Patient Registration Form - Skyline...

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Patient Registration Form (Please Print & Complete in Full) PATIENT INFORMATION

MRN: ____________________

Date: _____________________

Date of Birth: _______/_______/_______ Sex: ☐ Male ☐ Female

Marital Status: ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Separated

Home Number: (____)_____-_______ Work Number: (____)_____-______ Cell Number: (____)_____-_______

Race: ☐ African American ☐ Asian ☐ Caucasian ☐ Hispanic ☐ Native American ☐ Other

Ethnicity: ____________________________ Preferred Language: ____________________________

If Patient is a child, lives with: ☐ Both Parents ☐ Mother ☐ Father ☐ Other: ___________

Name of Person (With Whom Child Lives With): ____________________________________________

RESPONSIBLE PARTY IF OTHER THAN PATIENT

Social Security #: _________-_________-__________Responsible Party Name: ____________________________________

Address: _______________________________________________________________________________________________

City: ________________________________ State: _____________ Zip: __________________

Home Number: (_______)________-__________ Work Number: (_______)________-__________

Date of Birth: ________/________/________ Sex: Male Female Relationship: _____________________

REFERRED BY:

Referring Physician: _________________________________ Phone: (_______)________-_____________

PCP Physician: _____________________________________ Phone: (_______)________-_____________

IN CASE OF EMERGENCY

Relative/Friend: _____________________________________ Relationship: __________________

Home Number: (_______)________-__________ Work Number: (_______)________-__________

PHARMACY INFORMATION

Pharmacy (Name, Street Name & Phone Number, if known): ________________________________________________

The above information is true to the best of my knowledge. Professional fees are due at the time services are rendered. These include but not limited to co-pays, deductibles, self pay and all discount plan payments. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for all balances that are not covered by my insurance plan. I also authorize Skyline Urology and the insurance company to release any information required to process my claims. If it becomes necessary to collect fees through the services of an attorney or collection agency, I understand this will increase my balance approximately 30%.

PATIENT SIGNATURE: ____________________________________________ DATE: __________________

Social Security Number

Email Address

First Name MI Last Name

Address

City State Zip

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SIGNATURE FORM

FINANCIAL RESPONSIBILITY AND RELEASE OF INFORMATION

Patient Name: _________________________________ MRN#: ______________________________________ Date: ________________________________________

I understand that I am financially responsible to Skyline Urology for charges not covered by my insurance carrier. Payment for services is due at time of service unless prior arrangements have been made. I also agree that, should I fail to assume that financial responsibility and credit action is necessary, I will pay for these costs in addition to the amount of the doctor’s charges. I authorize Skyline Urology to release to the Social Security Administration or its intermediaries or carriers, or other insurance carrier any medical or other information needed for this or a related insurance claim. A copy of this authorization may be used in place of the original.

_________________ ____________________________________________ Date Signature of Patient or Guardian

EXTENDED PAYMENT REQUEST (One Time Authorization) (Medicare and Medicaid Patients ONLY) I request that payment of authorized Medicare benefits or other insurance benefits be made on my behalf to Skyline Urology for any services furnished me by that provider. This one time signature will be maintained on file as verification for all subsequent services which are provided to you by this provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or other insurance carriers any information needed to determine these benefits or the benefits for related services.


MEDIGAP AUTHORIZATION (Medicare Patients only) I request that payment of authorized Medigap benefits be made on my behalf to Skyline Urology for any services furnished me by that provider. I authorize any holder of medical information about me to

Release to ___________________________________ any information needed to determine these benefits (Name of Medigap Insurer)

Or the benefits payable for related services.

Medicare Number: ______________________________________________

Secondary Insurance: _______________________________ Policy: ________________________________


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MRN: ____________________

Chief Complaint:

What is the main reason for your visit today? (Please describe in detail)

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

History of Present Illness:

Location of problem: Abdomen Back Genitals Other: ______________________

How long does the problem last? 30 minutes 1 day Always there Other: ________________________

On a scale of 1-10, with 10 being the most severe, circle the number that best describes your problem 1 2 3 4 5 6 7 8 9 10

Is there anything else occurring at the same time?

Yes No If Yes, explain ____________ Nausea Rash Headache Other: ___________________________

When did you first notice the problem?

2 days ago 1 week ago 1 month ago Other: ______________________________

Is the problem constant or variable? Dull, then sharp Sharp, then leaves Always there Other: __________________________

Does anything help or make the problem worse?

Yes No

Moving around Standing Eating

Does the problem interfere with your normal function? Yes No If yes, explain: _________________ ______________________________

Physician use (comments and notes)

Patient’s Name

Date

Age ☐ Married ☐ Single ☐ Widowed ☐ Divorced

Occupation (or former occupation)

Female New Patient Form

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MRN: ____________________

My Main Problems are:

☐ Blood in Urine ☐ Bladder Cancer ☐ Bladder Infection ☐ Bladder Pain

☐ Kidney Stones ☐ Interstitial Cystitis ☐ Leak Urine ☐ Overactive Bladder

☐ Dropped Bladder ☐ Other: ___________________________________________________________

Allergies:

☐ None ☐ PCN ☐ Sulfa ☒ Cipro ☐ Iodine/Contrast

☐ Other: ___________________________________________________________________________

Medications: ☐ None ☐ Aspirin ☐ Lortab ☐ Percocet ☐ Plavix ☐ Nitroglycerin

☐ Detrol ☐ Detrol LA ☐ Vesicare ☐ Allopurinol ☐ Coumadin

☐ Antibiotic: ____________________________________ ☐ Other: __________________________________

Surgical History: ☐ Appendectomy☐ Back/Hip/Knee ☐ Bladder Tack ☐ C-Section # ______

☐ Cystoscopy ☐ Gallbladder ☐ Heart Bypass ☐ Hysterectomy ☐ Kidney Stone Surgery

☐ Lithotripsy ☐ Sling (TVT) ☐ Vaginal Deliveries # ______ ☐ Other: ______________☐ No Changes

Medical History: ☐ Diabetes ☐ Emphysema ☐ Heart Attack ☐ Heart Murmur

☐ Hepatitis ☐ Hernia ☐ Hypertension ☐ Last Period: _____ ☐ Menopause

☐ Parkinson’s ☐ Pregnant ☐ Strokes ☐ Cancer: __________________________

☐ Other: ________________________________ ☐ No Changes

Family History: ☐ Kidney Cancer ☐ Kidney Stones ☐ Heart Disease

Social History:

Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed

Smoke: ☐ No ☐ Yes Occupation: ________________________ ☐ Retired

My Symptom(s) are:

General/Constitutional ☐ Fever ☐ Weight Loss ☐ Chills

Eyes ☐ Blurry Vision ☐ Double Vision ☐ Cataracts

Ears, Nose, Mouth, Throat ☐ Hearing Loss ☐ Nasal Stuffiness ☐ Sore Throat

Cardiovascular ☐ Chest Pains ☐ Swollen Ankles ☐ Irregular Heartbeat

Respiratory ☐ Shortness of Breath ☐ Wheezing ☐ Chronic Cough

Gastrointestinal ☐ Abdominal Pain ☐ Nausea/Vomiting ☐ Change in Bowels

Genitourinary ☐ Incontinence ☐ Painful Urination ☐ Blood in Urine

Musculoskeletal ☐ Chronic Back Pain ☐ Chronic Neck Pain ☐ Sore Muscles

Integumentary/Skin ☐ Rash ☐ Persistent Itching ☐ Skin Cancer History

Neurologic ☐ Numbness ☐ Tingling ☐ Dizziness

Hematologic/Lymphatic ☐ Swollen Glands ☐ Abnormal Bleeding ☐ Transfusion History

Urinary Symptom(s) are:

☐ Frequency ☐ Urgency ☐ Leakage ☐ Straining ☐ Abdominal Pain

☐ Bladder Pain ☐ Pain in Side R / L ☐ Not Emptying Bladder ☐ Urinating at Night # _________

Patient’s Name Date

Who referred you to this office? Medical Doctor/PCP

Why are you seeing the physician today?

When did your problem start? Pharmacy (Name & Number)

Male New Patient Form

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MRN: ____________________

My Main Problems are:

☐ Enlarged Prostate ☐ Blood in Urine ☐ High PSA ☐ Bladder Infection

☐ Kidney Stones ☐ Prostate Infection ☐ Urinary Incontinence ☐ Bladder Cancer

☐ Prostate Cancer ☐ Erectile Dysfunction ☐ Overactive Bladder ☐ Infertility

☐ Lump in Testicle ☐ Other: ___________________________________________________________

Allergies:

☐ None ☐ PCN ☐ Sulfa ☐ Cipro ☐ Iodine/Contrast

☐ Other: ___________________________________________________________________________

Medications (Please list all current medications):

_______________________________________________________________________________________________

Surgical History: ☐ Appendectomy ☐ Back/Hip/Knee ☐ Cystoscopy ☐ Gallbladder

☐ Heart Bypass ☐ Kidney Stone Surgery ☐ Lithotripsy ☐ Prostate Biopsy ☐ Prostate Seed

☐ Prostate Surgery ☐ Other: ________________________________ ☐ No Changes

Medical History: ☐ Diabetes ☐ Emphysema ☐ Heart Attack ☐ Heart Murmur

☐ Hepatitis ☐ Hernia ☐ Hypertension ☐ Parkinson’s ☐ Strokes

Cancer: ☐ Prostate ☐ Kidney ☐ Testis ☐ Other: ________________ ☐ No Changes

Family History: ☐ Prostate Cancer ☐ Kidney Cancer ☐ Kidney Stones ☐ Heart Disease

Social History:

Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed

Smoke: ☐ No ☐ Yes Occupation: ________________________ ☐ Retired

My Symptom(s) are:

General/Constitutional ☐ Fever ☐ Weight Loss ☐ Chills

Eyes ☐ Blurry Vision ☐ Double Vision ☐ Cataracts

Ears, Nose, Mouth, Throat ☐ Hearing Loss ☐ Nasal Stuffiness ☐ Sore Throat

Cardiovascular ☐ Chest Pains ☐ Swollen Ankles ☐ Irregular Heartbeat

Respiratory ☐ Shortness of Breath ☐ Wheezing ☐ Chronic Cough

Gastrointestinal ☐ Abdominal Pain ☐ Nausea/Vomiting ☐ Change in Bowels

Genitourinary ☐ Incontinence ☐ Painful Urination ☐ Blood in Urine

Musculoskeletal ☐ Chronic Back Pain ☐ Chronic Neck Pain ☐ Sore Muscles

Integumentary/Skin ☐ Rash ☐ Persistent Itching ☐ Skin Cancer History

Neurologic ☐ Numbness ☐ Tingling ☐ Dizziness

Hematologic/Lymphatic ☐ Swollen Glands ☐ Abnormal Bleeding ☐ Transfusion History

Urinary Symptom(s) are:

☐ Incomplete Emptying ☐ Frequency ☐ Intermittency ☐ Weak Stream ☐ Straining

☐ Testicle Pain ☐ Pain in Side R / L ☐ Urinating at Night # _____

Patient’s Name Date

Who referred you to this office? Medical Doctor/PCP

Why are you seeing the physician today?

When did your problem start? Pharmacy (Name & Number)

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3838 West Carson Street, Suite 220, Torrance, California 90503 Phone (424) 212-4594 Fax (424) 288-5222 www.skyuro.com

AUTHORIZATION for RELEASE of PROTECTED HEALTH INFORMATION (PHI)

Read & Complete Entire Document Before Signing Patient Name:__________________________________________ Maiden/Previous Name:__________________________________ Date of Birth:____________________ Medical Record # (if known):___________________Phone No.:________________________ Address:____________________________________________________________________________________________________ (Street) (City) (State) (Zip) I authorize the use or disclosure of the above named individual's PHI as described below: Name, Address and phone number of health provider or entity to release this information: Name:_________________________________________________ Phone Number:____________________________________ Address:_______________________________________________ Fax Number: _____________________________________ (Street) _____________________________________________________________ (City) (State) (Zip) Description of information to be used or disclosed: Medical Records from :__________________ To:______________________ Other: (Please specify records and dates:_________________________________________________________________________ __________________________________________________________________________________________________________ Name, Address and Phone Number of person (s) or organization to whom this information will be sent: Name:_________________________________________________ Phone Number:____________________________________ Address:_______________________________________________ Fax Number: _____________________________________ (Street) _____________________________________________________________ (City) (State) (Zip) This protected Health Information is being used or disclosed for the following purpose: ______ My personal records _______ For legal purposes, Attorney _______________________________________ ______ For other Healthcare Providers _______ Other (please describe)____________________________________________ I understand that:

I may refuse to sign this authorization and that it is strictly voluntary. My refusal to sign this authorization will not affect my ability to obtain treatment, except when health services are solely for the purpose of reporting to a third party.

I may revoke this authorization, in writing, at any time by sending such written notice to Health Care Provider specified above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

Once the information listed above has been disclosed, it may be re-disclosed by the recipient and the information may not be protected by Federal privacy laws or regulations.

This authorization will remain in effect unless you specify a date or event at which time this authorization expires, otherwise it will expire in one year. Expiration Date or Event:_______________________________________________________________________________ This authorization may include disclosure of the following information only if I place my initials on the appropriate line item below: ________ HIV related information ________ Mental health treatment ________ drug, alcohol, or substance abuse or treatment ________ communicable diseases (STD) We will provide your PHI in hardcopy format (fax or hardcopy) unless you specifically request otherwise. If you have records in our electronic health record, you may request an electronic copy of those records and you may request we send an electronic copy of those records to a third party. We will charge you the cost of the electronic media you specify and will report the fee to you upon receipt of your request. Please specify:___________________________________________________________________________________ All items on this form have been completed and my questions about this form have been answered & I have been provided a copy of the form. Signature of Patient/Guardian:_______________________________________________________Date:___________________ Photo ID required for records to be picked up. Relationship to Patient: Witness to ID:________________________________________ ________________________________________________

http://www.skyuro.com/

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PF-3000 (b) NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting your office’s Practice Administrator. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

By my signature below, I acknowledge receipt of the Notice of Privacy Practices. _______________________________________________ _____________________________ PRINT PATIENT’S NAME PATIENT MRN NUMBER

____________________________________________ __________________________ Patient or Legally authorized individual signature Date Time ____________________________________________ __________________________ Printed Name if signed on behalf of the patient Relationship to Patient (Notation, if any, by staff)

AUTHORIZATION FOR PERSONS TO WHOM INFORMATION MAY BE DISCLOSED:

_____________________________________________ ________________________ Print Name of person/organization Relationship to Patient

_____________________________________________ ________________________ Print Name of person/organization Relationship to Patient

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3838 West Carson Street, Suite 220 Torrance, California 90503

Phone (424) 212-4594 Fax (424) 288-5222 www.skyuro.com

NOTICE OF PRIVACY PRACTICES This Notice is effective February 18, 2010

Revised May, 2013

Revised November, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION

ABOUT YOU MAY BE USED AND DISCLOSED AND

HOW YOU CAN GET ACCESS TO THIS INFORMATION & RESTRICT USE AND

DISCLOSURES OF THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY

WE ARE REQUIRED BY LAW TO PROTECT MEDICAL INFORMATION ABOUT YOU.

We are required by law to protect the privacy of medical information about you and that identifies you. This medical information may be information about health care we provide to you or payment for health care provided to you. It may also be information about your past, present, or future medical condition.

We are also required by law to provide you with this Notice of Privacy Practices explaining our legal duties and

privacy practices with respect to medical information. We are legally required to follow the terms of this Notice. In other words, we are only allowed to use and disclose medical information in the mariner that we have described in this

Notice.

We may change the terms of this Notice in the future. We reserve the right to make changes and to make the new

Notice effective for all medical information that we maintain. If we make changes to the Notice, we will:

Provide copies of the new Notice in our waiting area.

Have copies of the new Notice available upon request (you may always contact our Privacy Officer at _________________________________ to obtain a copy of the current Notice).

The rest of this Notice will:

Discuss how we may use and disclose medical information about you.

Explain your rights with respect to medical information about you.

Describe how and where you may file a privacy-related complaint.

If, at any time, you have questions about information in this Notice or about our privacy policies, procedures or practices, you can contact our Privacy Officer at__________________________

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WE MAY USE AND DISCLOSE MEDICAL INFORMATION

ABOUT YOU IN SEVERAL CIRCUMSTANCES

We use and disclose medical information about patients every day. This section of our Notice explains in some detail how we

may use and disclose medical information about you in order to provide health care, obtain payment for that health care, and

operate our business efficiently. This information is typically referred to as TPO: Treatment, Payment and Health Care

Operations. This section then briefly mentions several other circumstances in which we may use or disclose medical

information about you. For more information about any of these uses or disclosures, or about any of our privacy policies,

procedures or practices, contact our Privacy Officer at ____________________________________

Treatment

We may use and disclose medical information about you to provide health care treatment to you. In other words, we may use

and disclose medical information about you to provide, coordinate or manage your health care and related services. This may

include communicating with other health care providers regarding your treatment and coordinating and managing your health

care with others. Examples of these communications include phone conversations regarding your medical care and providing

other health care providers with copies of the medical records we generate and maintain on your behalf. These

communications also include our attempts to contact you when necessary to convey test results or treatment

recommendations. If we are unable to reach you, we may leave a message asking for a return call at any of the numbers you

have provided us with.

1. Payment

We may use and disclose medical information about you to obtain payment for health care services that you received. This

means that, within the office, we may use medical information about you to arrange for payment (such as preparing bills

and managing accounts). We also may disclose medical information about you to others (such as insurers, collection

agencies, and consumer reporting agencies). In some instances, we may disclose medical information about you to an

insurance plan before you receive certain health care services because, for example, we may want to know whether the

insurance plan will pay for a particular service.

2. Healthcare Operations

We may use and disclose medical information about you in performing a variety of business activities that we call "health care

operations." These "health care operations" activities allow us to, for example, improve the quality of care we provide and reduce health care costs. For example, we may use or disclose medical information about you in performing the following activities:

Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.

Providing training programs for students, trainees, health care providers or non-health care professionals to help them practice or improve their skills.

Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty.

Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients.

Improving health care and lowering costs for groups of people who have similar health

problems and helping manage and coordinate the care for these groups of people.

Cooperating with outside organizations that assess the quality of the care others and we provide, including government agencies and private organizations.

Planning for our organization's future operations.

Resolving grievances within our organization.

Reviewing our activities and using or disclosing medical information in the event that control of our organization significantly changes.

Working with others (such as lawyers, accountants and other providers) who assist us to comply with this Notice and other applicable laws.

4. Appointment Reminders and Recommended Treatment Reminders. In the course of providing treatment to

you, we may use your health information to contact you (by phone or in writing) with a reminder that you have an

appointment for treatment or services, or that you are overdue for recommended evaluation or treatment.

As a service to our clients, we provide a courtesy appointment reminder call and possibly other important calls

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that may be placed using a prerecorded message. By providing your cell and/or home phone numbers, you consent to receiving such calls at these numbers.

5. Persons Involved in Your Care We may disclose medical information about you to a relative, close personal friend or any other person you identify if that person is involved in your care and the information is relevant to your care. If the patient is a minor, we may disclose medical information about the minor to a parent, guardian or other person responsible for the minor except in limited circumstances. For more information on the privacy of minors' information, contact our Privacy Officer at________________________________.

We may also use or disclose medical information about you to a relative, another person involved in your care or possibly a disaster relief organization (such as the Red Cross) if we need to notify someone about your location or condition.

You may ask us at any time not to disclose medical information about you to persons involved in your care. We will agree to your request and not disclose the information except in certain limited circumstances (such as emergencies) or if the patient is a minor. If the patient is a minor, we may or may not be able to agree to your request. Please complete our Patient Authorization to Disclose Protected Health Information Form if you wish to restrict your Personal Health Information. You may also use this form if you would like to make us aware of someone you would like us to share your information with. These forms are available in the office, or are available by writing to our Privacy Officer at our office address or____________________________.

6. Required by Law

We will use and disclose medical information about you whenever we are required by law to do so. There are many state and federal laws that require us to use and disclose medical information. For example, state law requires us to report gunshot wounds and other injuries to the police and to report known or suspected child abuse or neglect to the Department of Social Services. We will comply with those state laws and with all other applicable laws.

7. National Priority Uses and Disclosures

When permitted by law, we may use or disclose medical information about you without your permission for various activities that are recognized as "national priorities." In other words, the government has determined that under certain circumstances (described below), it is so important to disclose medical information that it is acceptable to disclose medical information without the individual's permission. We will only disclose medical information about you in the following circumstances when we are permitted to do so by law. Below are brief descriptions of the "national priority" activities recognized by law. For more information on these types of disclosures, contact our Privacy Officer at 3.

Threat to health or safety: We may use or disclose medical information about you if we believe it is necessary to

prevent or lessen a serious threat to health or safety.

Public health activities: We may use or disclose medical information about you for public health activities. Public

health activities require the use of medical information for various activities, including, but not limited to, activities

related to investigating diseases, reporting child abuse and neglect, monitoring drugs or devices regulated by the Food

and Drug Administration, and monitoring work-related illnesses or injuries. For example, if you have been exposed to

a communicable disease (such as a sexually transmitted disease), we may report it to the State and take other actions

to prevent the spread of the disease.

Abuse, neglect or domestic violence: We may disclose medical information about you to a government authority

(such as the Department of Social Services) if you are an adult and we reasonably believe that you may be a victim of

abuse, neglect or domestic violence.

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Health oversight activities: We may disclose medical information about you to a health oversight agency — which

is basically an agency responsible for overseeing the health care system or certain government programs. For

example, a government agency may request information from us while they are investigating possible insurance fraud.

Court proceedings: We may disclose medical information about you to a court or an officer of the court (such as an

attorney). For example, we would disclose medical information about you to a court if a judge orders us to do so.

Law enforcement: We may disclose medical information about you to a law enforcement official for specific law

enforcement purposes. For example, we may disclose limited medical information about you to a police officer if the

officer needs the information to help find or identify a missing person.

Coroners and others: We may disclose medical information about you to a coroner, medical examiner, or

funeral director or to organizations that help with organ, eye and tissue transplants.

Workers' compensation: We may disclose medical information about you in order to comply with workers'

compensation laws.

Research organizations: We may use or disclose medical information about you to research organizations if the

organization has satisfied certain conditions about protecting the privacy of medical information.

Certain government functions: We may use or disclose medical information about you for certain government

functions, including but not limited to military and veterans' activities and national security and intelligence

activities. We may also use or disclose medical information about you to a correctional institution in some

circumstances.

8. Authorizations

Other than the uses and disclosures described above (#1-7), we will not use or disclose medical information about you

without the "authorization" — or signed permission — of you or your personal representative. In some instances, we may

wish to use or disclose medical information about you and we may contact you to ask you to sign an authorization form. I n

other instances, you may contact us to ask us to disclose medical information and we will ask you to sign an authorization

form.

If you sign a written authorization allowing us to disclose medical information about you, you may later revoke (or cancel) your

authorization in writing (except in very limited circumstances related to obtaining insurance coverage). If you would like to

revoke your authorization, you may write us a letter revoking your authorization. If you revoke your authorization, we will follow

your instructions except to the extent that we have already relied upon your authorization and taken some action.

The following uses and disclosures of medical information about you will only be made with your authorization (signed

permission):

Uses and disclosures for marketing purposes.

Uses and disclosures that constitute the sales of medical information about you.

Most uses and disclosures of psychotherapy notes, if we maintain psychotherapy notes.

Any other uses and disclosures not described in this Notice.

YOU HAVE RIGHTS WITH RESPECT

TO MEDICAL INFORMATION ABOUT YOU

You have several rights with respect to medical information about you. This section of the Notice will briefly mention each of

these rights. If you would like to know more about your rights, please contact our Privacy Officer at xxx-xxx-xxxx or . com

1. Right to a Copy of This Notice

You have a right to have a paper copy of our Notice of Privacy Practices at any time. In addition, a copy of this Notice will always

be available in our waiting area. If you would like to have a copy of our Notice,

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ask the receptionist for a copy or contact our Privacy Officer at xxx- xxx-xxxx or .com.

2. Right of Access to Inspect and Copy

You have the right to inspect (which means see or review) and receive a copy of medical information about you that we

maintain in certain groups of records. If we maintain your medical records in an Electronic Health Record (EHR) sy stem,

you may obtain an electronic copy of your medical records. You may also instruct us in writing to send an electronic copy

of your medical records to a third party. If you would like to inspect or receive a copy of medical information about you,

you must provide us with a request in writing. You may complete our HIPAA complaint Release of Information Form (to

send records to others), complete our Access Request Form (to review or obtain a copy for yourself) or write us a letter

requesting access to your medical record. We may charge a fee for the costs of copying, printing, mailing or other supplies

associated with your request for copies.

We may deny your request in certain circumstances. If we deny your request, we will explain our reason for doing so in

writing. We will also inform you in writing if you have the right to have our decision reviewed by another health care

professional. The person conducting the review will not be the person who denied your request. You have additional rights to

appeal a denial to the New York State

Department of Health.

We may be able to provide you with a summary or explanation of the information. Contact our Privacy Officer for more

information on these services.

3. Right to Have Medical Information Amended

You have the right to have us amend (which means correct or supplement) medical information about you that we maintain

in certain groups of records. if you believe that we have information that is either inaccurate or incomplete, we may amend

the information to indicate the problem and notify others who have copies of the inaccurate or incomplete information. If

you would like us to amend information, you must provide us with a request in writing and explain why you would like us to

amend the information. You may write us a letter requesting an amendment. Your request must include a reason that

supports your request for amendment.

We may deny your request in certain circumstances. if we deny your request, we will explain our reason for doing so in writing.

You will have the opportunity to send us a statement explaining why you disagree with our decision to deny your amendment

request and we will share your statement whenever we disclose the information in the future.

4. Right to an Accounting of Disclosures We Have Made

You have the right to receive an accounting (which means a detailed listing) of disclosures that we have made for the previous six

(6) years. If you would like to receive an accounting, you may send us a letter requesting an accounting to our Privacy Officer.

The accounting will not include several types of disclosures, including disclosures for treatment, payment or health care

operations. If we maintain your medical records in an Electronic Health Record (EHR) system, you may request that we

include disclosures for treatment, payment or health care operations. The accounting will also not include disclosures made

prior to April 14, 2003.

If you request an accounting more than once every twelve (12) months, we may charge you a fee to cover the costs of

preparing the accounting.

5. Right to Request Restrictions on Uses and Disclosures

You have the right to request that we limit the use and disclosure of medical information about you for treatment, payment and

health care operations. Under federal law, we must agree to your request and comply with your requested restriction(s) if:

1. Except as otherwise required by law, the disclosure is to a health plan for purpose carrying out payment

of health care operations (and is not for purposes of carrying out treatment); and,

mailto:315-424-1430%20or%[email protected]

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2. The medical information pertains solely to a health care item or service for which the health care provided

involved has been paid out-of-pocket in full.

Once we agree to your request, we must follow your restrictions (except if the information is necessary for emergency treatment).

You may cancel the restrictions at any time. In addition, we may cancel a restriction at any time as long as we notify you of the

cancellation and continue to apply the restriction to information collected before the cancellation.

You also have the right to request that we restrict disclosures of your medical information and healthcare treatment(s) to a health

plan (health insurer) or other party, when that information relates solely to a healthcare item or service for which you, or another

person on your behalf (other than a health plan), has paid us for in full. Once you have requested such restriction(s), and your

payment in full has been received, we must follow your restriction(s).

If you would like to request restrictions on Uses and Disclosures of your medical information you may complete our Restrict

Use & Disclosure Form or write us a letter regarding your request for restrictions.

6. Right to Request Confidential Communications and/or an Alternative Method of Contact You have

the right to request to be contacted at a different location or by a different method. For example, you may prefer to

have all written information mailed to your work address rather than to your home address.

We will agree to any reasonable request for alternative methods of contact. If you would like to request an alternative method of

contact, you must complete the Alternative/Confidential Request Form or write us a letter regarding your request.

7. Right to Notification if a Breach of Your Medical Information Occurs

You also have the right to be notified in the event of a breach of medical information about you. If a breach of your medical

information occurs, and if that information is unsecured (not encrypted), we will notify you promptly with the following

information:

A brief description of what happened;

A description of the health information that was involved;

Recommended steps you can take to protect yourself from harm;

What steps we are taking in response to the breach; and,

Contact procedures so you can obtain further information.

8. Right to Opt-Out of Fundraising Communications

If we conduct fundraising and we use communications like the U.S. Postal Service or electronic email for fundraising, you have the

right to opt-out of receiving such communications from us. Please contact our Privacy Officer to opt-out of fundraising

communications if you chose to do so.

YOU MAY FILE A COMPLAINT

ABOUT OUR PRIVACY PRACTICES

If you believe that your privacy rights have been violated or if you are dissatisfied with our privacy policies or procedures, you may

file a written complaint either with us or with the federal government.

We will not take any action against you or change our treatment of you in any way if you file a complaint.

To file a written complaint with us, you may bring your complaint directly to our Privacy Officer ( ###-###-#### or ___________________________.com), or you may mail it to the following address:

SKYLINE UROLOGY

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ATTN: PRIVACY OFFICER 3838 West Carson Street, Suite 220

Torrance, California 90503

To file a written complaint with the

federal government, please use the following contact information:

U.S. Department of Health and Human Services

Office for Civil Rights 200 Independence Avenue, S.W.

Room 509F, HHH Building Washington, D.C. 20201 Website: http://vvww.hhs.goviocr/privacy/hipaa/complaints/index.htmlEmail: [email protected]

Toll-Free Phone: (800) 368-1019 TDD Toll-

Free: (800) 537-7697

mailto:[email protected]

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3838 West Carson Street, Suite 220, Torrance, California 90503

FINANCIAL AND PRACTICE POLICIES

Welcome to Skyline Urology. Please take the time to review and acknowledge receipt of

Skyline's financial and payment related policies.

PATIENT RESPONSIBILITY:

We will answer questions relating to your insurance to the best of our ability, however, your

insurance is a contract between you and your insurance carrier. It is your responsibility to know

the terms of your coverage.

We will do our best to verify your eligibility at the time of service, however you or your responsible party accept responsibility for any and all charges deemed not eligible for coverage by your insurance

carrier.

COLLECTION OF CO-PAYMENTS, CO-INSURANCE & DEDUCTIBLES & CHECK-

IN/REGISTRATION PROCEDURES:

Co-payments, co-insurance amounts and outstanding deductibles are collected at check-in. It is

your responsibility to bring your insurance card to all appointments and to pay applicable

member cost sharing amounts at the time of check in. Your appointment may be rescheduled if your insurance card and member cost-sharing amounts are not provided at the time of service. If

there is a balance due after actual services rendered, you will be billed by Skyline for the

outstanding amounts. Additionally, if Skyline receives an EOB (Explanation of Benefits) from

your carrier that shows you have made an overpayment a refund will be issued immediately).

REFERRALS and PRE-AUTHORIZATIONS:

You as the patient/responsible party must obtain any authorization or referral required by your

insurance carrier for services provided by Skyline. You understand that failure to do so could result in

additional out-of-pocket expenses. Referrals MUST be present at the time of your appointment or your appointment will be rescheduled.

MEDICARE:

If you are a Medicare beneficiary, you certify that the information given by you for payment under Medicare is correct. You request that payment of authorized Medicare benefits be made payable to

Skyline Urology for any services furnished to you by Skyline. You give permission to Skyline to

release to the Centers for Medicare and Medicaid Services and its agents any information needed to

determine benefits or the benefits payable for services or to obtain payment of any claims relating to

these services.

MEDI-CAL: If you are a Medi-Cal beneficiary, you certify that the information given by you for payment under

Medi-cal is correct. You request that payment of authorized Medi-Cal benefits be made payable to

Skyline Urology for any services furnished to you by Skyline. You give permission to Skyline to release to Centers for Medicare and Medi-cal Services and its agents any information needed to

determine benefits or the benefits payable for services or to obtain payment of any claims relating to

these services.

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NO-SHOWS AND CANCELLATION POLICY: We at Skyline Urology understand that situations arise in which you much cancel your appointment. Therefore, if you must cancel your appointment please provide more than 24 hours' notice. Office appointments which are cancelled with less than 24 hours' notification may be subject to a $25.00 cancellation fee. Procedure/surgery cancellations require 5 – 7 business days advance notice, without notification they may be subject to a $100.00 cancellation fee. Patients who do not show for their appointment without a call to cancel within the outlined time frame will be considered a "No Show". Patients who are a no show will be subject to a $50.00 fee for our office appointments and $150.00 fee for procedure/surgery appointments.

GUARANTEE OF PAYMENT, PERSONAL BALANCES AND RELATED FEES:

You agree to pay all applicable charges, which are not paid in full by your insurance. You understand that charges deemed as patient responsibility by your insurance carrier or not covered by your insurance carrier are your responsibility and are payable upon receipt of an invoice from

Skyline. All outstanding personal balances for which the patient or responsible party have received an invoice must be paid in full prior to being seen for scheduled appointments.

Skyline will charge a $25.00 fee for all returned checks, credit card charge backs or ACH rejections (debit cards declined or charged back for non-sufficient funds). There is a monthly finance charge of 1% for accounts 30 days past due.

In the event that you default on payment of your account, you understand that you are responsible for any and all costs incurred for the collection of your account, including interest, collection fees, court

costs and reasonable attorney's fees.

You also understand and acknowledge that you are responsible to pay Skyline in full for services that your health insurer will not cover due to non-payment of your health insurance premiums.

ASSIGNMENT OF BENEFITS:

You hereby request that payment of authorized Medicare/Medi-cal, and all other insurance benefits be made on your behalf to Skyline Urology for any services provided to you and/or your dependents by any practitioner or employee of Skyline. You give Skyline permission to submit the necessary claims to Medicare/Medi-cal or any private insurance carrier on your behalf.

AUTHORIZATION TO RELEASE INFORMATION:

You authorize release of your medical record information, pursuant to applicable federal and state laws,

rules and regulations, to third party payers and other providers participating in your care. You further authorize any other individual or entity that has provided health care to you to release to Skyline

Urology any and all of your medical record information, whether in printed or electronic form, needed to provide you with necessary care. You may revoke your consent for the release of this information at any time, except to the extent that action has been taken in reliance on this consent.

WRITTEN ACKNOWLEDGEMENT OF PRACTICE POLICIES:

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You acknowledge that you have received and had an opportunity to ask questions

concerning thePractice Policies of Skyline Urology. You agree to the terms and conditions

contained herein. __________________________________ _______________________________ Patient Signature Date __________________________________ _______________________________ Responsible Party Relationship to patient

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