New Patient Packet - Scarsdale Medical · New Patient Packet. ... / / ☐ Single ☐ Married ☐ Divorced ☐ Widowed Preferred contact method: Street ... PARENT AUTHORIZATION FOR

New Patient

Packet

Dear Patient,

Welcome to Scarsdale Medical Group! We are happy you chose us to take care of your healthcare needs. We

are dedicated to providing patients with high-quality, individualized care, delivered with compassion and respect.

We focus on providing care for the entire family with access to primary care and a wide range of medical

specialties. Getting comprehensive care has never been more convenient. With expanded office hours, in-house,

state-of-the-art diagnostics and an on-site laboratory, we make it easier to get the care you deserve.

Please take a moment to review the contents of your WELCOME PACKET. It provides valuable information

about Scarsdale Medical Group, including information on our online NextMD Patient Portal. This easy to use

online tool allows you to have access to your health information at any time – from your mobile device or

computer. Through the portal, you can communicate with your physician, request appointments, view test

results and renew prescriptions.

Scarsdale Medical Group is continually adding to our wide array of clinical services and programs. We will keep

you informed through our website and monthly patient e-newsletters as new doctors join us, when we introduce

new technologies and other innovations, if our office hours change, or when weather conditions cause

emergency closings. And, we’ll let you know when we offer free patient & community lectures, or participate in

community activities, such as blood drives, fundraising walks and immunization campaigns.

Scarsdale Medical Group knows you have choices when it comes to your medical care. We appreciate you

choosing us and we take great pride in being your healthcare provider.

Never hesitate to reach out to us with any questions or concerns at (914) 723-8100.

In good health, Kim Carriere, MBA Chief Operating Officer

PATIENT INFORMATION New Patient Registration Form - Adult

Last name: First name: Middle initial: Mr. Miss Mrs. Ms.

Today’s Date:

Birth date: Age: Sex: Marital Status: SSN:

/ / ☐ Single ☐ Married ☐ Divorced ☐ Widowed Preferred contact method:

Street address (including Apt. #): Home phone: Work phone:

City: State: ZIP Code: Cell phone: Email address:

Occupation: Employer Name/Employer Address: Employer phone:

Race: ☐ American Indian/Alaskan Native ☐ Asian ☐ Black/African American ☐ Native Hawaiian/Other Pacific Islander ☐ White ☐ Decline

Ethnicity: ☐ Hispanic/Latino ☐ Non-Hispanic ☐ Decline

Primary Language: Name of physician seeing for today’s visit:

Referring Physician: How did you hear about SMG?

INSURANCE INFORMATION: Insured/Guarantor: (Please be sure to provide a copy of your insurance card to the registration coordinator)

Name of Primary Insurance Company:

Subscriber’s name: Subscriber’s SSN: Birth date: Group no.: Policy no.:

/ /

Home phone: Address (if different):

Cell phone:

Subscriber’s Employer: Employer address: Employer phone no.:

Patient’s relationship to subscriber: Self Spouse Child Domestic Partner Other

Name of Secondary Insurance Company:


/ /


Cell phone:



EMERGENCY CONTACT

Full Name: Address: City: State/Zip:

Relationship to patient: Home phone: Work phone: Cell phone:

The above information is true and correct to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician or Scarsdale Medical Group. I understand that I am financially responsible for any balance. I also authorize Scarsdale Medical Group or responsible insurance company to release any information required to process my claims.

Signature of Patient Print Name Date

Protected Health Information Designee Form

I understand that Scarsdale Medical Group may release protected health information to a designated family member, friend or other person involved in my care. I am designating the following person(s) listed below, as a person(s) involved in my health care or payment for my health care. I am circling ‘yes’ for the type of information that I am allowing you to share with each designee. I understand that I may object to sharing all, some, or specific information with anyone listed here and will indicate such on the lines provided below for that purpose. Your protected health information includes your medical and billing records maintained by Scarsdale Medical Group. Patient Name: ________________________________________ Date of Birth: ____________

Address: _____________________________________________________________________

I authorize Scarsdale Medical Group to disclose my PHI to: 1. Name: ____________________________________________ Phone #: ________________

Relationship to patient: _______________________________

I want to share: Health Information (Yes/No) Billing Information (Yes/No)

2. Name: ____________________________________________ Phone #: ________________



3. Name: ____________________________________________ Phone #: ________________



Please indicate any specific information that should not be shared with any of the contacts listed above. ____________________________________________________________________________________ ____________________________________________________________________________________

SIGNATURE: _______________________________________________________ _____________ Signature of Patient or Legally Authorized Representative Date Printed Name of Legally Authorized Representative (if applicable): ___________________________ If representative, relationship to patient: _______________________________________

PATIENT INFORMATION Patient Demographic Update Form (To be updated yearly or with any info changes)


Today’s Date:

Birth date: Age: Sex: Marital Status: SSN:

/ / ☐ Single ☐Married ☐Divorced ☐ Widowed Preferred Contact Method:


City: State: ZIP Code: Cell phone: Email address:



Ethnicity: ☐ Hispanic/Latino ☐ Non-Hispanic ☐ Decline

Primary Language: Name of physician seeing for today’s visit:

Referring Physician:




/ /


Cell phone:





/ /


Cell phone:



EMERGENCY CONTACT

Full Name: Address: City: State/Zip:

Relationship to patient: Home phone: Work phone: Cell phone:


Signature of Patient Print Name Date

PATIENT INFORMATION New Patient Registration Form - Pediatrics


Today’s Date:

Birth date: Age: Sex: SSN:

/ / Preferred Contact Method:


City: State: ZIP Code:

Cell phone: Email address:



Ethnicity: ☐ Hispanic/Latino ☐ Non-Hispanic ☐ Decline Primary Language:

Name of physician seeing for today’s visit: How did you hear about SMG?

Parent/Legal Guardian Information

Mother’s Full Name: Mother’s SSN: Mother’s Birth date:

/ /

Mother’s Mailing Address:(including Apt. #) Mother’s Email: Mother’s Primary phone:

Father’s Full Name: Father’s SSN: Father’s Birth date:

/ /

Father’s Mailing Address:(including Apt. #) Father’s Email: Father’s Primary phone:

Legal Guardian Full Name/Relationship to Patient: Legal Guardian SSN: Legal Guardian Birth date:

/ /

Legal Guardian Mailing Address:(including Apt. #) Legal Guardian Email: Legal Guardian Primary phone:




/ /


Cell phone:





/ /


Cell phone:


EMERGENCY CONTACT

Full Name: Address (including Apt. #)/City/State/Zip: Relationship to patient: Primary Phone:


Signature of Patient/Parent/Guardian Print Name Date

PARENT AUTHORIZATION FOR CAREGIVERS The following people are authorized to accompany _____________________________ (child’s name)/___________________ (date of birth) to his/her appointments at Scarsdale Medical Group. Each of the below people are fully authorized to accompany my child, meet and speak with treatment providers if needed, receive medical information about my child and make medical decisions for my child on my behalf during these appointments. I understand that if extraordinary care is needed or an emergency arises, Scarsdale Medical Group will use reasonable efforts to contact me prior to treatment. However, in my absence and in the event Scarsdale Medical Group cannot contact me, all of the below-named individuals have full authority to give informed consent relating to my child, in my absence.

Full Name: Relationship: Primary phone:



Parent signature: ________________________________________________________________________ Date: ________________________

PATIENT INFORMATION Patient Demographic Update Form - Pediatrics

Last name: First name: Middle initial: Primary Phone #: Today’s Date:

Birth date: Age: Sex: Street address (including Apt #)/City/State/Zip: Preferred Contact Method:

/ /

Parent/Legal Guardian Information

Mother’s Full Name: Mother’s SSN: Mother’s Birth date:

/ /

Mother’s Mailing Address (including Apt. #) Mother’s Email: Mother’s Primary phone:

Father’s Full Name: Father’s SSN: Father’s Birth date:

/ /

Father’s Mailing Address: (including Apt. #) Father’s Email: Father’s Primary phone:

Legal Guardian Full Name/Relationship to Patient: Legal Guardian SSN: Legal Guardian Birth date:

/ /

Legal Guardian Mailing Address (including Apt. #) Legal Guardian Email: Legal Guardian Primary phone:




/ /


Cell phone:





/ /


Cell phone:


EMERGENCY CONTACT

Full Name: Address (including Apt. #)/City/State/Zip: Relationship to patient: Primary Phone #:


Signature of Patient/Parent/Guardian Print Name Date

PARENT AUTHORIZATION FOR CAREGIVERS The following people are authorized to accompany _____________________________ (child’s name)/___________________ (date of birth) to his/her appointments at Scarsdale Medical Group. Each of the below people are fully authorized to accompany my child, meet and speak with treatment providers if needed, receive medical information about my child and make medical decisions for my child on my behalf during these appointments. I understand that if extraordinary care is needed or an emergency arises, Scarsdale Medical Group will use reasonable efforts to contact me prior to treatment. However, in my absence and in the event Scarsdale Medical Group cannot contact me, all of the below-named individuals have full authority to give informed consent relating to my child, in my absence.




Parent signature: _________________________________________________________________________ Date: _________________________

Medical Records Release Form (Release from Scarsdale Medical Group)

To request release of medical/health information, please complete and sign this form and return it to:

Patient Information:

Last Name __________________________First Name _________________________ Date of Birth____/____/________ Street Address____________________________________________________City______________________________ State _____________________Zip_________________ Telephone___________________________________________

Information Requested: (please be specific and enter dates of service, if known)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Restrictions and Exclusions: □ Psychiatric □ HIV/Aids Testing □ STD Testing

Medical Records are released to the following:

Doctor ______________________________________Practice Name___________________________________________ Street Address______________________________________________________________________________________ City_______________________________________ State____________________ Zip____________________________ Telephone Number___________________________________ Fax Number_____________________________________

Reason for requested Information disclosure:

Transfer of health coverage Personal Use Form Completion Referral Change of healthcare provider

*** If your request is for purpose of personal use (self), please be aware there will be flat rate of no greater than $25.00 plus shipping and handling when applicable*** ***All requests less than 20 pages will be free of charge***

CHECK MUST BE PAYABLE TO: “DATAFILE”

I hereby authorize Scarsdale Medical Group to release any medical information as requested above. This may include information about drug and/or alcohol use, psychiatric, social work, or other protected information unless otherwise excluded.

Information will not be released without a valid signature below. This authorization will expire 90 days from the signature date. I can, however, revoke this authorization at any time, except to the extent that Scarsdale Medical Group has acted upon it. The information disclosed in this authorization may be subject to re-disclosure by the practice and no longer be protected by federal law. I understand that the Scarsdale Medical Group will continue to provide care, even if I do not authorize this release. __________________________________________________________ __________________________________ Signature of Patient Date

__________________________________________________________ __________________________________ Signature of Parent/Guardian (if minor) Date

PLEASE MAKE A COPY OF THIS RELEASE FOR YOUR RECORDS. This release is intended to comply with the Health Information Portability and Accountability Act (HIPAA).

If you need help completing this form,

Please contact our Health Information

Department at (914)723-8100, Ext. 158

Scarsdale Medical Group, LLP

Health Information Department,

600 Mamaroneck Avenue, Suite 200, Harrison NY 10528

Fax: 914-219-1933

Email: [email protected]

mailto:[email protected]

Authorization for release of

medical record Information from an

outside physician

Patient Information:

Last Name First Name Date of Birth / /

Street Address

City State Zip

Telephone (H) (W) _(C)

I, , am under the care of Scarsdale Medical Group. I hereby authorize the provider named below to transfer my medical records to the Scarsdale Medical Group doctor and location as indicated.

(Please fill in the name and the complete address of the medical provider from whom the information is being requested)

Doctor _________________________ Practice Name _________________________________ Street Address _________________________________________________________________________ City ________________________ State ____ Zip ________ Phone Number ___________________ Fax Number __________________________________

Please send the requested information to Scarsdale Medical Group to the attention of: Doctor _______________________ at ________________________________________

Scarsdale Medical Group - Health Information Department 600 Mamaroneck Avenue, Suite 200, Harrison, NY 10528

Description of information to be enclosed:

__ All records __ Immunization Records

Dates of treatment Other:

Reason for requested Information disclosure: Transfer of health coverage Personal Use Form Completion Referral Change of healthcare provider

Patient signature Date

Signature of patient representative Date

259 Heathcote Rd, Scarsdale NY 10583 550 Mamaroneck Ave, Suite 101, Harrison NY 10528

600 Mamaroneck Ave, Suite 102 / 200 / 301, Harrison NY 10528 T (914) 723 - 8100 F (914) 219 – 1933 WWW.SCARSDALEMEDICAL.COM

Health Care Proxy Appointing Your Health Care Agent in New York State

The New York Health Care Proxy Law allows you to appoint someone you trust — for example, a family member or close friend – to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes. Your agent can also decide how your wishes apply as your medical condition changes. Hospitals, doctors and other health care providers must follow your agent’s decisions as if they were your own. You may give the person you select as your health care agent as little or as much authority as you want. You may allow your agent to make all health care decisions or only certain ones. You may also give your agent instructions that he or she has to follow. This form can also be used to document your wishes or instructions with regard to organ and/or tissue donation.

About the Health Care Proxy Form This is an important legal document. Before signing, you should understand the following facts:

1. This form gives the person you choose as your agent the authority to make all health care decisions for you, including the decision to remove or provide life-sustaining treatment, unless you say otherwise in this form. “Health care” means any treatment, service or procedure to diagnose or treat your physical or mental condition.

2. Unless your agent reasonably knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube or intravenous line), he or she will not be allowed to refuse or consent to those measures for you.

3. Your agent will start making decisions for you when your doctor determines that you are not able to make health care decisions for yourself.

4. You may write on this form examples of the types of treatments that you would not desire and/or those treatments that you want to make sure you receive. The instructions may be used to limit the decision-making power of the agent. Your agent must follow your instructions when making decisions for you.

5. You do not need a lawyer to fill out this form.

6. You may choose any adult (18 years of age or older), including a family member or close friend, to be your agent. If you select a doctor as your agent, he or she will have to choose between acting as your agent or as your attending doctor because a doctor cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special

restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions.

7. Before appointing someone as your health care agent, discuss it with him or her to make sure that he or she is willing to act as your agent. Tell the person you choose that he or she will be your health care agent. Discuss your health care wishes and this form with your agent. Be sure to give him or her a signed copy. Your agent cannot be sued for health care decisions made in good faith.

8. If you have named your spouse as your health care agent and you later become divorced or legally separated, your former spouse can no longer be your agent by law, unless you state otherwise. If you would like your former spouse to remain your agent, you may note this on your current form and date it or complete a new form naming your former spouse.

9. Even though you have signed this form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped if you object, nor will your agent have any power to object.

10. You may cancel the authority given to your agent by telling him or her or your health care provider orally or in writing.

11. Appointing a health care agent is voluntary. No one can require you to appoint one.

12. You may express your wishes or instructions regarding organ and/or tissue donation on this form.

Frequently Asked Questions Why should I choose a health care agent? If you become unable, even temporarily, to make health care decisions, someone else must decide for you. Health care providers often look to family members for guidance. Family members may express what they think your wishes are related to a particular treatment. Appointing an agent lets you control your medical treatment by:

•allowing your agent to make health care decisions on your behalf as you would want them decided;

•choosing one person to make health care decisions because you think that person would make the best decisions;

•choosing one person to avoid conflict or confusion among family members and/or significant others.

You may also appoint an alternate agent to take over if your first choice cannot make decisions for you.

Who can be a health care agent? Anyone 18 years of age or older can be a health care agent. The person you are appointing as your agent or your alternate agent cannot sign as a witness on your Health Care Proxy form.

How do I appoint a health care agent? All competent adults, 18 years of age or older, can appoint a health care agent by signing a form called a Health Care Proxy. You don’t need a lawyer or a notary, just two adult witnesses. Your agent cannot sign as a witness. You can use the form printed here, but you don’t have to use this form.

When would my health care agent begin to make health care decisions for me? Your health care agent would begin to make health care decisions after your doctor decides that you are not able to make your own health care decisions. As long as you are able to make health care decisions for yourself, you will have the right to do so.

What decisions can my health care agent make? Unless you limit your health care agent’s authority, your agent will be able to make any health care decision that you could have made if you were able to decide for yourself. Your agent can agree that you should receive treatment, choose among different treatments and decide that treatments should not be provided, in accordance with your wishes and interests. However, your agent can only make decisions about artificial nutrition and hydration (nourishment and water provided by feeding tube or intravenous line) if he or she knows your wishes from what you have said or what you have written. The Health Care Proxy form does not give your agent the power to make non-health care decisions for you, such as financial decisions.

Why do I need to appoint a health care agent if I’m young and healthy? Appointing a health care agent is a good idea even though you are not elderly or terminally ill. A health care agent can act on your behalf if you become even temporarily unable to make your own health care decisions (such as might occur if you are under general anesthesia or have become comatose because of an accident). When you again become able to make your own health care decisions, your health care agent will no longer be authorized to act.

How will my health care agent make decisions? Your agent must follow your wishes, as well as your moral and religious beliefs. You may write instructions on your Health Care Proxy form or simply discuss them with your agent.

How will my health care agent know my wishes? Having an open and frank discussion about your wishes with your health care agent will put him or her in a better position to serve your interests. If your agent does not know your wishes or beliefs, your agent is legally required to act in your best interest. Because this is a major responsibility for the person you appoint as your health care

Frequently Asked Questions, continued

agent, you should have a discussion with the person about what types of treatments you would or would not want under different types of circumstances, such as:

•whether you would want life support initiated/ continued/removed if you are in a permanent coma;

•whether you would want treatments initiated/ continued/removed if you have a terminal illness;

•whether you would want artificial nutrition and hydration initiated/withheld or continued or withdrawn and under what types of circumstances.

Can my health care agent overrule my wishes or prior treatment instructions? No. Your agent is obligated to make decisions based on your wishes. If you clearly expressed particular wishes, or gave particular treatment instructions, your agent has a duty to follow those wishes or instructions unless he or she has a good faith basis for believing that your wishes changed or do not apply to the circumstances.

Who will pay attention to my agent? All hospitals, nursing homes, doctors and other health care providers are legally required to provide your health care agent with the same information that would be provided to you and to honor the decisions by your agent as if they were made by you. If a hospital or nursing home objects to some treatment options (such as removing certain treatment) they must tell you or your agent BEFORE or upon admission, if reasonably possible.

What if my health care agent is not available when decisions must be made? You may appoint an alternate agent to decide for you if your health care agent is unavailable, unable or unwilling to act when decisions must be made. Otherwise, health care providers will make health care decisions for you that follow instructions you gave while you were still able to do so. Any instructions that you write on your Health Care Proxy form will guide health care providers under these circumstances.

What if I change my mind? It is easy to cancel your Health Care Proxy, to change the person you have chosen as your health care agent or to change any instructions or limitations you have included on the form. Simply fill out a new form. In addition, you may indicate that your Health Care Proxy expires on a specified date or if certain events occur. Otherwise, the Health Care Proxy will be valid indefinitely. If you choose your spouse as your health care agent or as your alternate, and you get divorced or legally separated, the appointment is automatically cancelled. However, if you would like your former spouse to remain your agent, you may note this on your current form and date it or complete a new form naming your former spouse.

Can my health care agent be legally liable for decisions made on my behalf? No. Your health care agent will not be liable for health care decisions made in good faith on your behalf. Also, he or she cannot be held liable for costs of your care, just because he or she is your agent.

Is a Health Care Proxy the same as a living will? No. A living will is a document that provides specific instructions about health care decisions. You may put such instructions on your Health Care Proxy form. The Health Care Proxy allows you to choose someone you trust to make health care decisions on your behalf. Unlike a living will, a Health Care Proxy does not require that you know in advance all the decisions that may arise. Instead, your health care agent can interpret your wishes as medical circumstances change and can make decisions you could not have known would have to be made.

Where should I keep my Health Care Proxy form after it is signed? Give a copy to your agent, your doctor, your attorney and any other family members or close friends you want. Keep a copy in your wallet or purse or with other important papers, but not in a location where no one can access it, like a safe

Frequently Asked Questions, continued

deposit box. Bring a copy if you are admitted to the hospital, even for minor surgery, or if you undergo outpatient surgery.

May I use the Health Care Proxy form to express my wishes about organ and/or tissue donation? Yes. Use the optional organ and tissue donation section on the Health Care Proxy form and be sure to have the section witnessed by two people. You may specify that your organs and/or tissues be used for transplantation, research or educational purposes. Any limitation(s) associated with your wishes should be noted in this section of the proxy. Failure to include your wishes and instructions on your Health Care Proxy form will not be taken to mean that you do not want to be an organ and/ or tissue donor.

Can my health care agent make decisions for me about organ and/or tissue donation? Yes. As of August 26, 2009, your health care agent is authorized to make decisions after your death, but only those regarding organ and/or tissue donation. Your health care agent must make such decisions as noted on your Health Care Proxy form.

Who can consent to a donation if I choose not to state my wishes at this time? It is important to note your wishes about organ and/or tissue donation to your health care agent, the person designated as your decedent’s agent, if one has been appointed, and your family members. New York Law provides a list of individuals who are authorized to consent to organ and/or tissue donation on your behalf. They are listed in order of priority: your health care agent; your decedent’s agent; your spouse, if you are not legally separated, or your domestic partner; a son or daughter 18 years of age or older; either of your parents; a brother or sister 18 years of age or older; or a guardian appointed by a court prior to the donor’s death.

Health Care Proxy Form Instructions Item (1) Write the name, home address and telephone number of the person you are selecting as your agent.

Item (2) If you want to appoint an alternate agent, write the name, home address and telephone number of the person you are selecting as your alternate agent.

Item (3) Your Health Care Proxy will remain valid indefinitely unless you set an expiration date or condition for its expiration. This section is optional and should be filled in only if you want your Health Care Proxy to expire.

Item (4) If you have special instructions for your agent, write them here. Also, if you wish to limit your agent’s authority in any way, you may say so here or discuss them with your health care agent. If you do not state any limitations, your agent will be allowed to make all health care decisions that you could have made, including the decision to consent to or refuse life-sustaining treatment.

If you want to give your agent broad authority, you may do so right on the form. Simply write: I have discussed my wishes with my health care agent and alternate and they know my wishes including those about artificial nutrition and hydration.

If you wish to make more specific instructions, you could say:

If I become terminally ill, I do/don’t want to receive the following types of treatments....

If I am in a coma or have little conscious understanding, with no hope of recovery, then I do/ don’t want the following types of treatments:....

If I have brain damage or a brain disease that makes me unable to recognize people or speak and there is no hope that my condition will improve, I do/don’t want the following types of treatments:....

I have discussed with my agent my wishes about____________ and I want my agent to make all decisions about these measures.

Examples of medical treatments about which you may wish to give your agent special instructions are listed below. This is not a complete list: • artificial respiration • artificial nutrition and hydration

(nourishment and water provided by feeding tube) • cardiopulmonary resuscitation (CPR) • antipsychotic medication • electric shock therapy • antibiotics • surgical procedures • dialysis • transplantation • blood transfusions • abortion • sterilization

Item (5) You must date and sign this Health Care Proxy form. If you are unable to sign yourself, you may direct someone else to sign in your presence. Be sure to include your address.

Item (6) You may state wishes or instructions about organ and /or tissue donation on this form. New York law does provide for certain individuals in order of priority to consent to an organ and/or tissue donation on your behalf: your health care agent, your decedent’s agent, your spouse , if you are not legally separated, or your domestic partner, a son or daughter 18 years of age or older, either of your parents, a brother or sister 18 years of age or older, a guardian appointed by a court prior to the donor’s death.

Item (7) Two witnesses 18 years of age or older must sign this Health Care Proxy form. The person who is appointed your agent or alternate agent cannot sign as a witness.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Health Care Proxy (1) I, ___________________________________________________________________________________

hereby appoint ________________________________________________________________________ (name, home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) Optional: Alternate Agent If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby

appoint _____________________________________________________________________________ (name, home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely. (Optional: If you want this proxy to expire, state the date or conditions here.) This proxy shall expire (specify date or conditions): _____________________________________

(4) Optional: I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If you want to limit your agent’s authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary): __________________________

In order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent what your wishes are or include them in this section. See instructions for sample language that you could use if you choose to include your wishes on this form, including your wishes about artificial nutrition and hydration.

___________________________________________________________________________________

________________________________________ ___________________________________________

(5) Your Identification (please print)

Your Name ___________________________________________________________________________

Your Signature _________________________________________________ Date ________________

Your Address __________________________________________________________________________

(6) Optional: Organ and/or Tissue Donation

I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply)

■ Any needed organs and/or tissues

■ The following organs and/or tissues ____________________________________________________

■ Limitations ________________________________________________________________________

If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf.

Your Signature ___________________________ Date_______________________________________

(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.)

I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.

Date____________________________________ Date_______________________________________

Name of Witness 1 Name of Witness 2 (print) __________________________________ (print) _____________________________________

Signature _______________________________ Signature __________________________________

Address _________________________________ Address ____________________________________

1430 7/12

NYS Donate Life Organ and Tissue Donor Registry Enrollment Form

Please Print ( * required ) Prefix: ___________ (Dr., Fr., etc) *First Name: ______________________________________________________ Middle Init: __________ *Last Name: _______________________________________________________ Suffix: ____________ (Jr, Sr, II, etc) *Address: _________________________________________________________ __________________________________________________________ *City: __________________________ *State: ________ *Zip: _________ Phone: (_____) ______ - _________ *Date of Birth: _____/_____/_____ *Gender: _____Male______Female *Height: _____feet_______inches *Eye Color: __________________ 9- digit Motor Vehicle license or non-driver license DMV issued ID number: ___________________________ * I offer the donation of:

All Organs, Tissues and Eyes

Limited Organs, Tissues and Eyes as specified below

Please CHECK the box of the organs and tissues that YOU WISH TO DONATE:

Bone and Connective Tissue

Corneas

Eyes

Heart (For Valves)

Heart with Connective Tissue

Kidneys

Liver/Iliac Vessels

Lungs

Pancreas (with Iliac Vessel)

Skin

Small Intestine

Veins

* I wish to donate the organs and or tissues specified above for:

Transplantation and Research

Transplantation only

Research only

I wish to enroll in the New York State Donate Life Organ and Tissue Donor Registry maintained by the State Department of Health. I understand that by enrolling in the registry I am giving legal consent to the donation of my organs tissues and eyes (as specified above) in the event of my death. I authorize the State Department of Health to access this information as needed in administration of the registry, and to share this information at or near the time of my death with federally regulated organ procurement organizations, New York State licensed tissue and eye banks and entities formally approved by the Commissioner. ________________________________________________________________ _____/_____/_____

Signature Date

Mail to: New York State Donate Life Organ and Tissue Donor Registry

NYS Department of Health

875 Central Avenue

Albany, NY 12206

Empire State Plaza, Corning Tower, Albany, NY 12237│health.ny.gov

HIPAA Notice of Privacy Practices

Scarsdale Medical Group LLP

I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. II. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).

Pursuant to the Privacy Rules established by the Health Insurance Portability and Accountability Act of 1996, we are legally required to protect the privacy of your health information. We call this information “protected health information,” or “PHI” for short. It includes information that can be used to identify you and that we’ve created or received about your past, present, or future health condition, the provision of health care to you, or the payment for this health care. We are required to provide you with this notice about our privacy practices. It explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice.

We reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Whenever we make an important change to our policies, we will promptly change this notice and post a new notice in the main reception area. You can also request a copy of this notice from the contact person listed in Section VI below at any time and can view a copy of this notice on our Web site at www.scarsdalemedical.com.

III. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION.

We use and disclose health information for many different reasons. For some of these uses and disclosures, we need your specific authorization. Below, we describe the different categories of uses and disclosures.

A. Uses and Disclosures Which Do Not Require Your Authorization.

We may use and disclose your PHI without your authorization for the following reasons:

1. For treatment. We may disclose your PHI to hospitals, physicians, nurses, and other health care personnel in order to provide,

coordinate or manage your health care or any related services, except where the PHI is related to HIV/AIDS, genetic testing, or federally-funded drug or alcohol abuse treatment facilities, or where otherwise prohibited pursuant to State or Federal law. For example, if you’re being treated for a knee injury, we may disclose your PHI to an x-ray technician to coordinate your care.

2. To obtain payment for treatment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services

provided to you. For example, we may provide portions of your PHI to our billing staff and your health plan to get paid for the health care services we provided to you. We may also disclose patient information to another provider involved in your care for the other provider’s payment activities.

3. For health care operations. We may disclose your PHI, as necessary, to operate this organization. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health care services to you. We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure we’re complying with the laws that affect us.

4. When a disclosure is required by federal, state or local law, judicial or administrative proceedings, or law enforcement. For

example, we may disclose PHI when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with gunshot or other wounds; for the purpose of identifying or locating a suspect, fugitive, material witness or missing person; or when subpoenaed or ordered in a judicial or administrative proceeding.

5. For public health activities. For example, we may disclose PHI to report information about births, deaths, various diseases, adverse events and product defects to government officials in charge of collecting that information; to prevent, control, or report disease, injury or disability as permitted by law; to conduct public health surveillance, investigations and interventions as permitted or required by law; or to notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.

6. For health oversight activities. For example, we may disclose PHI to assist the government or other health oversight agency with activities including audits; civil, administrative, or criminal investigations, proceedings or actions; or other activities necessary for appropriate oversight as authorized by law.

7. To coroners, funeral directors, and for organ donation. We may disclose PHI to organ procurement organizations to assist them in organ, eye, or tissue donations and transplants. We may also provide coroners, medical examiners, and funeral directors necessary PHI relating to an individual’s death.

8. For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.

http://www.scarsdalemedical.com/

8. For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.

9. To avoid harm. In order to avoid a serious threat to the health or safety of you, another person, or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm.

10. For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. We may also disclose PHI for national security and intelligence activities.

11. For workers’ compensation purposes. We may provide PHI in order to comply with workers’ compensation laws.

12. Appointment reminders and health-related benefits or services. We may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits we offer. Please let us know if you do not wish to have us contact you for these purposes, or if you would rather we contact you at a different telephone number or address.

B. Uses and Disclosures Where You to Have the Opportunity to Object:

1. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part.

C. All Other Uses and Disclosures Require Your Prior Written Authorization. Other than as stated herein, we will not disclose your PHI

without your written authorization. You can later revoke your authorization in writing except to the extent that we have taken action in reliance upon the authorization.

D. Authorization for Marketing Communications. We will obtain your written authorization prior to using or disclosing your PHI for marketing

purposes. However, we are permitted to provide you with marketing materials in a face-to-face encounter, without obtaining a marketing authorization. We are also permitted to give you a promotional gift of nominal value, if we so choose, without obtaining a marketing authorization. In addition, as long as we are not paid to do so, we may communicate with you about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings. We may use or disclose PHI to identify health-related services and products that may be beneficial to your health and then contact you about the services and products.

E. Sale of PHI. We will disclose your PHI in a manner that constitutes a sale only upon receiving your prior authorization. Sale of PHI does not

include a disclosure of PHI for: public health purposes; research; treatment and payment purposes; sale, transfer, merger or consolidation of all or part of our business and for related due diligence activities; the individual; disclosures required by law; any other purpose permitted by and in accordance with HIPAA.

F. Fundraising Activities. We may use certain information (name, address, telephone number, dates of service, age and gender) to contact you

for the purpose of various fundraising activities. If you do not want to receive future fundraising requests, please write to the Privacy Officer at the below address.

G. Incidental Uses and Disclosures. Incidental uses and disclosures of information may occur. An incidental use or disclosure is a secondary

use or disclosure that cannot reasonably be prevented, is limited in nature, and that occurs as a by-product of an otherwise permitted use or disclosure. However, such incidental uses or disclosure are permitted only to the extent that we have applied reasonable safeguards and do not disclose any more of your PHI than is necessary to accomplish the permitted use or disclosure. For example, disclosures about a patient within the office that might be overheard by persons not involved in your care would be permitted.

H. Business Associates. We may engage certain persons to perform certain of our functions on our behalf and we may disclose certain health

information to these persons. For example, we may share certain PHI with our billing company or computer consultant to facilitate our health care operations or payment for services provided in connection with your care. We will require our business associates to enter into an agreement to keep your PHI confidential and to abide by certain terms and conditions.

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI.

You have the following rights with respect to your PHI:

A. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to request in writing that we limit how we use and disclose your PHI. You may not limit the uses and disclosures that we are legally required to make. We will consider your request but are not legally required to accept it. Notwithstanding the foregoing, you have the right to ask us to restrict the disclosure of your PHI to your health plan for a service we provide to you where you have directly paid us (out of pocket, in full) for that service, in which case we are required to honor your request. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. Under certain circumstances, we may terminate our agreement to a restriction.

B. The Right to Choose How We Send PHI to You. You have the right to ask that we send information to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, via e-mail instead of regular mail). We must agree to your request so long as we can easily provide it in the manner you requested.

C. The Right to See and Get Copies of Your PHI. In most cases, you have the right to look at or get copies of your PHI that we have, but you

must make the request in writing. If we don’t have your PHI but we know who does, we will tell you how to get it. We will respond to you within 10 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed.

If you request a copy of your information, we will charge reasonable fees for the costs of copying, mailing or other costs incurred by us in complying with your request, in accordance with applicable law. Instead of providing the PHI you requested, we may provide you with a summary or explanation of the PHI as long as you agree to that and to the cost in advance. Note also that, you have the right to access your PHI in an electronic format (to the extent we maintain the information in such a format) and to direct us to send the e-record directly to a third party. We may charge for the labor costs to transfer the information; and charge for the costs of electronic media if you request that we provide you with such media.

**Please note, if you are the parent or legal guardian of a minor, certain portions of the minor’s records may not be accessible to you. For example, records relating to care and treatment to which the minor is permitted to consent himself/herself (without your consent) may be restricted unless the minor patient provides an authorization for such disclosure. **

D. The Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have disclosed your

PHI. The list will not include uses or disclosures made for purposes of treatment, payment, or health care operations, those made pursuant to your written authorization, or those made directly to you or your family. The list also won’t include uses and disclosures made for national security purposes, to corrections or law enforcement personnel, or prior to April 14, 2003. We will respond within 60 days of receiving your written request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide one (1) list during any 12-month period without charge, but if you make more than one request in the same year, we will charge you $10 for each additional request. To the extent that we maintain your PHI in electronic format, we will account all disclosures including those made for treatment, payment and health care operations. Should you request such an accounting of your electronic PHI, the list will include the disclosures made in the last three years.

E. The Right to Receive Notice of a Breach of Unsecured PHI. You have the right to receive notification of a “breach” of your unsecured PHI. F. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is

missing, you have the right to request, in writing, that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request in writing. We may deny your request if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you don’t file one, you have the right to have your request and our denial attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI.

G. The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice

via e-mail, you also have the right to request a paper copy of this notice. V. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES.

If you think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section VI below. You also may send a written complaint to the Secretary of the Department of Health & Human Services at 200 Independence Ave., S.W.; Room 615F; Washington, DC 20201. We will take no retaliatory action against you if you file a complaint about our privacy practices.

VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES.

If you have any questions about this notice or any complaints about our privacy practices, please contact our HIPAA Privacy Officer at 914-723-8100. Written correspondence to the Privacy Officer should be sent to Scarsdale Medical Group LLP, Attn: Privacy Officer, 550 Mamaroneck Avenue, Suite 302, Harrison, New York 10528.

VII. EFFECTIVE DATE OF THIS NOTICE

REVISED NOTICE – EFFECTIVE NOVEMBER 2015

Notice of Privacy Practices

Acknowledgment of Receipt

I have received a copy of Scarsdale Medical Group’s HIPAA Notice of Privacy Practices, which contains information on

the uses and disclosures of my protected health information. I understand Scarsdale Medical Group has the right to

change its HIPAA Notice of Privacy Practices without prior notification. I may contact Scarsdale Medical Group to obtain a

current copy of the HIPAA Notice of Privacy Practices or may find a copy on Scarsdale Medical Group’s website:

www.scarsdalemedical.com.

I acknowledge that I was provided with a copy of the Scarsdale Medical Group’s Notice of Privacy Practices.

_________________________ _____________________________

Patient Name (Print) Patient Signature/Date If completed by a patient’s personal representative, please print and sign your name below. __________________________ _______________________________ Personal Representative (Print) Signature/Date _______________________________

Relationship

For Scarsdale Medical Group use only.

Complete this section if this form is not signed and dated by the patient or patient’s representative.

I have made a good faith effort to obtain written acknowledgment of receipt of Scarsdale Medical Group’s Notice of Privacy Practices but was unable to for the following reason: ___ Patient refused to sign ___ Patient unable to sign/Did not have a representative present ___ Other: __________________________________________________________ ________________________________ _______________ Employee Name Date ________________________________ Employee Signature

New Patient Packet - Scarsdale Medical · New Patient Packet. ... / / ☐ Single ☐ Married ☐ Divorced ☐ Widowed Preferred contact method: Street ... PARENT AUTHORIZATION FOR

Documents