disclose your health information in order to comply with applicable laws and regulations related to Workers Compensation.

Appointment Reminders and Miscellaneous Other Uses – PREMIER MED GROUP may also use your health information to provide appointment reminders, or to send you materials with respect to treatment alternatives or other health-related information that may be of interest to you.

PATIENT’S HEALTH INFORMATION RIGHTS

• You have the right to inspect and copy your health record. (However, federal and/or state laws may prohibit inspection of certain records, such as psychotherapy notes.)
• You have the right to request a restriction on certain uses and disclosures of your information. However, PREMIER MED GROUP is not obliged to agree to the requested restriction.
• You have the right to request communications of your health information by alternative means or at alternative locations. (We will accommodate reasonable requests made, in writing, to our Privacy Officer.)
• You may have the right to have your physician amend your health information. (You may request an amendment, and in certain cases we may deny your request, in which event, you may file a statement of disagreement and we may opt to prepare a rebuttal thereto, in which case, we will provide you with a copy of such rebuttal.)
• You have a right to revoke your authorization to use or disclose your health information, except to the extent that action has already been taken.
• You have the right to receive an accounting of certain disclosures of protected health information we have made. (This right pertains to disclosures made after April 14, 2003 and does not include disclosures made for treatment, payment or operation purposes or as covered by other restrictions, exceptions or limitations set forth in federal regulations at 45 CFR Section 164.58.)
• You have the right to obtain a paper copy of this Notice from us upon request.

COMPLAINTS

You may complain to PREMIER MED GROUP and/or to the Department of Health and Human Services if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint. You may file a complaint with us by notifying our management, whose number and address is set forth below:

Phone: (908)-904-1900
Practice Name: Premier Med Group
Address: 501 Omni Drive, Hillsborough, NJ 08844

You may also contact us if you have any questions concerning our policies or your health information.

OUR RESPONSIBILITIES
PREMIER MED GROUP is legally responsible to:

• protect the privacy of your health information
• provide you with this Notice of its duties and practices
• comply with the terms of this Notice
• obtain your written authorization to use and/or disclose your information for reasons other than those listed above or permitted by law.

MODIFICATION OF PRIVACY NOTICE
PREMIER MED GROUP reserves the right to change its information practices and make new provisions effective for all protected health information it maintains. Any modification shall have prospective application, but will apply to health records made both before and after the effective date of the policy modification. Revised Notices will be made available to all then current patients and posted in a prominent location within our office. We will also mail copies to any current or former patient who has advised us, in writing, that they want us to mail them copies.

ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of the Notice of Privacy Practices of the Office of Dr. Vivek T. Das, Premier Med Group. Our Notice of Privacy Practices provides information as to how we may use and disclose your protected health information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting us at (908)-904-1900. If you have any questions about our Notice of Privacy Practices of the Office of Dr. Vivek T. Das, Premier Med Group please contact the office.

INABILITY TO OBTAIN ACKNOWLEDGEMENT

To be completed only if no signature is obtained. If it is not possible to obtain the individual’s acknowledgement, describe the good faith efforts made to obtain the individual’s acknowledgement, and the reasons why the acknowledgement was not obtained: