Primary Insurance Information

PRIMARY INSURANCE INFORMATION:

NAME OF INSURANCE CARRIER: ______

INSURANCE CARRIER’S BILLING ADDRESS: ______

POLICY HOLDER’S NAME: ______RELATIONSHIP TO PATIENT: ______

POLICY HOLDER’S SOCIAL SECURITY NUMBER: ______DATE OF BIRTH: ______

POLICY ID# ______GROUP NUMBER: ______

NAME/ADDRESS OF POLICY HOLDER’S EMPLOYER: ______

DOES THIS POLICY HAVE A CO-PAYMENT AMOUNT? ______IF SO, WHAT IS THE AMOUNT? ______

SECONDARY INSURANCE INFORMATION:

NAME OF INSURANCE CARRIER: ______

INSURANCE CARRIER’S BILLING ADDRESS: ______

POLICY HOLDER’S NAME: ______RELATIONSHIP TO PATIENT: ______

POLICY HOLDER’S SOCIAL SECURITY NUMBER: ______DATE OF BIRTH: ______

POLICY ID#: ______GROUP NUMBER: ______

NAME/ADDRESS OF POLICY HOLDER’S EMPLOYER: ______

PLEASE PROVIDE THE FRONT DESK WITH THE INSURANCE CARD(S) WHICH IS LISTED ABOVE AS WELL AS A PHOTO ID TO VERIFY YOUR IDENTITY.

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DAVID F. JAFFE, M.D., P.A. NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to :

-Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

-Obtain payment from third party payers.

-Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand the Notice of Privacy Practices of David F. Jaffe, M.D., P.A. containing a more complete description of the uses and disclosures of my health information. I understand that David F. Jaffe, M.D., P.A. has the right to change its Notice of Privacy Practices from time to time and that I may contact the office at any time at the address provided to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that David F. Jaffe, M.D., P.A. restrict how my private information is used or disclosed to carry out treatment, payment or health care operation. I also understand David F. Jaffe, M.D., P.A. is not required to agree to my requested restrictions, but if the corporation agrees then the corporation is bound to abide by such restrictions.

Sharing information with those involved in my care:

_____ Yes, you may speak with any member of my family and/or

_____ these individuals: ______

_____ No, do not speak with my family or friends about my healthcare unless I give you specific permission at a later time.

PATIENT NAME: ______RELATIONSHIP TO PATIENT: ______

SIGNATURE: ______DATE: ______