HIPAA Notice of Privacy Practices
We respect your right to privacy regarding medical information. May we share information with your spouse?
We understand that you may have concerned relatives. Please list names of adult children, other family members and/or contact persons with whom we may share information without additional written consent
I have read, acknowledged and agree to the terms above
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application
Definition: A legal document giving a person the power to make decisions for another person, (e.g. current medical decisions, financial decisions).
I understand that David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, and/or Albert Saporta reserve the right to the following in the event that you need to reschedule:
This allows other patients to be scheduled into the appointment slot and for you to be efficiently rescheduled
I have read, acknowledged and agree to the terms above
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application
(If you are not of Medicare age please put N/A)
NOTE: If Medicare doesn't pay for (D. ) below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the (D. ) below
E. Reason Medicare May Not Pay: Not indicated for diagnosis and/or treatment in this case
F. Estimated Cost: No More than $600
Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
G. OPTIONS: Check only one box. We cannot choose a box for you
H. Additional Information
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application
I request that payment of authorized Medicare Benefits be made on my behalf for any service furnished to me by David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, and/or Albert Saporta, and/or the Nurse Practitioners. I authorize any holder of medical or other information about me be released to the Health Care Financing Administration and its agents for any information needed to determine these benefits for related services.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application
(Authorization good for one year from the above date)
A. Notifier: Summit Digestive & Liver Disease Specialists
CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn; PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (Exp. 03/2020)
Form Approved OMB No. 0938-0566
1. Are you receiving benefits from any of the following programs?
(If yes to any of the above, STOP – Medicare is secondary)
I confirm that to the best of my knowledge, the above information is accurate
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application
If no, please be aware we are unable to schedule you without proper identification and insurance information. Thank you for your understanding.
Your information will be encrypted.