TDII Patient Registration Updated 9/2019

PATIENT REGISTRATION FORM Date:

Last Name First Name MI Maiden Name

Mailing Address Marital Status M S W D

City

State

Zip Code Sex Male Female

Home Phone

Cell Phone

Email

Date of Birth

Social Security #

Employer

Occupation

Work Phone

American Indian or Asian Native of Hawaii or other Black or African White Two or I do not wish Race Alaska Native Pacific Island American more races to disclose

Ethnicity Hispanic or Latino Non Hispanic or Latino I do not wish to disclose

Preferred Language

Who is your primary care provider?

How did you hear about us? Driving By Employer Existing Hospital Insurance Plan Newspaper Patient

Patient Referral Physician Referral Billboard Website Unknown

What Pharmacy do you generally use?

Location? Complete this section only if the patient is a minor

Last Name First Name MI

Mailing Address Marital Status M S W D

City

State

Zip Code

Sex Male Female

Date of Birth

Relationship to Patient

Employer

Social Security #

Primary Insurance Company Effective Date Secondary Insurance Company Effective Date

Claims Mailing Address (Street or Box) Claims Mailing Address (Street or Box)

City State Zip City State Zip

Policy ID Number Group Number Policy ID Number Group #

Name of Subscriber (Policy Holder) Date of Birth Name of Subscriber (Policy Holder) Date of Birth

Subscriber Social Security Number Relationship to Patient Subscriber Social Security Number Relationship to Patient

Subscriber Employer Work Phone # Subscriber Employer Work Phone #

Subscriber Employer Address (Street or Box) Subscriber Employer Address (Street or Box)

City State Zip City State Zip

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TDII Patient Registration Updated 9/201ф

EMERGENCY CONTACT INFORMATION

Contact Name Relationship to Patient

Home Phone Cell Phone

ASSIGNMENT/CONSENT TO TREAT I certify that all information provided is true to the best of my knowledge. I, the undersigned (patient or legal guardian) authorize

medical or surgical treatment to be rendered by the staff of The Doctor Is In. I understand that payment is due at the time of service, that there will be a charge for all returned checks, a finance charge of 1 ½% per month for all late payments, and that I will be

responsible for all costs incurred as a result of the delinquency of my account.

Patient/Guardian Signature Date

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge that you have received a copy of this office’s Notice of Privacy Practices.

Patient/Guardian Signature Date

COMMUNICATION CONSENT I authorize The Doctor Is In staff to leave medical information pertaining to my care by the following methods and will assume

responsibility to notify them whenever this information changes:

YES NO Home Telephone/Answering Machine Work Telephone Cell Phone/Voice Mail Fax Medical Records for referrals to another entity

If you would like to have information released to someone other than yourself, please complete the following:

YES NO Spouse: Parent: Other Names: (Please list name/relationship) Printed Name Patient/Guardian Signature Date

TDII Notice of Privacy Practices 9/2013

This letter serves as a brief summary of the attached Notice of Privacy Practices.

The Notice describes how medical information about you may be used and disclosed and how you can get access to this information.

I. Who We Are and Who This Notice Applies To

The Doctor Is In ("the Practice") is a medical practice which consists of all employed doctors, nurses, employees and other healthcare professionals. This Notice applies to these individuals as well as all services that are provided to you at our facility.

II. Our Privacy Obligations

We are required by law to maintain the privacy of your health information ("Protected Health Information" or "PHI") and to provide you with this Notice of our legal duties and privacy practices with respect to your PHI. When we use or disclose your PHI, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

III. How We May Use Your PHI Without Your Written Authorization

The Practice may use and disclose your PHI for permitted purposes as described in the posted Notice. These include uses and disclosures for/to: Treatment, Payment and Health Care Operations; a Directory of Individuals in The Doctor Is In; Relatives, Close Friends and Other Caregivers involved in your care; Public Health Activities; Victims of Abuse or Neglect Reporting; Health Oversight Activities; Judicial and Administrative Proceedings; Law Enforcement Purposes; Funeral Directors or Medical Examiners; Organ and Tissue Procurement; Research; Emergencies; Specialized Government Functions; Compliance with Workers' Compensation Programs; and as Required by Law.

IV. When Your Written Authorization Is Required

The Notice describes when we must obtain your written authorization to disclose your PHI.

V. Your Rights

Your rights with regard to your PHI include: Right to Request Restrictions on how your PHI is used/disclosed; Right to prevent information about your visit from being sent to your Insurance Company; Request Confidential Communications; Revoke Your Authorization; Request access to and/or a copy of your PHI; Request an Amendment to your PHI; Request an Accounting Of Disclosures; Be Notified Following a Breach of your Unsecured PHI; Receive a Paper Copy of this Notice; and to file a privacy complaint.

VI. Effective Date

Effective date of this Notice is September 23, 2013. Last updated September 23, 2013.

VII. Contact Information: Randy S. Klein, MD

Privacy Officer The Doctor Is In, PA 149M Highway 31 Flemington, NJ 08822 (908) 782-7700 PrivacyOfficer@thedoctorisin.net

For copies of Medical Record, telephone 908-782-7700.

_____________________________________ Name of Patient (Please Print) Date

NOTICE OF PRIVACY PRACTICES

TDII Payment Policy

Rev 03/20нл

This information sheet will explain our patient payment policies to help avoid

possible misunderstandings.

The Doctor Is In will submit claims to certain insurance companies with whom we participate. Our office makes no representation that we participate with your particular insurance plan. Each insurance company has multiple plans and The Doctor Is In has no way of knowing your specific coverage. If you have any questions regarding details and/or restrictions of your plan, please contact your insurance carrier directly. Outlined below are our practice’s policies with regard to payment for services rendered.

Payment is due at the time of service for the following:

Self-pay patients

Insurance eligibility cannot be verified

Copayments

Insurance plan requires selection of Primary Care Provider “PCP” and The Doctor Is In is not the PCP

New patients from out of the area (if insurance pays, a refund will be issued)

Insured patients must present a valid insurance card and identification at every visit.

If a claim is submitted on your behalf, you will be balance billed for all non-covered services, co-insurance and deductibles.

You will be expected to pay your balance on any insurance claim not paid within 60 days of date of service.

Payment is due within fifteen (15 days) of receipt of bill.

Balances not paid within fifteen (15 days) will be subject to a $7.00 rebilling charge and any additional costs associated with collections. Additional collection costs may include: Certified Letter fee of $10.00, Court Preparation fee of $6.00, current Court filing fees, and fees from a third party collection agency (may be up to 50%) as assessed by said company.

A fee of $30.00 will be assessed for all returned checks.

A fee of $75.00 may be assessed for appointments not cancelled within 24 hours. Acceptable methods of payment include cash, check, money order, Visa, MasterCard, or Discover

I have read the above policy and understand and agree to its terms. ______________________________ ______________________ Patient Name (Please Print) Date

PAYMENT POLICY