Patient Registration Form

NOTICE OF PRIVACY PRACTICES 

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. 

In accordance with modifications to the Health Insurance Portability and  Accountability Act (HIPAA Omnibus Rule), this Notice of Privacy Practices describes our  obligations under the law, how our office may use and disclose your protected health  information (PHI), and your rights to access and control the use of your PHI. PHI is  individually identifiable health information related to physical or mental health, provision of  health care, or payment for health care. 

Under HIPAA, we are required to abide by the terms of this Notice. We are required  to maintain the privacy of PHI, to provide you with notice of our legal duties and privacy  practices regarding your PHI and to notify you if the security of your PHI has been breached. 

We reserve the right to change the terms of this Notice at any time, and any new or  revised notice provisions will be effective for all PHI maintain by our office. In the event of  such revision, you may request a copy of the Notice at our office. 

PERMITTED USE AND DISCLOSURE OF YOUR PHI 

We may use and/or disclose your PHI to provide treatment, obtain payment for  services, and support our health care operations. 

Treatment is the provision, coordination, or management of health care and related  services by one or more health care providers, including the coordination or management of  health care by a health care provider with a third party; consultation between health care  providers relating to a patient; or the referral of a patient for health care from one health care  provider to another. PHI may be disclosed in the course of providing treatment. For example,  PHI may be shared with a physician or specialist to whom you have been referred. 

Payment means to obtain or provide reimbursement for the provision of health care,  including: 1) Determinations of eligibility or coverage and adjudication or subrogation of  health benefit claims; 2) Risk adjusting amounts due based on enrollee health status and  demographic characteristics; 3) Billing, claims management, collection activities, obtaining  payment under a contract for reinsurance, and related health care data processing; 4) Review  of health care services with respect to medical necessity, coverage under a health plan,  appropriateness of care, or justification of charges; 5) Utilization review activities, including  pre-certification and pre-authorization of services, concurrent and retrospective review of services; and 6) Disclosure to consumer reporting agency. 

Your PHI may be used and disclosed to obtain payment for the health care services  you receive. For example, your PHI may be disclosed to your health insurance plan in order  to determine whether you are eligible for coverage for services. 

Health care operations means any of the following activities: 1) Conducting quality  assessment and improvement activities; 2) Reviewing the competence or qualifications of  health care professionals, evaluating practitioner and provider performance, health plan  performance, conducting training programs in which students, trainees, or practitioners in  areas of health care learn under supervision to practice or improve their skills as health care  providers, training of non-health care professionals, accreditation, certification, licensing, or  credentialing activities; 3) Underwriting, premium rating, and other activities relating to the  creation, renewal or replacement of a contract of health insurance or health benefits, and  ceding, securing, or placing a contract for reinsurance of risk relating to claims for health  care; 4) Conducting or arranging for medical review, legal services, and auditing functions,  including fraud and abuse detection and compliance programs; 5) Business planning and  development; and 6) Business management and general administrative activities. 

USES AND DISCLOSURES OF PHI THAT DO NOT REQUIRE YOUR  AUTHORIZATION 

Our office is permitted or required to use or disclose PHI without your written  authorization under the following circumstances: 

1. When required by law 

2. For public health activities, including: 

● Disclosure to a public health authority authorized by law to collect and receive the  information to prevent or control disease, injury, or disability 

● Disclosure to a government agency authorized to receive reports of child abuse and  neglect. 

● Disclosure to an authorized individual with respect to the quality, safety, effectiveness  of an FDA-regulated product or activity 

● Disclosure to an individual who may have been exposed to or is at risk of contracting or  spreading a disease or 

condition, if such disclosure is authorized by law 

● Disclosure to an employer, in limited circumstances related to an employee’s work related illness or injury or workplace-related medical surveillance (notice must be  posted in place of employment or written notice must be given to employee) ● Disclosure to a school, in limited circumstances related to proof of immunization 

3. Subject to requirements of applicable state and federal laws, when a covered entity  reasonably believes an individual to be a victim or abuse, neglect, or domestic violence to a  government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence (the covered entity is  generally required to promptly inform the affected individual when such disclosure has been  made) 

4. For authorized oversight activities by health oversight agencies, including audits;  civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions;  civil, administrative, or criminal proceedings or actions; or other activities necessary for  appropriate oversight 

5. For judicial and administrative proceedings, in limited circumstances 6. For law enforcement purposes to law enforcement officials, in limited circumstances 

7. For providing information about decedents to coroners, medical examiners, and funeral  directors 

8. For making disclosures to organ procurement organizations or other entities engaged  in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissue for the  purpose of facilitating organ, eye or tissue donation and transplantation 

9. For research purposes, when such research has been approved by an Institutional Review  Board or privacy board 

10. To avert a serious threat to health or safety 

11. For specialized government functions, including but not limited to military and  veterans’ activities, national security and intelligence activities, and provision of protective  services to the President 

12. To comply with laws relating to workers’ compensation or other similar programs,  established by law, that provide benefits for work-related injuries or illness without  regard to fault. 

USES AND DISCLOSURES OF PHI THAT REQUIRE YOUR AUTHORIZATION 

We must obtain your authorization to use or disclose your PHI in the following  instances: 

1. When use or disclosure is of psychotherapy notes, except when such use or disclosure  is to carry out specified treatment, payment, or health care operations.

 2. When use or disclosure is for marketing, unless we do so in a face-to-face  communication with you or give a promotional gift of nominal value. We must inform  you if marketing involves financial remuneration. 

3. When use or disclosure constitutes a sale of PHI. 

Unless otherwise permitted or required by law, we are required to obtain your written  authorization to use and/or disclose your PHI. You may revoke your authorization in writing  at anytime. 

PATIENT RIGHTS 

You have certain rights to access and control your PHI. 

You have the right to ask that we do not use or disclose your PHI to carry out treatment,  payment, or health care operations or to provide notification to the family members or friends  involved in your care. If you have paid us in full for a service or item, and you ask us not to disclose  PHI pertaining to that service or item to a health plan, we must agree to the request. However, we  are not required to agree to other restrictions. If we agree to the requested restriction, we will not  be permitted to use or disclose PHI in violation of the restrictions, except when such PHI is needed  to provide emergency treatment 

1. You have the right to receive confidential communications of PHI at alternate locations  and/or by alternative means. We will accommodate reasonable written requests. 

2. You have the right to inspect and obtain a copy of your PHI, subject to certain  restrictions, limitations, and exceptions. 

3. You have the right to request an amendment to PHI or a record contained in a  designated record set, and you may make such request in writing and provide a reason. We  may deny the request if we did not create the PHI or record, if the record is not available for  inspection, or if the information in the PHI is complete and accurate. If we deny your request,  you may file a statement of disagreement. This statement of disagreement would be provided  along with any subsequent disclosure of the PHI related to the disagreement. 

4. You have the right to receive an accounting of disclosures we have made of your PHI,  subject to certain restrictions, limitations, and exceptions.

5. You have the right to receive a paper copy of this Notice upon request.  

If you believe that your privacy rights have been violated, you may complain to our office  or to the federal Secretary of Health and Human Services. A complaint may be filed with our  office in writing. Our office will not retaliate in any manner against anyone filing such a  complaint. Contact our office if you would like further information regarding your PHI, your rights, or Modern  Orthopaedics of New Jersey’s obligations under HIPAA, please contact Jennifer Van Beekum  at 973-898-5999.  

Acknowledgment 

By signing below, the patient acknowledges that he/she has read the foregoing Notice  of Privacy Practices for PHI and understands its terms. 

FINANCIAL POLICY NOTICE 

At Modern Orthopaedics of New Jersey, we are a participating provider with  Medicare, but we are “out-of-network” with commercial insurance companies (BCBS,  United, Aetna, etc). We bill for our services using a Usual, Customary, and  Reasonable (UCR) fee schedule (fair-market value in our region). On your behalf, and  in accordance with the Affordable Care Act administrative simplification requirements,  MONJ will request and validate your coverage benefits. This will include whether the  planned services are covered, and what your maximum out-of-pocket financial  responsibility will be based on your plan terms. We also encourage you to contact  your insurance company for further consultation on costs associated with these  services. Upon your request, we will provide the Current Procedural Terminology  (CPT) and an estimate of the billed amount.  

It has been our experience that your insurance company or its third-party  vendors will often engage with us to provide a discount on your behalf. Even in  these circumstances, your cost share amount (deductible and co-insurance) will still  apply, and this amount is due once we have determined the exact amount your plan will cover. This process of determining the out-of-pocket costs often takes several  months. In some circumstances, a balance bill (the difference between our billed amount  and your healthcare plan’s covered expense) may also apply if we cannot come to terms with your plan on a reasonable reimbursement amount for the services provided. 

At MONJ, we understand that the costs of healthcare are high. Additionally, financial hardship scenarios including temporary personal financial stresses, combined  with insurance plans with extremely high deductibles and co-insurances, may negatively  affect your ability to pay your full balance. If this is the case, we encourage you to contact our practice manager, Jennifer Van Beekum (973-898-5999) to discuss our financial  assistance program. 

If your account becomes 30 days past due, you will be responsible for any and all collection expenses including expenses the practice may incurincollecting delinquent balancessuch as court costs and a reasonable attorney's fee. A late charge interest of 1.5% per month will also be added to each billing cycle until the balance is completely paid. Any balance left unpaid after 90 days, without any attempts at resolution will be considered delinquent and may be submitted to a collection agency. 

I hereby acknowledge that I have been advised of the foregoing.

ASSIGNMENT OF BENEFITS/DESIGNATED AUTHORIZED REPRESENTATIVE/LIMITED SPECIAL POWER OF ATTORNEY 

It is our policy, for your convenience, as well as to facilitate payment, to file health benefit claims on your behalf. To enable your insurance policy or benefit plan  to deal with us directly, please read the following, sign and print your name below and enter today’s date. 

Assignment of Benefits 

I hereby assign and convey to the fullest extent permitted by law any and all benefit and non-benefit rights (including the right to any penalties or equitable relief)  under my health insurance policy or benefit plan to Modern Orthopaedics of New Jersey and Peter DeNoble, MD, David Ratliff, MD, Lorraine Stern MD (collectively, the  “Providers”) with respect to any and all medical/facility services provided by the Providers to me for all dates of service, including without limitation, the right of  one or more of the Providers, or their attorney (or other representative) to (i) execute, in my name and on my behalf, any form, document or instrument required  under any applicable insurance policy or benefit plan to further evidence my intent as set forth herein and to avoid any delay in pursuing rights under applicable  Federal and State laws, rules, regulations or requirements (collectively, “Laws”), (ii) pursue penalties for and exclusively on behalf of Providers against any  insurance policy or benefit plan for failure of the plan administrator (or other fiduciary) to timely produce or respond to requests (including appeals) for all  information relating to any plan documents as required by any applicable Laws, (iii) to assert claims and initiate legal action for breach of fiduciary duty against  any person or entity, and (iv) to endorse for me any checks made payable to me for benefits and claims collected toward my account. 

In the event the insurance carrier responsible for making medical payments to Modern Orthopaedics of New Jersey and Peter DeNoble MD, David Ratliff MD, Lorraine Stern MD for medical services rendered to me does not accept my assignment of benefit rights, or my assignment is challenged or deemed invalid, I execute this limited/ special power of attorney and appoint and authorize Provider and his/her/its attorney (or other representative) as my agent and attorney, in fact, to assert any and  all of my benefit and non-benefit rights for and on my behalf, including, without limitation, to bring any appeal, pre-litigation demand, demand for payment,  arbitration, lawsuit, independent dispute resolution or administrative proceeding, for and on my behalf, in my name against any person and/or entity involved in  the determination and payment of benefits under any insurance policy or benefit plan. I agree that any recovery shall be applied to payment due my  provider including attorney fees and costs. To this end, Provider has exclusive settlement authority.  

Designated Authorized Representative 

I hereby appoint as a Designated Authorized Representative each of my Providers and each of their respective assistant surgeons, physician assistants, teaching  assistants, billing staff, lawyers (including Cohen Howard, LLP) or any other person or business that provides healthcare activity services as a “business associate’  under the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”), and their respective designees (collectively referred to herein as  an “Authorized Representative”). This authorization is intended to comply with all requirements of the Employment Retirement Income Security Act of 1974, as  amended (ERISA”) and any applicable State law. Each Authorized Representative is granted the same rights which I have as a member or beneficiary under my  insurance policy or benefit plan, including without limitation:  

1. The right of my Authorized Representative to file claims for benefits on my behalf and directly receive payment for benefits and non-benefits under my insurance  policy or benefit plan, including the right to penalties, interest and attorney fees. 

2. The right of my Authorized Representative to communicate with insurers, plan fiduciaries, employers and plan and claim administrators relative to all my benefit  information and protected health information (“PHI” as further defined under HIPAA) and to share and exchange such information with a “covered person” or  “business associate” as those terms are defined under HIPAA.  

3. The right of my Authorized Representative to send and receive follow-up information and obtain all documentation that ERISA or any State law requires to be  provided to me, including, without limitation, plan documents, explanation of benefits, adverse benefit determinations, all relevant documents involving my claim,  identity of all persons involved in determining my claim and all documents relied upon in making any determination as to the payment of any amount under the  applicable plan documents. 

4. The right of my Authorized Representative to file any internal or external member appeal for payment of benefits under any applicable insurance policy or benefit  plan. 

5. The right of my Authorized Representative to pursue any rights, claim or cause of action through pre-litigation demands, demands for payment, arbitration,  independent dispute resolution or administrative proceeding, litigation or otherwise under any Federal or State law with respect to payment for services provided  by a Provider to me, including penalties, interest and attorney fees. 

6. The right of my Authorized Representative to receive a genuine copy of my ANSI X12 electronic digital interchange (EDI) data files to include the fully-adjudicated  EDI 837 invoice to Plan Sponsor, the ERA835, and the IRS 5500 Form (Plan Annual Return) in connection with healthcare services provided. Release of Private Health Information 

It is specifically intended that any Provider or Authorized Representative is authorized and directed to provide and release my PHI for purposes of exercising all  rights and benefits set forth in this Assignment of Benefits/Designated Authorized Representative authorization to any ”covered person” or ”business associate”,  including third-party payors, internal and external utilization review organizations, regulatory review entities and other organizations and/or companies that may/ will assist with claims processing/reimbursement. I also direct any plan or claim administrator or plan sponsor to share all PHI with any Provider or Authorized  Representative and not to inhibit the exercise of rights under my insurance policy or benefit plan by requiring any further authorization signed by me. I understand  that I remain fully responsible for any billed charges remaining due for services provided to me by a Provider, including co-pays, co-insurance and deductibles. If I  receive any check or other payment from an insurance company or third-party payor for services rendered to me by a Provider, I will immediately endorse the  check over to the Provider or otherwise make payment to the Provider for the amount of payment received from such insurance company or third-party payor. I  agree that if the Provider is required to pursue collection efforts against me for these amounts, I will be responsible for all legal fees, interest and costs associated  therewith. 

This Assignment of Benefits/Designated Authorized Representative authorization/ Limited Special Power of Attorney shall remain in full force and effect for all  current and future dates of service, until such time that all rights have been exercised under applicable Federal and State law as determined by Providers. I may  revoke or withdraw this authority upon written notice to the Providers. In the event of any revocation, I will be responsible for payment of all outstanding amounts  then due to the Providers.

 

I hereby acknowledge and understand that even with the best training, skill and experience, a  medically trained professional is not always capable of solving my medical problems. Therefore; 

✔ I understand it is important that any and all recommendations by doctors are  followed completely in order to increase the likelihood of a positive and healthy  treatment/outcome.  

✔ I acknowledge and understand that if any physician in this office prescribes medicine to  me, that the proper taking of any such medicine shall be my sole responsibility (or my  guardian who has attended this consultation). I agree to properly follow the prescribed  dosage and frequency amounts of these medicines as recommended by my doctor. 

✔ I understand that if a doctor in this office refers me to see another doctor or receive  another test including, but not limited to, a blood test, an MRI, or CT scan, this timely  recommendation is important and essential to the ultimate success of my treatment/outcome.  

✔ I understand that it is not possible for any person in this office to constantly follow-up to  ensure that I have followed these recommendations. Therefore, I understand that if I fail  to see that specialist or obtain the test for which I was referred immediately, this can  risk my current health or increase future health risks. 

✔ I understand that it is solely my responsibility to follow any of the medical advice  given by any medical person in this office and any bad health outcome from my failure  to follow the advice of my doctors should be expected. 

THIS CONSENT DOES NOT GRANT PERMISSION FOR MODERN ORTHOPAEDICS of NEW JERSEY (MONJ) TO USE MY NAME OR FACE IN ANY PHOTOGRAPH or VIDEO.

I do grant permission and give my consent for MONJ to take photographs and/or videos of parts of my body parts in isolation as they relate to my treatments, procedures, or surgeries that are performed.  I understand that photographs or videos may be taken before, during, and after my procedure(s) as a routine part of my medical care. 

I authorize the use of these photographs and/or videos for educational purposes in the form of social media posts (Instagram, Facebook, LinkedIn, Etc), MONJ advertisements, placement on the MONJ website, or in medical or other publications as a voluntary contribution in the interest of educating/informing the public about orthopaedic methods and patient experiences. 

I understand that I will never be personally identified by name or face in any of these photographs without my separate consent, but that in some circumstances the photographs may portray features which make my identity recognizable to some, such as a tattoo or birthmark.

Release of Photographs and Videos

I waive any right to inspect or approve the finished product, advertising or other copy that may be used in connection with mediums aforementioned.

I release and discharge MONJ, the facility used, and all parties acting under their license and authority from any and all claims and actions that I have or may have relating to such use and publication of the photographs or videos.

I understand that refusal to consent to photographs and/ or video recordings will in no way affect the medical care I will receive.  If I have any questions or wish to withdraw my consent in the future, I may contact the staff at MONJ.

I certify that I have read the above Consent and Release and fully understand its terms.  I grant this consent voluntarily.

In the event I do not wish to grant this consent to my doctor, I will write “NO CONSENT” in the signature field below.

Modern Orthopaedics of New Jersey (MONJ) understands that personal situations may arise  and you may need to cancel your appointment. If you must cancel or reschedule your  appointment, we kindly ask that you try to do so at least 24 hours in advance. We understand  that extenuating circumstances may arise, however if missing appointments becomes a habit,  then you will be charged a $50.00 fee. 

We respect the time of all our patients. We try to stay on schedule so that you do not have to  wait. If you are delayed and arrive late for your appointment, every effort will be made to see  you the same day, but you may have an abbreviated visit, or you may be asked to wait or  reschedule your appointment. 

INSURANCE CHECK TO PATIENT POLICY NOTICE 

It may be the customary practice of your insurance plan and/or agents acting on its behalf to send  payment for services performed by providers of Modern Orthopaedics of New Jersey directly to  you despite us obtaining authorization and/or assignment of benefits. N.J.S.A. 26:2S6.1(c)  requires a health carrier offering a managed care plan that provides for both in-network and out of-network benefits to remit payment for the reimbursement of medically necessary health care  services direct to the health care provider if the patient has assigned their healthcare benefits. The  Act further provides that if payment is remitted to the covered person solely, when a covered person has assigned his or her benefits to an out-of-network provider, the payment will be  considered unpaid and overdue. 

Healthcare reimbursements which are not utilized for healthcare benefits may be considered  miscellaneous compensation and taxable to both the plan participant and the plan. In addition,  under the Affordable Care Act (ACA), it may not be claimed as a part of medical loss ratio by your  plan or the plan administrators. 

  

I understand that if I receive healthcare reimbursements from my insurance carrier and do not either forward that payment to MONJ or make other arrangements,  that reimbursement may be taxable as income to me and reported appropriately. Furthermore,  under the ACA it may not be claimed as a part of medical loss ratio by the health plan or the plan  administrators. I understand and agree that I am legally responsible for any and all actual total  charges expressly authorized by me regardless of any applicable insurance or benefit payments. 

By Signing this form, I agree that when I receive any payments for the services  performed on this date of service I will: 

• Sign the check and do not deposit or cash it. 

• After making copies, enclose the check with all the accompanying letters or forms such as  Explanation of Benefits (EOB), place in an envelope and immediately mail to: 

Modern Orthopaedics of New Jersey 

P.O. BOX 4239 

Wayne,NJ 07474 

• Or, drop it off to the MONJ office in person.

 In the event that the insurance reimbursement check for these services is not immediately sent to  MONJ or other arrangements made; I will be; 1) Responsible for full payment of services  regardless of any financial hardship policies which have been agreed to by me; 2) understand that  collection procedures will be initiated, which includes reporting to the appropriate credit reporting  agencies; and 3) miscellaneous tax implications may apply. In addition to full payment, I  understand I will be responsible for reasonable interest and penalties including collection fees and  legal costs, as incurred by MONJ, in order to collect payment for services rendered by this  provider. 

A copy of this agreement can be provided to you as a reminder of what is required when you  receive the payment from your insurance company.