Workers Compensation Form

ISLAND NEURO CARE

924 North Broadway, Suite 2, Massapequa, NY 11758
Phone (516) 520-5507, Fax (516) 520-5493

Birendra K. Trivedi, M.D.

Padmaja Aradhya, M.D.

*Patient Name:

*DATE OF BIRTH:

Medication List

1) Name of Medication:

Direction:

Dosage:

2) Name of Medication:

Direction:

Dosage:

3) Name of Medication:

Direction:

Dosage:

Registration Form

*Date:

*Patient Full Name:

*Home Phone:

*Cell Phone:

Responsible Party (if a minor):

Home Phone:

Cell Phone:

*Street Address:

*City:

*State:

*Zip:

Age:

*Date of Birth:

MaleFemale

*Relationship Status:

Patient Employer/School:

Employer/School Address:

Occupation:

Employer/School Phone:

(Cardholder) Employed by:

Business Address:

Occupation:

Business Phone:

*Purpose of visit:

Social Security Number (Optional):

Card Holder Info:

Relationship to Patient:

Name:

DOB:

*Do you have Medical Insurance?

*Name of Primary Insurer:

*Contact #

*Group #

*Subscriber #

Name of Secondary Insurer:

Contact #

Group #

Subscriber #

Insurance Type:

Claim ID #

Medical/Primary Dr. Information:

INSURANCE ASSIGNMENT AND RELEASE

I certify that I, and/or my independent(s), have Insurance coverage with: ,
and assign directly to Dr.

all Insurance benefits, if any, otherwise payable to me for services rendered, I understand that I am financially responsible for all charges whether or not paid by Insurance. I authorize the use of my signature on all Insurance submissions.

The above-named physician may use my health care Information and may disclose such information to the above-named insurance Company(ies) and purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related service. This consent will end when current treatment plan is completed or one year from the date signed below.

Name of Patient, Parent, Guardian or Personal Representative:

Relation:

Date:

*In case of emergency, who should be notified?:

*Phone #

Your Drugstore Name:

Phone #

is giving Island Neuro Care, P.C. permission to speak to the following family members.

1st Relative Information

Name:

Phone #

Relationship:

2nd Relative Information

Name:

Phone #

Relationship:

3rd Relative Information

Name:

Phone #

Relationship:

NOTICE OF PRIVACY PRACTICES (Effective as of APRIL 14, 2003)

Record of Acknowledgements

Island Neuro Care P.C, is committed to preserving the privacy and confidentiality of your health information whether created by us or maintained on our premises. We are required by certain state and federal regulations to implement policies and procedures to safeguard the privacy of your health information. We are required by state and Federal regulations to abide by the privacy practices described in the notice provided to you including any future revisions that we may make to the notice as may become necessary or as authorized by law.

Changes or Revisions to our Notice of Privacy Practices

We reserve the right to change our facility's Notice of Privacy Practices at any time and to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future about you. Should we revise or change our Privacy Notice, we will post a copy of the new or revised notice in our main lobby. You may obtain a copy of the new/revised Privacy Notice from the registration department.

Privacy Notices, Information Restrictions, Record Amendments/Corrections, Disclosures of Information, Revoking an Authorization, Inspection and Copying of Records, Confidential Communications, Filing Complaints, Etc.

Should you have any questions concerning Island Neuro Care P.C., privacy practices, obtaining copies of our Notice of Privacy Practices, requesting restrictions on the release of your information, revoking an authorization, amending or correcting your health information, obtaining a listing of the information we disclosed concerning your health information, requests to inspect or copy your medical information, requests that we communicate information about your health matters in a certain way, denial of access to your health information, filing complaints, or any other concerns you may have relative to our facility's privacy practices, please contact:

Privacy Officer
Island Neuro Care P.C.
924 N. Broadway Massapequa,
NY 11758
516-520-5507

YOU MAY ALSO FILE COMPLAINTS
U.S. Department of Health and Human Services
200 Independence Avenue,
S.W. Washington, DC 20201
(202) 619-0257
Toll Free 1-877-696-6775

Record of Acknowledgements

I certify that I received a copy of this facility's Notice of Privacy Practices and that I have had an opportunity to review this document and ask questions to assist me in understanding my rights relative to the protection of my health information. I am satisfied with the explanations provided to me and I am confident that the facility is committed to protecting my health information.

Your Name:

Date:

Witness Name:

Date:

I certify that I am the authorized representative of: and that I have received the Notice of Privacy Practices on behalf of this individual and that the facility provided me with an opportunity to review this document and ask questions to assist me in understanding his/her privacy rights. I am satisfied with the explanations provided to me and I am confident that the facility is committed to protecting health information.

Representative Name:

Date:

Relationship to Individual:

Witness Name:

Date:

WORKMAN COMPENSATION INFORMATION

Patient's Name:

Date of Accident:

Carrier Case #:

Insurance Career:

Address:

Phone:

Person handling Claim:

Days out of work:

Returned to work:

ISLAND NEURO CARE

Medication List

Registration Form

Card Holder Info:

*Do you have Medical Insurance?

INSURANCE ASSIGNMENT AND RELEASE

1st Relative Information

2nd Relative Information

3rd Relative Information

NOTICE OF PRIVACY PRACTICES (Effective as of APRIL 14, 2003)

Record of Acknowledgements

Changes or Revisions to our Notice of Privacy Practices

Record of Acknowledgements

WORKMAN COMPENSATION INFORMATION

WORKER COMPENSATION INFORMATION

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