Uec.11. 2013 3:06PM Stmcraz \ 7288 P. 1

Uec.11. 2013 3:06PM Stmcraz \ 7288 P. 1 Mount Asnnani Professor, ursnoprthths thageg Spine Surgery, Moont Sinai Hospital Chief of Spare Trauma, Bathurst Hospital Sinai Lehi & Peter W. May Department of Orthopaedic 5ursery The Mount Sinai Medical Center One Gustave I. Levy Place, Box 1148 New York, NY 10029-6574 ' Tel Ext Name: Date: DOB: Referring Physician: Primary Care Physician: Location of pain (circle all that apply): Neck Pain Upper Extremity Pain Mid Back Paln Dominant Hand (circle one): Right Left Review of Systems [Please check all items you feel are applicable to you]: _ Recent Infection _ Fever or chills _Weight Loss _ Difficulty Hearing Arm numbness _ Leg numbness _ Genital numbness _ Cough _ Bowel incontinence _ Change In appetite _ Bladder Incontinence _ Shortness of breath _ Fatigue — Headaches _ Poor Sleep — Muscle weakness ___ Swollen glands _ Sore throat _ Eye pain _ Severe nighttime pain _Sinusitis _ Cold hands/feet _ Hoarse voice _ Cough blood _ Anemia _ Bronchitis _ Leg swelling _ Loss of vision — Pneumonia _ Palpitations _ Asthma _ Ringing in ears _ Murmur _ Double vision _ Chest pain _ Sputum — Ulcer _ Indigestion _ Blood in stool _ Limited motion _ Constipation ___ Pain on urination Blood In urine _ Muscle aches _ Moult urination _Kidney stones _Swollen joints _ Thyroid problem _ Kidney Infection Red joints ___ GOUT _ Painful Intercourse _Arthritis Dry mouth _ 3itteriness _Rash _ Dry, eyes _ Cold Intolerance _ Vulvar pain _ Nausea ^,atess sweating _ Painful periods _Prostate enlargement _ Abdominal pain Low Back Pain Lower Extremity Pain EFTA00283637 • 7^C: ❑ Dr. Cho New Patient Registration Form ❑ Dr. Lichtblau 0 Dr. Colvin Department of Orthopaedics ❑ Dr. Markinson ❑ Dr. Flatow Mount Sinai School of Medicine ❑ Dr. Parsons ❑ Dr. Forsh ❑ Dr. Qureshi ❑ Dr. Gladstone ❑ Dr. Weinfeld ❑ Dr. Hausman Dr. Hecht ❑ Dr. Wittig Patient Information WIC NF Legal • 2 Last Name: First Name: Middle Initial Social Security Number: Date of Birth: Age: Sex: Male Female Marital Status: Guarantor Information Address: Apt. # City. State, and Zip: Home Telephone: Cell: E-mail Address: Employer Name: Employer Address: City, State, Zip: Employer Telephone: Student/Empbyment Status: Occupation: Emergency Contact Information Rel to Guarantor: Guarantor Name: Guarantor SSN: Guarantor DOB: Guarantor Address: Emergency Contact: Relationship: Telephone Number: Guarantor Telephone: Guarantor Employer's Name: Guarantor Employer's Address: Guarantor Employer's Telephone: Additional Patient Information Condition that brings you here: Date of Onset: If accident, where and how did it occur? Were you referred by a physician? YES NO If yes, name of physician requesting this consultation: Address of Physician: Phone: EFTA00283638 Uec. l i. 1013 3:06PM Insurance Information No. 7288 P. 3 Insurance Co. Name: Insurance Co. Address. Insurance Co. Telephone: Policy Number: Group Number: Name of Insured: Insured's Date of Birth: Relationship of Insured: Effective Date: Expiration Date: Primary Secondary PERMANENT INSURANCE SIGNATURE I request that payment of authorized Medical Benefits be made either to me or on my behalf to the Department of Orthopaedics — Faculty Practice Associates for any service furnished to me by my physician. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. Photostat of this authorization shall be considered as effective and valid as the original. I acknowledge that I am financially responsible for charges not covered by my insurance carrier due to the physician's non-participating/ out-of-network status with my insurance carrier and /or due to a lack of referral or prior authorization required for today's services should one not be present at the time of service. I acknowledge that I am financially responsible for any deductible, coinsurance, and/or co-payment deemed my responsibility by my insurance carrier as well as any non-covered charges. Print Patient's Name Patient's (Or Guardian's) Signature Date EFTA00283639 )ec. 2:)13 3:07:A1 O Dr. Allen 0 Dr. Cho 0 Dr. Colvin O Dr Flatow C] Dr. Forsh O Dr. Gladstone O Dr. Hausman New Patient Registration Form Department of Orthopaedics Mount Sinai School of Medicine 5 East 98th Street, 9th Floor Additional Patient Information \o. 7236 O Dr. Hecht O Dr. Iofin O Dr. Lichtblau O Dr. Parsons O Dr. Qureshi O Dr. Weinfeld Cl Dr. Wittig Condition that brings you here: Date of Onset: If accident, where and how did it occur: Did a physician refer you? Yes No If yes, name of physician requesting this consultation: Address of referring Physician: Telephone Number : rermanentinsurance Signature I request that payment of authorized Medical Benefits be made either to me or on my behalf to the Department of Orthopaedics — Faculty Practice Associates for any service furnished to me by my physician. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. Photostat of this authorization shall be considered as effective and valid as the original. I acknowledge that I am financially responsible for charges not covered by my insurance carrier due to the physician's non-participating/ out-of-network status with my insurance carrier and /or due to a lack of referral or prior authorization required for today's services should one not be present at the time of service. I acknowledge that I am financially responsible for any deductible, coinsurance, and/or co- payment deemed my responsibility by my insurance carrier as well as any non-covered charges. Print Patient's Name Patient's (Or Guardian's) Signature Date (il kiln,: New naliciu regisianion form.2 Billing 2012 EFTA00283640 • Dec.11. 2013 3:07PM No. 7288 P. 5 MOUNT SOW SCHOOL OF neorcimi The Mount Sinai Diagnostic and Pi1OtirrtHospital 1.1J t North Shore [Actin Treatment Sinai of Queens Sir 'di Medical Group Sinai Center ACKNOWLEDGEMENT OF RECEIPT OF NOTICE'OF PRIVACY PRACTICES (NOPP) By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the hospitals and the facilities listed at the beginning of this notice, and how I may obtain access to and control this information Patient Name Signature of Patient or Personal Representative Print Name of Patient or Personal Representative Date Description of Personal Representative's Authority I was not able to obtain the patient's acknowledgement of receipt of the NOPP upon registration because: ❑ The patient refused to sign despite good faith efforts O The patient was unaccompanied and not alert and oriented ❑ The patient was unaccompanied and needed emergency care O Other,( explain) Employee Signature: Employee Title: Print Name: Date: O Acknowledgement subsequently obtained, (see above). MR-205 (Rev 5/04)) EFTA00283641 Dec. 11. 2013 3:07PM LUC LYLUUM 0111H1 No. 7288 P. 6 Mount Sinai • MOUnt Sinai Hospital of Queens A Dtvizataf The MotmiStrsalHosphe Mount Sinai North Shore Medical Group CONSENT FOR COMMUNICATION VIA E-MAIL (Provider -Patient) MOUNT SIKH SCHOOL Of MEDICINE , hereby consent to have my physician, communicate with me or members of his staff, where appropriate or other physidians, nurse practitioners and pharmacists via e-mail regarding the following aspects of my medical care and treatment: (test results, prescriptions, appointments, billing, etc.]. I understand that e-mail is not a confidential method of communication. I further understand that there is a risk that e-mail communications between my physician and me or members of my physician's office staff, or between my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any e-mail communications between my physician and me or members of his office staff, or between my physician and other physicians, nurse practitioners or pharmacists regarding my medical care and treatment will be printed out and made a part of my medical record. I understand that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on e-mail. Signature: Date: E-Mail: NR-240 (9/03) (Orthopaedics) EFTA00283642 • Dec. 11. 2013 3:07PM No. 7288 P. 7 1 MOUNT IJNIJ SCHOOL OF NtOICINI lir im The Mount Sinai Hospital of Queens North Shore Medical Group MOUNT SINAI USE OF INFORMATION AUTHORIZATION Diagnostic and and Treatment Center Dear Patient, Like other major academic medical centers, Mount Sinai depends greatly upon the generosity of our patients to help us provide the finest in patient care, educate the next generation of physicians, and promote research and discovery of new treatments and cures. Federal law now requires hospitals to obtain your written authorization prior to informing you of marketing or philanthropic initiatives that support the work of your doctors. Your authorization below permits Mount Sinai doctors, development officers, trustees, and other staff to learn the name(s) of your health care provider(s) for the purpose of contacting you about marketing or philanthropic efforts that may be of interest to you. No other information about you or your medical treatment will be disclosed — that is strictly between you and your doctor. Maintaining patient confidentiality and ensuring your right to privacy has always been, and will always be, a priority at Mount Sinai. We hope you will take a moment to read this authorization and sign below. If you have any questions, please call the Compliance Officer in the Mount Sinai Development Office at (212) 659.1570. Thank you. 1 authorize that the Mount Sinai Hospital and Mount Sinai School of Medicine (" Mount Since) may disclose the name of my health care provider(s) to Mount Sinai development officers, and other staff volunteers, and consultants and contractors assisting in fund-raising efforts, for the purpose of contacting me about Mount Sinai: 2 Marketing Pund-raising opportunities. I understand that this authorization will expire five (5) years from the date of my signature below. I also understand that my health care treatment at Mount Sinai will not be affected in any way by my refusal or failure to sign this form. I further understand that this authorized information will not be released to any third party vendors for any purpose other than that expressed above. I may revoke this authorization at any time by writing to the Mount Sinai Development Office, One Gustave L. Levy Place, Box 1049, New York, New York 10029.6574. By signing below, I acknowledge that ! have read and accept all of the above. X_--- X X Signature of Patient Print Name of Patient Date or Personal Representative/Guardian or Personal Representative/Guardian X-- Address of Patient If Applicable, Description of Authority of Personal Representative/ Guardian The patient or personal representative/guardian may request a copy of this form. MR-212 (REV 4/08) OFFICE USE ONLY EFTA00283643 Dec. 1 i. 2013 3:08PM 1. 7^0e•—: Mount Sinai Global Fracture Care Dear Mr./Ms. Lent &Peta W. May Deportment of Orthopaedics The Mount Seth Raspiest One GostaveL Lay Plue, Box 1188 New York, NY 100294574 Tel: (212) 2414144 You insurance company requires that we report our services to them using a coding system known as CPT (Current Procedural Terminology). The CPT codes used to describe the services we did for you are found In the 'Surgery" section of the CPT workbook. This does not mean we are implying that you had an operation. This is merely the way the CPT book Is organized for ease of use by both insurance companies and physicians. According to CPT guidelines, fracture care may be reported to the insurance company as a 'packaged' service. This means that at the time of Initial care, a claim is generated that includes thefollowing work/service: 1. The application of the first cast or splint 2. 90 days of normal, uncomplicated, follow-up care The services that are not included in the fee associated with the fracture are billed separately: 1. X-rays (initial and all follow-up) 2. All casting supplies (Including those used in the first cast or splints) 3. Replacement cast application for medical necessity . 4. Evaluation and management of any additional problems or injuries 5. Treatment9f complications, return to operating room There will be a separate charge for these and any appropriate copayments, deductibles, or coinsurances may apply. Note: Cast replacements that are not for medical necessity may be denied by your insurance company and may be billed to you, the patient or guarantor of service. • If you have any questions, please do not hesitate to contact the billing office at 212-241-6980. EFTA00283644