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Louis J. Avvento, M.D. Alexander Zuhoski, M.D. Deepali Sharma, M.D. Sharon Sparacino, ANP-c, Cynthia Cichanowicz, ANP-c Melanie Acierno, DNP, Denise A. Albano, ANP-c 325 Meetinghouse Lane Southampton, NY 11968 Tel: (631) 204-9700 Fax: (631) 287-7277 1333 East Main Street
Riverhead, NY 11901 Tel: (631) 727-8500 Fax: (631) 208-9800
Patient Registration Forms
Name ______________________________________________ DOB _______________ Age _________
Birth Place City _____________________________ State __________ Country ____________________
Mailing Address _______________________________________________________________________
E-Mail Address _____________________________________________ SS# ____________________
Home # ________________________ Work # ____________________ Cell # _____________________
Emergency Contact __________________________________________ Relationship ________________
Home # ________________________ Work # ____________________ Cell # ______________________
Primary Care Doctor _________________________________________ Phone # ____________________
Living Will: Yes No (if yes, name: ____________________________________________) DNR: Yes No
Durable Power of Attorney: Yes No (if yes, name: _____________________________________________)
Ethnicity: Are you Hispanic/Latino? Yes No
Race (circle ALL that apply): American Indian Asian White Black/African American Other
Marital Status: Single Married Divorced Domestic Partner Widowed
Current / Past Occupation: ________________________________________________________________
Medical Insurance Information
Primary Insurance ______________________________________ ID # ____________________________
Secondary Insurance ____________________________________ ID # ____________________________
Name of insured if other than patient ______________________________ DOB _____________________
Drug Prescription Information
Plan Name ___________________________ ID# ___________________ PCN# ____________________
BIN# ______________________ Tel no. __________________________
Mail Order Pharmacy: ________________________________ Tel no. ___________________________ __
Local Retail Pharmacy: ______________________________ Tel no. _____________________________
Authorization:
I hereby give authorization for Eastern LI Hematology/Oncology to furnish information to insurance carriers concerning my illness/accident and irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not they are covered by my insurance.
PATIENT ACKNOWLEDGEMENTS
PLEASE READ AND INITIAL EACH SECTION
APPOINTMENT CHECK IN
To ensure that Eastern LI Hematology Oncology has accurate up-to-date information please understand that our receptionists will ask you at EVERY appointment to provide the name of your insurance, pharmacy, primary care physician and any other pertinent information as deemed necessary. In order to update/confirm your current
medications, you will be asked to bring your medication bottles to every appointment. You may be also be asked to complete forms that have previously have been completed.
PT INITIALS _______________
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
I have read and understand the Privacy Notice outlining Eastern LI Hematology/Oncology’s responsibilities and my rights under HIPAA. A copy of this notice is online at available at www.ELIHO.com or provided upon request from the patient.
PT INITIALS _______________
INSURANCE (existing/changing) and REFERRALS
It is up to you to know your insurance coverage. For questions regarding your coverage/responsibilities, you should contact a customer service representative. The number can usually be found on the back of your insurance card. You should know what laboratory, radiology, home care agency and referral requirements that are set by your insurance company. This office will not take responsibility for obtaining that information. We REQUIRE a minimum of 2 business day’s notification when you are changing insurances. Please contact our billing department with your new insurance information. If we are not properly notified, referrals and/or pre-certifications may not be requested/received and charges accrued will be the patient’s financial responsibility.
PT INITIALS _______________
INSURANCE CO-PAYMENTS/COINSURANCES/DEDUCTIBLES
Co-payments are to be collected upon checking in with our front desk staff. No exceptions will be made unless arrangements have been made prior with our billing department and/or managers. Insurances that apply coinsurances/deductibles will require a credit card authorization on file unless arrangements are made prior to appointment with the Practice Administrator, Lynn Kay Winters.
PT INITIALS _______________
DRUG CO-PAYMENT ASSISTANCE PROGRAMS
Our office may investigate manufacturer’s co-pay assistance programs for some medication(s) commonly prescribed at Eastern LI Hematology/Oncology. You hereby authorize Eastern LI Hematology Oncology to apply on your behalf.
PT INITIALS ______________
MISSED APPOINTMENTS
Appointments that are missed for any reason aside from medical emergencies wit hout 2 business day’s notice are subject to a 25$ MISSED APPOINTMENT CHARGE. Any such charges are due and payable upon receipt of notice.
PT INITIALS ______________
I acknowledge that I have read and understand all of the above.
AUTHORIZATION FOR MEDICAL INFORMATION TO BE GIVEN
WHO MAY WE GIVE INFORMATION TO IN REGARDS TO YOUR CASE?
We take patient confidentiality very seriously. In order to ensure that our staff does not
give out information to individual(s) that you have not approved, we ask that you fill out the
section below. Only these individuals will be apprised of your case history and progress.
Name/Relationship
Primary Contact #
Secondary Contact #
PLEASE CHECK AND INITIAL IF YOU DO NOT WISH ANYONE TO HAVE
INFORMATION IN REGARD TO YOUR MEDICAL CONDITION. THIS CAN ONLY
BE CHANGED IN WRITING BY YOU. PT INITIALS ________________
TO ENSURE CONTINUITY OF CARE, PLEASE SEND ALL PROGRESS NOTES, TEST
RESULTS TO:
Doctor Name
Address
Phone
Fax
PATIENT SIGNATURE ________________________________________ DATE _________
MEDICATION / ALLERGY LIST (attach additional sheets if necessary)
Name ______________________________ Pharmacy _________________________________
MEDICATIONS
Name of Medication
(attach additional sheets if necessary)
Dose
Frequency
DRUG ALLERGIES
Name of Drug
(attach additional sheets if necessary)