New Patient Vein Forms

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Authorization for Release of Medical Records

Name

First Last

Date of Birth

I hereby authorize PREMIER SPINE AND PAIN MANAGEMENT and it’s associates to release or request from other Doctors or Hospitals, any and all information which they possess or require relating to my examinations and illness, which may be part of the medical record, including psychiatric/psychological, alcohol, drug abuse, AIDS, ARC, or HIV related diagnosis, treatments and rehabilitation for the following period:

Physician, Hospital, Agency

Name

First Last

Address

Street Address City State ZIP Code

Information is being released or requested for the following reasons:

To a Physician for continued medical care

Insurance

Attorney

Other

Signature of patient or other legal representative

Date

Witness Signature

Date

Assignment Of Benefits & Authorization

To Pursue Appeal And / Or Litigation Of Health Care Benefits

In consideration of the professional services rendered by Premier Spine and Pain Management and its affiliate healthcare providers, (“Health Care Providers”), I hereby irrevocably direct, authorize, assign and consent to the following:

The assignment of my rights to bill, collect, appeal and/or arbitrate my claims for health insurance benefits with regard to the above-captioned claim to healthcare providers, including but not limited to surgical facility fees, supplies, primary physician, assistant, anesthesia and any other fees related to my claims, pursuant to my rights under state and/or federal law including but not limited to the federal ERISA statues, Health Claims Authorization, Processing and Payment Act (HCAPPA), and HealthCare Quality Act (HCAA).
The authorization of Health care providers to act as my agent-in-fact with regard to all aspects regarding the above-captioned claim and to receive any and all communications regarding the claim any appeals or arbitration of the denial of my claim as a substitute beneficiary under my policy of health insurance whether fully founded or self-funded.
The authorization of healthcare providers to initiate, prosecute, and resolve any and all appeals and/or arbitrations and/or legal actions on the denial of my claim, including but not limited to internal appeals with the insurer, outside reviewing entities or agencies as well as arbitrations and litigations matters in state or federal court including but not limited to claims under the federal ERISA statutes, Health Claims Authorization, Processing and Payment Act (HCAPPA), and HealthCare Quality Act (HCQA).
The authorization of Health care providers to obtain and/or disclose any Private health information as contemplated by HIPAA limited to my claim for insurance benefits and any appeal there from. I have signed a separate HIPAA authorization in this regard.
The authorization of healthcare providers to file a complaint with regard to any denial of my claims(s) with the Department of Health and Senior Services, the Department of Banking and Insurance, the federal department of labor as it relates to ERISA plans, as well as any other governmental agency with jurisdiction over my claim and/or the insurer.
The authorization for payment of any and all insurance benefits directly to HealthCare providers to which I might be entitled under the above-captioned claim.

(Patient Name)

(Witness Name)

(Date)

(Patient Signature)

(Witness Signature)

(Date)

Our notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The patient has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or sent a text to you to confirm appointments?

Yes

May we leave a message on your answering machine at home or on your cell phone?

Yes

May we discuss your medical condition with any member of your family?

Yes

If YES, please name the members allowed:

(Print Patient Name)

(Patient Signature)

(Date)

Affordable Care Act Disclosure

Dear Patient:

As your patient advocate (PA), we offer the highest quality care and safety possible at the most affordable cost to you, regardless of whether you are covered by an in-network or out-of-network health plan.
We offer an Affordable Care Act Discount (ACA Discount) under our Corporate Compliance policy to anyone who qualifies, on a case-by-case basis. You only pay what you can afford or are willing to pay for your deductible and co-insurance, as outlined in your plan cost-sharing obligations, based on your medical need. Most people may qualify and your satisfaction is guaranteed.
Our Affordable Care Act (ACA) discount is similar to or even better than all PPO discounts, as our ACA discount is available for both in-network and out-of-network providers and facilities.
Once you qualify, you will NOT receive any unexpected invoices, bills, or collection letters FROM US, even if your insurance denies your claims.
As your patient advocate and authorized representative, and under federal health reform law PPACA (Patient Protection and Affordable Care Act or ACA), we may appeal all of the claims denials or delays on your behalf, which is strictly in compliance with the federal health reform law, PPACA.
As your patient advocate, your best interest is our best interest. To ensure that you also get this ACA Discount from other providers known to us or affiliated with us, we will inform you of these facilities and/or providers so you may also receive the best care possible along with the ACA discounts and savings.
With your informed choice, we will refer you to a provider who may also offer a compliant ACA discount and ensure that you are always protected from any unexpected costs and bills under the federal health reform law (PPACA).
As your patient advocate, we want you to be fully protected from any unexpected costs and bills from any providers, unless otherwise authorized by you.
You always have freedom of choice to receive healthcare from any provider you choose. However, we cannot speak for, or guarantee anything on behalf of other providers we don’t know or are not affiliated with, regarding their discount or collection policies. You are advised to contact them directly before scheduling your next appointment(s) or medical procedure(s).
If you are willing to be protected from any unexpected costs and bills, feel free to apply for our Affordable Care Act Discount under our corporate PPACA Indigency policy. “Once indigency is determined, collection is no longer undertaken with regard to the patient for the forgiven amount.” Your satisfaction is guaranteed.

I have read and fully understand this Patient Protection & Advocacy Policy. My questions are fully answered.

(Print Patient Name)

(Patient Signature)

(Date)

New Jersey Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act (“Act”) Disclosure and Acknowledgement Form

WE, DR. VIVEK DAS, DR. ARUN KANDRA, & DR. SHANTI EPPANAPALLY (“Provider”), hereby notify you of the following:

Dr. Vivek Das is in-network with respect to the following health benefit plans:
HORIZON BCBS, CIGNA & TRADITIONAL MEDICARE

Dr. Shanti Eppanapally is in-network with respect to the following health benefit plans:
TRADITIONAL MEDICARE.

Dr. Arun Kandra is in-network with respect to the following health benefits plans:
TRADITIONAL MEDICARE; HORIZON NJ HEALTH.

NP Jeremey Cohen is in-network with respect to the following health benefit plans:
TRADITIONAL MEDICARE.
Provider is out-of-network with respect to all health benefits plans not listed in I above.
Providers are affiliated with the following facilities: ROBERTWOOD JOHNSON UNIVERSITY HOSPITAL SOMERSET, EASTON HOSPITAL PA, SOMERSET AMBULATORY SURGICAL CENTER, WEST MORRIS SURGERY CENTER, UNIVERSITY CENTER FOR AMBULATORY SURGERY, TEAM MD SURGERY CENTER
You have the right to request from the Provider the amount or estimated amount the Provider will bill you for the services, which is available to you upon your request.
You have the right to request that Provider provide you, in writing, with a list of the services and CPT Codes associated with those services, absent any unforeseen medical circumstances which may arise during the course of your treatment, as well as the amount or estimated amount that Provider will bill you for such services.
You should be aware that, with respect to a Provider who is out-of-network with your health benefits plan, you will have a financial responsibility applicable to the health care services provided by the Provider in excess of your copayment, deductible, or coinsurance, and you may be responsible for any costs in excess of those allowed by your health benefits plan; and you should contact your carrier for further additional information regarding those costs.
Other Providers:
1. Please note that it is your responsibility to check your insurance participation and benefits for services provided by facilities we refer you to in order to coordinate your care, such as but not limited to: “Referred to” Specialist Physicians; Physical Therapy; Urine Drug Screen Laboratories; Radiology Imaging Facilities; and/or other specialists or surgeons.
2. You can determine the health plans in which the foregoing healthcare provider(s) participate by contacting them at their respective phone numbers. You should contact your carrier for further consultation on costs associated with this/these provider’s/providers’ services mentioned above.
The receipt and acknowledgment of this disclosure shall not waive or otherwise affect any protection you may have under existing statutes or regulations regarding in-network health benefits plan coverage available to you or created under the Act.
If between the time you were notified of Provider’s network status and the time of your procedure the network status of Provider changes, then Provider shall promptly notify you of the same.

I HEREBY ACKNOWLEDGE THAT, PRIOR TO THE SCHEDULING OF MY APPOINTMENT, I HAVE RECEIVED THE FOREGOING DISCLOSURES. I HAVE READ THE FOREGOING, UNDERSTAND ITS CONTENTS, AND HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS REGARDING THE SAME, AS WELL AS CONSULT WITH MY HEALTH BENEFITS PLAN IN CONNECTION WITH THE DISCLOSURES PROVIDED IN THIS DOCUMENT.

BEING FULLY AWARE OF THE OUT-OF-NETWORK STATUS OF THE PROVIDER, I HEREBY KNOWINGLY, VOLUNTARILY AND SPECIFICALLY SELECT PROVIDER FOR THE PERFORMANCE OF SERVICES/MY PROCEDURE AND RELATED ANCILLARY SERVICES. I CERTIFY THAT I AM AT LEAST 18 YEARS OF AGE, COMPETENT, NOT UNDER THE INFLUENCE OF ANY DRUG, ALCOHOL OR OTHER SUBSTANCE THAT WOULD IMPAIR MY ABILITY TO UNDERSTAND THESE DISCLOSURES, AM NOT BEING COERCED TO SIGN THIS DISCLOSURE, AND DO SO UPON MY OWN FREE WILL.

Patient Signature

Patient Name

Date

New Patient Vein Forms