Summit Digestive & Liver Disease Specialists

HIPAA Notices of Privacy Practices/Power of Attorney/Appointment and Procedure Cancellation Policy/Advance Beneficiary of Non-Coverage

Your Right to Privacy

We respect your right to privacy regarding medical information. May we share information with your spouse?

If so, their Name

Contact Number

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

Add Additional Name

I authorize David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, M.D, Albert Saporta, M.D., and/or the Nurse Practitioners, to access my electronic prescription records for continued care and further treatment

The Summit Digestive and Liver Disease Specialists facilities are hereby authorized to review/access my Summit Digestive and Liver Disease Specialists medical record, treatment record and diagnostic record

I Acknowledge and agree that I have access to print or read the notice of Privacy Practices for David C. Chua, M.D., Rajeev Nayar, M.D., Maria Hernandez, M.D, and/or Albert Saporta

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

Name

Date

Power of Attorney

Definition: A legal document giving a person the power to make decisions for another person, (e.g. current medical decisions, financial decisions).

Name of person who holds Power of Attorney

Phone Number

Appointment and Procedure Cancellation Policy

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:

$25.00 Charge for cancelled office visit without giving at least one (1) business days’ notice.
$50.00 Charge for cancelled procedures without giving at least two (2) business days’ notice.

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

Patient Name

Date

Advance Beneficiary Notice of Non-Coverage (ABN)

(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

WHAT YOU NEED TO DO NOW

Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the (D. ) listed above.

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

OPTION 1. I want the (D. ) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 2. I want the (D. ) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
OPTION 3. I don't want the (D. ) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

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

I. Name

If you are not of Medicare age please put N/A

J. Date

Medicare Long Term Authorization

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.

Name

If you are not of Medicare age please put N/A

Date

(Authorization good for one year from the above date)

A. Notifier: Summit Digestive & Liver Disease Specialists

B. Patient Name

If you are not of Medicare age please put N/A

C. Identification Number

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

Medicare Secondary Payer Questionnaire

1. Are you receiving benefits from any of the following programs?

Black Lung

Yes No

Research Grant

Yes No

Veterans Affairs

Yes No

(If yes to any of the above, STOP – Medicare is secondary)

2. Was the illness/injury due to a work-related accident/condition? (If yes, STOP – Medicare is secondary)

Yes No

3. Was illness/injury due to a non-work related accident? (If yes, STOP – Medicare is secondary)

Yes No

3. Was illness/injury due to a non-work related accident? (If yes, STOP – Medicare is secondary)

Yes No

4. Are you entitled to Medicare based on

Age Disability End Stage Renal Disease

5. Do you have health insurance sponsored through your own or spouse's employer? (If NO – Proceed to question 7)

Yes No

6. Does the employer that sponsors your insurance plan employ 100 or more employees? (If yes, STOP – Medicare is secondary)

Yes No

7. Are you currently a patient in a skilled nursing facility (SNF) such as a nursing home? (If yes, we will bill SNF, not Medicare)

Yes No

I confirm that to the best of my knowledge, the above information is accurate

Patient Signature

Date

If no, please be aware we are unable to schedule you without proper identification and insurance information. Thank you for your understanding.

Email address

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