NYU Langone

NYU Langone Health FACULTY GROUP PRACTICE FINANCIAL POLICIES AND PATIENT RESPONSIBIL1 I understand that NYU School of Me3rane, my treating physicians and their respective designees, will use and disclose my health information for all purposes necessary ice treatment payment and healthcare operations. including but not limited to release of information requested by my insurance company ter carrier) and any information necessary for discharge planning purposes • ASSIGNMENT OF INSURANCE I hereby authcnze my insurance benefits to be pad directly to NYU School of Medicine I uncerstard I am financa.y responsible for non-covered services. I authorize the release of any medical Or other information necessary to process insurance clams on my tehm • FINANCIAL LIABILITY: I have been provided a copy of the NYU School of Medicine financia policies and agree to the specified terms. I hereby agree to pay an charges due (cc to become due) to NYU School of Meicine for care and treatment including co-payments and dedix,trbles as provided under my plan Benefits, 4 any, paid by a third party, will be created on account I understand that I will be responsible for any charges if any of the foovnag apply • My health plan requires prior referral by a Pnmary Care Physician (PCP) before recaving services at NYU School of Medicine and I have not obtained such a referral or I receive services in excess of the referral. ancitor • My health plan *stemmas that the senaces I receive at NYU School of Medicine are not medically necessary anctior not covered by my Insurance plan. andior • My health plan coverage has lapsed or expired at the time I receive services at NYU School of Medicine. and • I have cr.osen not to use my health plan coverage, andeor • The physician I see does not participate with my health care plan • MEDICARE SIGNATURE ON FILE (Medicare Patients Only): I re0uest that payment of authorized Medcare benefits be made either to me or on my behalf to all pro-Mews who treat me during my hospital stay or any services furnished to me by those providers I authonze the holder of medical and other information about me to release :o Medcare and its agents arty information needed to determine related seMces. Patients Medicare N lent Signature • ANCILLARY SERVICES: I understand I may receive certain ancaary medical services We I am at NYU School of Medicine. Such as. anesthesia, interpretation of cardiac tests imaging services (e.g.. x-rays. MR's) and pathology specimen examination. I understand that some phystians may not provide services In my presence, but are actvely involved in the course of diagnosis and treatment. I hereby authorize payment directly for these services under tne policy(s) or plen(s) issued to me by my insurance canes' I understand that I may incur additional charges as a resit of these ancillary services. I agree to pay air charges duo with respect to such services to the extent the Marge is due after credit is green for benefits paid on my behalf by any third party payor • CANCELED OR NGSHOW APPOINTMENTS: I understand that, based on the policy of individual physics') offices. I may mmoue a cancelation fee glib not provide the re:It:red notice of cancelabon. or if I do not keep my aPcontment and have not canceled. I have been provided the Faculty Group Practice Patient Financial Policies. I understand the Information listed above which has bean fully explained to me. Wit Signature I I - Guarantor Signature bate Form Rz..r.o.t1 9/t4/2016 EFTA00313913