NEW PATIENT REGISTRATION FORM

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Notice of Privacy Practices: The following describes how your medical information may be used, disclosed, and accessed: In accordance with the Health Insurance Portability Accountability Act of 1996 (HIPAA), New York House Call Physicians® will keep all of your health information confidential. Note that for the purposes of medical treatment (e.g. discussing your case with a consulting physician), payment (e.g. insurance paperwork which shows your diagnosis and corresponding diagnostic codes), health care operations (e.g. self-auditing our medical records, quality improvement), and medico-legal considerations (e.g. medical examiners, law enforcement officials, public health authorities), your health information may released, obtained and/or disclosed by telephone, email, mail, or fax. Important notes for new patients regarding New York House Call Physicians Fees®: If you are a Medicare patient, note that New York House Call Physicians® does not participate in Medicare, that services normally covered by Medicare will not be reimbursed by Medicare, nor can you or New York House Call Physicians® bill Medicare for services. You may seek Medicare reimbursed services from a physician other than New York House Call Physicians®, and your Medigap insurance coverage may not reimburse you for New York House Call Physicians® services. If you have health insurance, note that New York House Call Physicians® does not participate with any health insurance plans. New York House Call Physicians® can provide you with an invoice which you may submit to your health insurance company to obtain reimbursement. A 100% cancellation fee will be applied for all appointments cancelled with less than 24 hours notice. Any medical issues arising after your New York House Call Physicians® consultation shall be addressed to your physician or by New York House Call Physicians® if you opt to pay New York House Call Physicians® for another consultation. Additional fees may be applied for house calls outside of New York City and for consultations occurring late as a result of patient or guardian tardiness. ANY CONSULTATION INCLUDING AN EMAIL OR PHONE CALL OR TEXT MESSAGE REQUIRING A NEW PRESCRIPTION, A PRESCRIPTION REFILL, &/OR A PRESCRIPTION CHANGE WILL BE SUBECT TO A CONSULTATION FEE.