New Patient Registration

Medicare Patients

I request that payment of authorized Medicare benefits be made on my behalf to Advanced Gastroenterology Center, PC for services furnished to me by that practice. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I hereby authorize Medicare to furnish to the above named practice/physician any information regarding my Medicare claim under Title XVIII of the Social Security Act.

All Patients

I hereby authorize Advanced Gastroenterology Center, PC to apply for benefits on my behalf for covered services rendered by this practice/physician or by physician’s order. I request that payment from my insurance company be made directly to Advanced Gastroenterology Center, PC. I authorize the release of any medical information necessary to process this claim. I permit a copy of this assignment to be used in place of the original. This assignment will remain effective until revoked by me in writing.

I understand I am financially responsible for any balance allowed by my insurance carrier.

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I. Preferred Contact Method (check all that apply)

Select how we may reach you, and how much detail we may leave in a message.

II. Designated Relatives, Friends & Caregivers

I agree that Advanced Gastroenterology Center, PC may disclose health information relevant to a family member, close friend, or other caregiver involved with my care or payment, limited to what is relevant to that person’s involvement. I understand I am not required to list anyone, and may update this list at any time in writing.

Acknowledgement of Privacy Practices Notice

I acknowledge that I have received a copy of Advanced Gastroenterology Center, PC’s Notice of Privacy Practices, and that Advanced Gastroenterology Center, PC may use and disclose my health information as described in the Notice.

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This notice describes how your medical information may be used and disclosed, and how you can access it. Please review it carefully.

Effective: April 14, 2003

Your Health Information & Our Duty

Your health information is protected under federal and state law. We are required to maintain its privacy, provide you this Notice, and abide by its terms. We may update this Notice from time to time; any revised version will be posted at our offices and on our website, and a printed copy is available on request.

How We May Use or Disclose Your Health Information

We may use or disclose your health information without your consent for treatment, payment, and health care operations, and for certain other purposes permitted or required by law, as summarized below.

Treatment. To provide and coordinate your care, including sharing information with other providers, hospitals, or pharmacies involved in your treatment.

Payment. To bill and collect payment for services, including submitting claims to your insurance and coordinating with health benefit plans.

Health Care Operations. For quality assessment, staff training, and general practice management.

Required by Law. When required by law, including reporting to health authorities or in cases involving abuse, neglect, or domestic violence.

Public Health & Safety. To prevent or control disease, injury, or disability, or to avert a serious threat to health or safety.

Health Oversight. To agencies such as the NJ Department of Health or U.S. HHS for investigations, licensure, or compliance reviews.

Legal Proceedings. For judicial or administrative proceedings, pursuant to your authorization, a court order, or a valid subpoena.

Death & Organ Donation. To coroners, medical examiners, funeral directors, or organ procurement organizations as applicable.

Research. When an institutional review board has approved privacy protocols for the research.

Special Government Functions. Including military, national security, and intelligence activities as required.

Worker’s Compensation. As authorized by workers’ compensation and similar laws.

Family & Friends. To individuals involved in your care or payment, limited to information relevant to their involvement, unless you object.

Appointment Reminders. To contact you about appointments or relevant treatment options and services.

Your Authorization. Any other use requires your written authorization, which you may revoke at any time in writing.

Your Individual Rights

You may contact our Privacy Officer at any time with questions or to request the forms below.

Request Restrictions. You may ask us to limit how we use or share your information. Requests must be made in writing; we are not required to agree except in limited circumstances.

Confidential Communications. You may request we contact you in a specific way or at a specific location. Submit requests in writing; we will accommodate all reasonable requests.

Inspect & Copy Records. You may review or request a copy of your health information, subject to a reasonable fee for copying and postage.

Request Amendments. You may ask us to amend your health information in writing, with your reason for the request. We may deny the request in certain cases and will explain why in writing.

Accounting of Disclosures. You may request a list of certain non-routine disclosures made in the last six years.

Paper Copy. You may request a paper copy of this Notice at any time.

Complaints

You may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. Filing a complaint will not affect your care or result in retaliation. Complaints to our office may be delivered in person or mailed to the address above, attention Privacy Officer. Complaints to the Secretary should be mailed to: Region II, Office of Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza – Suite 3312, New York, NY 10278.