BARRY H. KAPLAN, MD PH.D JAVIER A. ROCA, MD MALVINA FULMAN, MD LIHONG WEI, MD

PHYSICIAN (Check One)

GABRIEL H. JUNG, MD AVRAM L. ABRAMOWITZ, MD ABHISEK SWAIKA, MD PAVEL GROYSMAN, DO

Patient Registration Form

PREFERRED LANGUAGE English Spanish Korean Chinese Russian

PATIENT INFO Last Name First Name Address Apt# City State Zip Code Date of Birth / /

Sex [ ] Male [ ] Female

SS# - -

Marital Status S M W SEP D

PREFERRED MODE OF CONTACT (CHECK ONE)

Home Phone ( ) -

Cell Phone ( ) -

Work Phone ( ) -

Email Address: REFERRING PHYSICIAN

Referring Physician Name:

Address

City State Zip Code

Tel ( ) - Fax ( ) -

PRIMARY CARE PHYSICIAN Primary Care Physician Name:

Address

City State Zip Code

Tel ( ) - Fax ( ) -

PRIMARY INSURANCE CARD HOLDER Name

Date of Birth / /

SS# - -

Relation to patient

Status: [ ] Employed [ ] Retired [ ] Other Employer Name Tel ( ) -

Address

City State Zip Code

EMERGENCY CONTACT INFO Emergency Contact Info No Emergency Contact Available

Tel ( ) - Relationship

Emergency Contact Info

Tel ( ) - Relationship

PREFERRED PHARMACY NAME

TEL ( )

-

FAX (

) - ADDRESS

CITY STATE ZIP CODE

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFIT

I hereby assign to Queens Medical Associates, PC any and all payment or benefits for any services provided to me. I understand that Queens Medical Associates, PC has the right to refuse or accept assignment of such benefits. If the benefits are not assigned to Queens Medical Associates, PC. I agree to forward any and all insurance and third party payments that I may receive to Queens Medical Associates, PC immediately upon receipt.

I hereby certify that I have completed and answered all information requested above to the best of my knowledge, and that all information I provided is correct.

SIGNATURE DATE / /

New Patient Intake Form

Patient Name: D.O.B:

Medication History:

Drug When Did you

Start taking this What dosage were

you prescribed

How often do you take the medication

Ordering

Physician

Allergy Reaction

Are you allergic to: ❑ Iodine ❑ Latex ❑ Shellfish ❑ CT Scan Dye / IV Contrast ❑ Eggs ❑ Peanuts

Have you had any surgery? No

Yes (Please complete the chart below)

Surgery Date Outcome

Have you been hospitalized in the last 30 days? No

Yes Date: __________ Reason: ________________________________________________________

Patient Name: ________________________________________________ DOB: ________________

Have you been in a Clinical Trial? No

Yes Date: __________ Reason: ________________________________________________________

Past Medical History

❑ None

❑ Anemia

❑ Anxiety

❑ Asthma

❑ Atrial Fibrillation

❑ Bleeding Disorder

❑ Blood Clots

❑ Blood Disorder

❑ Cancer

❑ Chronic back pain

❑ Chronic Lung (COPD)

❑ Cirrhosis of Liver

❑ Colon Polyps

❑ Congestive Heart Failure

❑ Crohn’s Disease

❑ Depression

❑ Diabetes

❑ Diverticulitis

❑ Drug Use

❑ Enlarged prostate

❑ Fracture

❑ Freq. Urinary Tract Infections

❑ Frequent Infections

❑ Gallstones

❑ GERD/Heartburn

❑ Glaucoma/Cataracts

❑ Hearing Loss

❑ Heart Attack-MI

❑ Heart Disease

❑ Heart Murmur

❑ Heartburn/Reflux

❑ Hepatitis A/ B/ C

❑ Hiatal Hernia

❑ High Blood Pressure

❑ High Cholesterol

❑ Irregular Heart Beat

❑ Irritable Bowel Syndrome

❑ Kidney Disease/Failure

❑ Kidney Stone

❑ Leukemia

❑ Lupus-Autoimmune

❑ Lymphoma

❑ Migraines

❑ Neuropathy

❑ Osteoarthritis

❑ Osteoporosis

❑ Pancreatitis

❑ Paralysis

❑ Parkinson’s Disease

❑ Peripheral Vascular Disease

❑ Pneumonia/Bronchitis

❑ Problems with Anesthesia

❑ Reynaud’s Syndrome

❑ Rheumatic Fever

❑ Rheumatoid Arthritis

❑ Seizures

❑ Shingles

❑ Sleep Apnea

❑ Stomach Ulcers

❑ Stroke

❑ TB (Tuberculosis)

❑ Thyroid Disease

❑ Ulcerative Colitis Other Medical History: ______________________________________________________

Routine Cancer Screening:

Colonoscopy: Never Date of Last _______________ Doctor's Name _______________

Endoscopy: Never Date of Last _______________ Doctor's Name _______________

Mammogram: Never Date of Last _______________ Doctor's Name _______________

Pap smear: Never Date of Last _______________ Doctor's Name _______________

Menstrual Period

Age of first Menstrual period _____ Regular Periods Irregular Periods

Light Regular Heavy Last Menstrual Period ___________________

Patient Name: ________________________________________________ DOB: ________________

Hormone Supplementation

Current Former Never Type: ___________________________________________

Oral Contraceptive

Current Former Never Type: ___________________________________________

Other Contraceptive

Current Former Never Type: ___________________________________________ Maternity: ________Number of Pregnancies ________ Number of Births

Tobacco History

Non-smoker

Current Every Day Smoker

Current Someday Smoker

Heavy Tobacco Smoker

Light Tobacco Smoker

Former Smoker `

Type: Pipe Chewing Tobacco Cigarette

Number of Years Use ________

Alcohol Use (Present and/or Past)

❑ Non Drinker

❑ Beer number of bottles _________per ❑ Day ❑ Week ❑ Month

❑ Wine number of glasses _________per ❑ Day ❑ Week ❑ Month

❑ Liquor number of glasses _________per ❑ Day ❑ Week ❑ Month

Patient Name: ________________________________________________ DOB: ________________

Social History

Marital Status: Never Married Partnered Married Separated Divorced Widowed

Children: No Children Number of Children ____

Occupation: Never Employed Current: _________________ Former: _________________

Secondary Occupation: __________________

Family History

Mother: Alive (Age): ____ Deceased (Age): ____ Cause of Death: ________________

Father: Alive (Age): ____ Deceased (Age): ____ Cause of Death: __________________

Sibling Deceased

Age Cause of Death

Family Cancer History

Relative Sex Date Diagnosed Cancer Type Age when Diagnosed Status

Patient Signature: _____________________________________________ Date: _________________

Consent for Medical Treatment (All patients must sign)

I, ________________________________________, hereby voluntarily authorize ________ ________________ M.D.,

such assistant(s) as he/she may designate and other medical staff and personnel of Queens Medical Associates, PC to

provide care including any examinations, routine diagnostic tests, therapeutic procedure(s) and treatments which are

necessary for my care, and obtain pathology slides and/or tissue blocks. I further agree to allow the research

department to confidentially review my records.

I have read this consent and certify that I understand its contents.

PLEASE BE AWARE THAT PREGNANCY IS NOT ADVISIBLE

DURING ANY COURSE OF TREATMENTS.

___________________________________ _______/_______/_________ Signature of Patient Date

Or

______________________________________ ________________________________

Signature of Person Authorized to Relationship to Patient

Consent for Patient

_________________________________________ _______/_______/_________ Signature of Witness Date

176-60 Union Turnpike Ste. 360 Fresh Meadows, New York 11366

Tel. 718-460-2300 Fax 718-460-9697

Revised: 01/31/11 1

Revised: 10/17/17

NOTICE:

Queens Medical Associates Oral Oncology Department (OOD)

We are pleased to notify you about our Oral Oncology Department. You may be able to fill your medications prescribed

by our doctors at your convenience. Please feel free to ask our staff for more information.

Please note we may bill your pharmacy insurance for some portions of your treatment. You may receive notification from

your prescription plan. If you have any questions or concerns please feel free to call our pharmacist (718-312-3460, 1-

877-724-6718) or financial counselor (718-460-2300).

Frequently Asked Questions:

How to place a prescription order:

Call the main phone number at 718 460-2300 and ask to speak to your physician’s secretary.

How to obtain a refill:

Call the department directly at 877-724-6718 and speak to any department representative.

How to access medications in case of an emergency or disaster:

Call the main phone number at 718-460-2300. If no one answers the phone, listen to the messages for instructions. If there is

no phone service call 911 for all emergencies. If it is not an emergency and you are out of medication bring your medication

bottle(s) to a walk-in clinic or to another physician’s office.

How to check on a prescription status:

Call the Oral Oncology Department directly at 877-724-6718 and speak to any of our representatives.

Information on prescription substitutions:

Call the Oral Oncology Department directly at 877-724-6718 and ask to speak to one of our friendly pharmacists.

How to transfer a prescription to another pharmacy:

Go to the new pharmacy with your prescription bottle and ask the pharmacy to have the prescription transferred to them. You

may also call the main phone number at 718-460-2300 and ask to speak to your physician’s secretary.

How to obtain medications not available at the Oral Oncology Department:

A staff member will e-prescribe the prescription to your local pharmacy. If there is a special requirement, a staff member will

forward the prescription to the appropriate specialty pharmacy.

How to handle medication recalls:

Call the pharmacy or Oral Oncology Department, which dispensed the recalled medication and ask for instructions.

How to dispose of medications:

We are able to dispose of any of your medications. Please bring any portion of medication into our office and we can dispose

of them safely. If you have any questions, please call the Oral Oncology Department at 1-718-312-3460 or 1-877-724-6718.

How to handle adverse reactions:

In case of an emergency, call 911. If not an emergency, contact the Oral Oncology Department at 877-724-6718 or your

physician’s office at 718-460-2300.

How to handle a missed delivery of medication:

Please call the department directly at 877-724-6718 for further information. In case of medical emergencies, please call 911.

Information for inclement weather:

Please call our main phone number at 718-460-2300 for any office closures.

How to report concerns or errors:

Call the Oral Oncology Department directly at 877-724-6718 and ask to speak to a pharmacist. If the department is

unavailable, call the main phone number at 718-460-2300. If unable to contact the Oral Oncology Department or physician

and it is a medical emergency, call 911.

How to report any complaints/grievances:

Call the Oral Oncology Department directly at 877-724-6718 and ask to speak to a pharmacist. You also may report a

complaint to New York’s Professional Complaint Hotline at 1-800-442-8106 or conduct@nysed.gov or contact our

accreditation agency, Accreditation Commission for Healthcare (ACHC) at 1-919-785-1214.

AUTHORIZATIONS FOR USE OR

DISCLOSURE OF INFORMATION (HIPAA)

Section A: Must be completed for all authorization

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand

that this authorization is voluntary and that, except for research-related treatment, I cannot be denied treatment solely because

I refuse to sign this authorization. I understand that if the organization authorized to receive the information is not a health

plan or health care provider; the released information may no longer be protected by federal privacy regulations.

Patient Name:______________________________________ DOB:______________________

Party providing information:

Queens Medical Associates

Party using or receiving information: Family members: ___________________________________

___ New York Hospital of Queens ___ Flushing Hospital ___________________________________

___________________________________

___ Mt Sinai Hospital of Queens ___ North Shore LIJ ___________________________________

__________________________________________________________________________________________________

Specific description of information (including dates) if relevant:

____________________________________________________________________________________________________

_______________________________________ Disclosure may include HIV related medical information (initial___)

Description of each purpose of authorized use or disclosure:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

In addition for any other purpose for use or disclosure of my individually identifiable health information which I may

authorize, I hereby authorize Queens medical associates to disclose my individually identifiable health information to New

York Hospital Queens Cancer Center, including any healthcare providers participating in the New York Hospital Queens

Cancer Center such as radiation oncologists maintaining the Tumor Board on behalf of the New York Hospital Queens

Cancer Center, in each case for any lawful purpose.

(Note: At the request of [patients Name] is sufficient when patient initiates authorization and elects not to provide a more

detailed statement of purpose.)

This authorization will expire on ____/____/____ (DD/MM/YY) or on the occurrence of the following

event:_____________________________________________________________

Revocation

This authorization may be revoked at any time by notifying Queens Medical Associates in writing at 176-60 Union Turnpike

Suite 360, Fresh Meadows, NY 11366. If I revoke this authorization, I understand that it will not have any effect on actions

of Queens Medical Associates took before receiving the revocation.

_____________________________________ ________________________

Signature of Patient Date

Printed name of

Patients representative_________________________________________ Relation to patient:______________________

Witness:_______________________________________ Date:__________________________

This form must be updated annually.

List of Specialist

Please provide name of your physicians that you are currently being followed.

Radiation Oncology _____________________ M.D

Cardiology ______________________ M.D

GYN or OBGYN ______________________ M.D

Surgeon ______________________ M.D

Hepatology ______________________ M.D

Orthopedic ______________________ M.D

Gastroenterology ______________________ M.D

Endocrinology ______________________ M.D

Neurology ______________________ M.D

Urology _______________________ M.D

Infectious Diseases _______________________ M.D

QUEENS MEDICAL ASSOCIATES NOTICE OF PRIVACY PRACTICES

Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS

INFORMATION

PLEASE REVIEW IT CAREFULLY

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your

medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you, with certain exception. Your request must be in writing.

• You will have the opportunity to view your medical record in our facilities within 10 days of your request. We will provide a copy of your medical record, usually within 14 days of your request. We may charge a reasonable, cost-based fee up to 75 cents per page. We may not, however, refuse to give you access to your record solely because of your inability to pay.

Ask us to correct your • You can ask us to correct health information about you that you think is medical record incorrect or incomplete. Please ask us how to request this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say “yes” to all reasonable requests.

continued on next page

Notice of Privacy Practices • Page 1

Your Rights

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our business operations. • We are not required to agree to your request, and we may say “no” if

it would affect your care. • If you pay for a service or health care item out-of-pocket in full, you can ask

us not to share that information for the purpose of payment or our operations with your health insurer. • We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include in the list all the disclosures we have made except those we made for purposes of treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this • You can ask for a paper copy of this notice at any time, even if you have privacy notice agreed to receive the notice electronically. We will provide you with a

paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information at the bottom of this notice.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

Notice of Privacy Practices • Page 2

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we cannot share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of • We may contact you for fundraising efforts, but you can tell us not to contact fundraising: you again.

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you We can use your health information and share Example: Another doctor it with other professionals who are treating treating you for an injury asks you, such as nurses, lab technicians, dieticians, us about your overall health or your pharmacy. condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

continued on next page

Notice of Privacy Practices • Page 3

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as: • Preventing disease • Helping with product recalls • Reporting adverse reactions to medications • Reporting suspected abuse, neglect, or domestic violence • Preventing or reducing a serious threat to anyone’s health or

Do research We can use or share your information for health research.

Comply with the law We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ We can share health information about you with organ procurement and tissue donation organizations. requests

Work with a medical We can share health information with a coroner, medical examiner, examiner or funeral or funeral director when an individual dies. director

Address workers’ compensation, law enforcement, and other government requests

• We can use or share health information about you: • For workers’ compensation claims • For law enforcement purposes or with a law enforcement official • With health oversight agencies for activities authorized by law • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits We can share health information about you in response to a court or and legal actions administrative order, or in response to a subpoena.

SPECIAL RULES REGARDING DISCLOSURE OF PSYCHIATRIC, SUBSTANCE ABUSE AND HIV-RELATED INFORMATION.

For disclosures concerning health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment, special restrictions may apply. In general, health information relating to care for psychiatric conditions, substance abuse or HIV-related testing and treatment may not be disclosed without your permission or a court order. There are some exceptions, including the following:

HIV-RELATED INFORMATION. HIV-related information may be disclosed in the following circumstances: for purposes of treatment or payment; in connection with foster care or the adoption of a child; to an employee or agent of the New York State Division of Parole or Division of Probation or the Commission of Correction; in the case of a minor, to a parent or legally appointed guardian or committed that exercises rights on behalf of the child; or when required by law. SUBSTANCE ABUSE TREATMENT. If you are treated in a specialized substance abuse program, your written permission will be needed for most disclosures, not including emergencies.

Notice of Privacy Practices • Page 4

• We are required by law to maintain the privacy and security of your protected health information. • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your

information. • We must follow the duties and privacy practices described in this notice and give you a copy of it. • We will not use or share your information other than as described here unless you tell us we can in writing. If

you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

In addition to your rights related to your health information, you have a number of rights related to the care you receive and the services we provide:

• Be fully informed in advance about care/service to be provided, including the disciplines that furnish care and the frequency of visits, as well as any modifications to the plan of care

• Be informed, both orally and in writing, in advance of care being provided, of the charges, including payment for care/service expected from third parties and any charges for which the client/patient will be responsible

• Receive information about the scope of services that the organization will provide and specific limitations on those services

• Participate in the development and periodic revision of the plan of care • Refuse care or treatment after the consequences of refusing care or treatment are fully presented • Be informed of client/patient rights under state law to formulate an Advanced Directive, if applicable • Have one's property and person treated with respect, consideration, and recognition of client/patient

dignity and individuality • Be able to identify visiting personnel members through proper identification • Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of

unknown source, and misappropriation of client/patient property • Voice grievances/complaints regarding treatment or care or lack of respect of property, or recommend

changes in policy, personnel, or care/service without restraint, interference, coercion, discrimination, or reprisal

• Have grievances/complaints regarding treatment or care that is (or fails to be) furnished, or lack of respect of property investigated

• Confidentiality and privacy of all information contained in the client/patient record and of Protected Health Information (PHI)

• Be advised on the agency's policies and procedures regarding the disclosure of clinical records • Choose a healthcare provider, including choosing an attending physician, if applicable • Receive appropriate care without discrimination in accordance with physician’s orders, if applicable • Be informed of any financial benefits when referred to an organization • Be fully informed of one's responsibilities

In addition to these rights, you have several responsibilities related to your care:

• You must submit any forms that are necessary to receive services. • You must provide accurate medical and contact information and any changes to that information. • You must notify your treating provider of your participation in the services we offer. • You are responsible for maintaining any equipment provided.

Please notify us related to any concerns about the care or services you receive from us. Notice of Privacy Practices • Page 5

Additional Rights and Responsibilities

Changes to the Terms of This Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site, www.queensmedical.com

Contacting Us If you have any questions about this Notice or would like further information about our privacy practices, please contact the Q.M.A. Privacy Officer at (718) 460-2300, or by e-mail at sjoarder@queensmedical.com

Notice of Privacy Practices • Page 6

Patient Financial Policy P a g e | 1

Patient Financial Policy

Queens Medical Associates has formulated this financial policy that clearly outlines patient and practice financial responsibilities. We are committed to providing our patients with the best care and minimizing administrative costs. This financial policy has been established to avoid any misunderstanding or disagreement concerning payment for professional services. Patient Financial Policies:

Queens Medical Associates is available to all persons. However, all patients must accept responsibility for payment.

Patients are required to present a valid insurance card and a driver’s license or picture id upon request at check-in and as needed throughout their care.

Please notify us if your insurance carrier or policy has changed.

If medical care is rendered without the appropriate pre-requisites or inaccurate insurance information is presented at the time of the visit, you agree to assume financial responsibility for those services and you may be charged a re-billing fee.

Your Co-Pay:

If your insurance requires a co-pay, we are required to collect it. Please pay your co-pay when you check in.

We may reschedule your appointment if your co-pay is not paid at time of service Commercial Insurance Carriers:

If you have a health insurance policy in which we participate our billing office will submit a claim for services rendered. All necessary insurance information, including special forms, must be completed by you prior to leaving the office. We will expect your assistance in contacting your insurance carrier in the event of non-payment or discounted payments.

If your insurance plan will only allow you to see physicians that are members of their network, please contact the plan to verify that we do participate.

If you have insurance in which we do not participate, our office will file a claim upon request. However, payment in full is expected at the time of service.

It is the patient’s responsibility to pay any deductible or any portion of the charges as specified by the plan at the time of visit.

Insurance companies sometimes use the phrase “usual and customary” when discussing physician fees. It is important to note that the insurance companies set their own “usual and customary” rates based on a wide geographical area and the fees we charge may differ. We do not write off balances based on this language.

Our staff is happy to help with insurance questions relating to how a claim was filed, or regarding any additional information the payer might need to process the claim. Specific coverage issues, however, can only be addressed by your insurance company member services or your employer’s Human Relations Department.

Your insurance company may require additional information to process your claim(s) such as accident details, co-ordination of benefits or student status. Your insurance company will request this information in writing. It is very important that you provide your insurance with the information necessary to process your claims. We will allow 10 days to get this information to your insurance company. If, after 10 days your insurance company has not received this information from you, the balance will become your responsibility and you will receive a statement for payment in full.

If your insurance mistakenly sends you our payment, please forward the check immediately. Failure to do so may result in your account being turned over to a collection agency or small claims court. We will notify the IRS as this must be reported as income.

Worker’s Comp/Auto Insurance:

Workers compensation laws require the employee to report injuries to their employer. If your care involves a work related injury, we must know the date of onset, location and nature of the accident, and the telephone number of the adjuster for your case. If this information is not provided you are responsible for payment of the entire balance due based on our normal fee schedule. We cannot bill your regular health insurance for work related injuries.

If you were involved in an automobile accident, we need a copy of your Motor Vehicle Accident Insurance.

If you are unable to produce this letter at the time of your scheduled visit, it will be necessary for us to take an imprint of your credit card in the event that the claim is denied by your motor vehicle insurance and/or your health insurance.

Patient Financial Policy P a g e | 2

Global Fees: The insurance companies and Medicare’s National Correct Coding initiative have determined that procedures are billed as a global fee. This fee includes the physicians evaluation and management, of the case, the procedure, rehabilitation guidance and other care associated with this event. Depending on your procedure, the insurance company may allow an inclusive or “global” period of up to 90 days. Each visit during a global period includes a no-charge physician’s fee, but may incur fees for incidental items, supplies, etc. Private Pay:

Patients who do not have health insurance with which we participate are expected to pay for professional services at the time of visit unless prior arrangements have been made with us. We may require a deposit.

Financial assistance is available for qualified patients. If you think you may qualify for assistance, the receptionists should be notified for referral to our practice Financial Counselor.

Outstanding balances are due prior to your appointment. . Methods of Payment:

We accept cash, personal checks, or credit cards for payment of professional services

We do not accept post dated checks. Patient agrees to pay all costs of collecting balance including but not limited to: billing fees, legal fees, court costs, and attorney’s fees. In the event your account is turned over to collection, patient authorizes Queens Medical Associates to contact his/her employer for employment verification. Cancellation and Missed Appointments, Procedures, and Surgery:

If you are unable to keep a scheduled appointment, and fail to notify our office within 24 hours of your appointment, a missed appointment fee may be placed on your account.

If you are unable to keep your procedure appointment or fail to notify our office within 24 hours of your appointment, a $100.00 charge may be placed on your account.

Once these cancellation and missed appointment fees charges are incurred we reserve the option to halt any future appointments for you until the balance has been paid.

Disability and Insurance Forms:

We will complete your disability or other insurance forms. We ask that you turn in the forms as soon as possible. Please allow 5-7 business days for your forms to be completed. Please understand forms are completed in the order in which they are received.

Medical Records: If you need a copy of your medical records:

You will be asked to sign a release of medical records before fulfilling the request

Medical records cannot be released with a telephone request; we must have signed authorization.

Fees may apply. Be sure to ask the amount when requesting records. Minor Patients:

Written permission for treatment from the parent or guardian is required.

The adult accompanying a minor is responsible for payment at the time of service. For unaccompanied minors, non-emergent treatment will be denied unless charges have been pre-authorized and payment by cash, check, or credit card at the time of services has been pre-arranged.

Schedule of Miscellaneous Fees:

o Returned Check Fee $ 30.00 o Missed Appointment Fees (as described above): - Office visit $ 50.00 - Procedure and Injection appointments $100.00 o Medical Records, per page fee 0.75 o A Collection Charge is applied to all accounts unpaid after 60 days.

Collection Charge computed by a periodic rate of 1.5% per month, Which is the annual percentage rate of 18.00%. Minimum charge of $1.00 (Revised: 2/1/2011)

Welcome to our practice!

Thank you for choosing Queens Medical Associates. We are here to help you. Our practice

firmly believes that a good physician-patient relationship is based upon understanding and good

communications.

I acknowledge that I have received and read the following documents in this package. I

understand the policies clearly, and am aware of my responsibilities.

Medical Treatment Consent

Patient Bill of Rights

Notice of Privacy Practices

Financial Policy

Oral Oncology Department Notice

Questions about financial arrangements should be directed to our Financial Counselor.

___________________________________ _______/_______/__________

Signature of Patient Date

Or

______________________________________ ________________________________

Signature of Person Authorized to Relationship to Patient

Consent for Patient

_________________________________________ _______/_______/__________ Print Name Person Authorized to Date

Consent for Patient

176-60 Union Turnpike Ste. 360 Fresh Meadows, New York 11366

Tel. 718-460-2300 Fax 718-460-9697

Acknowledgement Form for

New Patient Package