NO_FAULT_INTAKE

Patient details

Patient information

Last name

First name

Address

City

State

ZIP code

Email address

Home phone

Phone number

Business phone

Date of birth

Social Security number (optional)

Sex

MaleFemale

Pharmacy

Pharmacy name and address

Pharmacy phone

Law firm

Law firm name

Phone number

Fax number

Email

Patient signature (type full name)

Date signed

Accident & insurance

Application and insurance information

Application date

Policy holder

Policy number

Claim number

Insurance carrier name

Insurance carrier address

New York Motor Vehicle No-Fault Insurance Law — Application for Motor Vehicle No-Fault Benefits. To enable us to determine if you are entitled to benefits under the New York No-Fault Law, please complete this form and return it promptly.

To be eligible for benefits you must complete and sign this application.
You must sign any attached authorization(s).
Return promptly with copies of any bills you have received to date.

Applicant name and address:

Accident information

6. Date of accident

Time of accident

7. Place of accident (street, city or town, and state)

8. Brief description of accident

9. Describe your injury

10. Vehicle you occupied or operated at the time of accident

Owner’s name

Make

Year

This vehicle was:

TruckMotorcycleBus or school busAutomobile

Care & work loss

Treatment and expenses

12. Were you treated by a doctor(s) or other person(s) furnishing health services?

YesNo

Name and address of such doctor(s) or person(s)

13. If you were treated at a hospital(s), were you an:

Out-patientIn-patient

Date of admission

Hospital’s name and address

14. Amount of health bills to date ($)

15. Will you have more health treatment(s)?

YesNo

Employment and lost time

16. At the time of your accident were you in the course of your employment?

YesNo

17. Did you lose time from work?

YesNo

Date absence from work began

Have you returned to work?

YesNo

If yes, date returned to work

Amount of time lost from work

18. Average weekly earnings ($)

Number of days you work per week

Number of hours you work per day

19. Were you receiving unemployment benefits at the time of the accident?

YesNo

20. Employers for one year prior to the accident date

List employer names and addresses, occupation, and dates of employment.

Employer 1

Employer name and address

Occupation

From

To

Employer 2

Employer name and address

Occupation

From

To

Employer 3

Employer name and address

Occupation

From

To

Other expenses and benefits

21. As a result of your injury have you had any other expenses?

YesNo

If yes, explanation and amounts of such expenses

22. Due to this accident have you received or are you eligible for New York State Disability payments?

YesNo

Due to this accident have you received or are you eligible for Workers’ Compensation payments?

YesNo

THE APPLICANT AUTHORIZES THE INSURER TO SUBMIT ANY AND ALL OF THESE FORMS TO ANOTHER PARTY OR INSURER IF SUCH IS NECESSARY TO PERFECT ITS RIGHTS OF RECOVERY PROVIDED FOR UNDER THE NO-FAULT LAW.

THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

I affirm the application as stated above.

Applicant signature (type full name)

Date signed

NYS FORM NF-2 (Rev. 1/2004). Bracketed language to be filled in by insurer or self-insurer.

Benefits assignment

New York Motor Vehicle No-Fault Insurance Law — Assignment of Benefits Form

For accidents occurring on and after 3/1/02.

I, , (“Assignor”) hereby assign to Farshad Hannanian, M.D., (“Assignee”) all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law.

The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle accident which occurred on , not withstanding any other agreement to the contrary.

This agreement may be revoked by the assignee when benefits are not payable based upon the assignor’s lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.

Print name of patient

Address of patient:

I agree to the assignment of benefits above.

Patient signature (type full name)

Date signed

Provider completion

Print name of provider

Address of provider

Provider signature (type full name)

Date signed

NYS FORM NF-AOB (Rev. 1/2004).

Authorizations

Authorization for release of work and other loss information

THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW).

Name (print or type)

Social Security no.:

I authorize release of work and other loss information as described above.

Signature (type full name)

Date signed

Authorization for release of health service or treatment information

THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW).

Name (print or type)

Capacity and relationship, if signing for a minor

I authorize release of health service or treatment information as described above.

Signature (type full name)

Date signed

If the applicant is a minor, parent or guardian shall sign and indicate capacity and relationship.

Authorization for release of documented information from the insurance company to the provider

Patient’s name:
Date of accident:

I hereby am granting the medical provider, Dr. Farshad D Hannanian, treating me for my no-fault case, permission to obtain any and all no fault information pertaining to my case. This includes PEER reviews, IME or any other documentation that the providing physician may need in order to obtain payment for my claim.

I authorize the release of information described above.

Patient signature (type full name)

Date signed

Patient consent form for neurological testing

I agree to give the consent that the neurodiagnostic study (NCV/EMG) of upper and Lower limbs be performed on me for the purpose of radicular and neuropathic pathology.

I consent to the neurological testing described above.

Patient signature (type full name)

Date signed

Privacy notice

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. This notice is provided in two layers: This first layer briefly summarizes how we handle your health information; the second layer is a full copy in greater detail of our privacy policies and procedures and is prominently posted in our waiting room and copies of which are available and provided to you at our front desk.

How we many use and disclose your health information. We use health information about you for treatment, to get paid for treatment, for administrative purposes, and to evaluate the quality of care that you receive. For example, your health information may be shared with other providers to whom you are referred. Information may be shared by paper mail, electronic mail, fax, or other methods. We may use or disclose your health information without your authorization for several reasons. But beyond those situations, we will ask for your written authorization before using or disclosing your health information. If you sign an authorization to disclose information you can later revoke it to stop any future uses and disclosures.

Your rights. In most cases, you have the right to look at or get a copy of your health information that we use to make decisions about you. If you request copies, we may charge you a cost-based fee. You also have the right to request a list of certain types of disclosures of your information that we have made. If you believe your health insurance is incorrect or information is missing, you have the right to request that we correct the existing information or add missing information.

Our legal duty. We are required by law to protect the privacy of your health information, provide this notice about our privacy practices, follow the privacy practices that are described in this notice, and seek your acknowledgement of receipt of this notice. We may change our privacy policies anytime. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more information about our privacy policies, contact the person listed below.

Privacy complaints, if you are concerned that we have violated your policy rights, our privacy policies, or if you disagree with a decision we made about access to your health information, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.

If you have any questions or complaints, please contact: Farshad D. Hannanian, M.D.,

475 Northern Blvd. Suite 18 Great Neck, NY 11021. (516)-773-3048.

Acknowledgement of receipt of Notice of Privacy Practices: Please sign and print your name and provide the date below acknowledge that you have received both layers of this Notice of Privacy Practices. Then return this acknowledgement of receipt to the receptionist or to the address above.

Name

Patient’s name, if other than signature

I acknowledge receipt as described above.

Signature (type full name)

Date signed

Doctors’ lien

Medical reports and doctors’ lien

This page is shown from the supplied scan. Some wording at the right edge is cut off in the source.

Open the supplied lien page at full size Medical reports and doctors’ lien, as scanned in the supplied packet

Patient completion

To: Attorney

Attorney address

RE: Patient:
Date of accident:
Patient’s name and address: ,

I have reviewed the lien and assignment shown above.

Patient signature (type full name)

Date signed

Attorney completion

Attorney’s name

Attorney’s address

Attorney signature (type full name)

Date signed

No Fault Intake

Patient details

Patient details

Patient information

Pharmacy

Law firm

Accident & insurance

Application and insurance information

Accident information

10. Vehicle you occupied or operated at the time of accident

11. Your role and household

Care & work loss

Treatment and expenses

Employment and lost time

20. Employers for one year prior to the accident date

Employer 1

Employer 2

Employer 3

Other expenses and benefits

Benefits assignment

New York Motor Vehicle No-Fault Insurance Law — Assignment of Benefits Form

Provider completion

Authorizations

Authorization for release of work and other loss information

Authorization for release of health service or treatment information

Authorization for release of documented information from the insurance company to the provider

Patient consent form for neurological testing

Privacy notice

Doctors’ lien

Medical reports and doctors’ lien

Patient completion

Attorney completion