Patient Information Form
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1 Francisco J. Gomez, MD, FAHS, FAHA Tracy Posdzich, PMHNP-BC 110 Wolf Rd. Albany, NY voice: fax: Patient Information Form Chief Complaint (reason for being seen) I am interested becoming certified for Medical Marijuana: YES NO Patient Name Mailing Address Phone Number: Hm: Cell: Responsible Party Name Mailing address Phone Number: Hm: Cell: Employer Work Phone Employer Work Phone DOB Gender SSN DOB Gender SSN Primary Ins Subscriber Name Group/Policy # Relationship to Patient Secondary Ins Group/Policy # Marital Status: Single Married Widow Subscriber Name Relationship to Patient Marital Status: Single Married Race: Asian Black/African American Native American/Alaskan Native Multi-Racial Caucasian Hispanic Native Hawaiian/Pacific Islander Unknown/Refused Ethnicity: Latino/Hispanic Non-Latino/Non-Hispanic Unknown/Refused Preferred Language: English Arabic Armenian Chinese French German Greek Gujarati Hindi Italian Japanese Korean Persian Polish Portuguese Russian Spanish Tagalog Urdu Vietnamese Other Patient information form vs
2 Who May We Contact in Case of Emergency Name Patient Relationship to Contact? Primary Phone Number Secondary Phone Number PATIENT'S FINANCIAL RESPONSIBILITY I understand that I am financially responsible for my health insurance deductible, coinsurance or noncovered service. Co-payments are due at time of service. If my plan requires a referral, I must obtain it prior to my visit. In the event that my health plan determines a service to be not payable, I will be responsible for the complete charge and agree to pay the costs of all services provided. If I am uninsured, I agree to pay for the medical services rendered to me at the time of service. NOTICE OF NOT ACCEPTING WORKER'S COMPENSATION AND NO-FAUL INSURANCE I hereby state that my condition is not covered under a Worker's Compensation or No-Fault insurance plan, and understand that Gomez Neurology does not accept such plans as payment. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS I hereby authorize and direct payment of my medical benefits to Gomez Neurology on my behalf for any service furnished to me by the providers. Signature Date
3 Obtaining Verbal/Written Permission to Use or Disclose Protected Health Information From time to time Gomez Neurology may need to collect or disclose your protected health information to individuals involved in your care for notification purposes. As stipulated by the Title 45, Section , we are permitted to make such uses or disclosures after we have obtained your verbal or written permission. Gomez Neurology is authorized to: (please check all that apply) Collect Protected Health Information from: Practice Name Date of Birth Practice Address Practice phone Fax Notify or speak regarding treatment or proposed treatment with (please specify name): (please specify name): Other (please specify): Name of Patient Signature of Patient address Date
4 How may we contact you with reference to your appointments, proposed treatment, follow-up appointments, billing questions/problems, surgery scheduling, lab testing, radiology, and other situations regarding your protected health information? HIPAA-compliant permission Statement I authorize Gomez Neurology its providers and employees to leave detailed messages specific to my medical care, including test results, through HIPAA-Compliant at the address listed below. I understand that this authorization can be revoked at any time by submitting a written request to Gomez Neurology. This authorization is not required to receive care at Gomez Neurology. Patients opting not to sign this authorization will receive medical information such as test results through the phone or USPS mail rather than a voice messaging system or . Name of Patient Signature of Patient address Date Voic Permission Statement I authorize Gomez Neurology its providers and employees to leave detailed messages specific to my medical care, including test results, on the telephone number listed below. I understand that when a voic message exists, it is no longer covered under the Health Insurance Portability and Accountability Act of 1996 and therefore is not protected from unauthorized access. I understand that this authorization can be revoked at any time by submitting a written request to Gomez Neurology. This authorization is not required to receive care at Gomez Neurology. Patients opting not to sign this authorization will receive medical information such as test results through the phone or USPS mail rather than a voice messaging system or . Name of Patient Signature of Patient address Date
5 Medical Marijuana Thank you for your interest in New York State's Medical Marijuana program. Below you will find some answers regarding the program. Dr Gomez is certified with New York State to recommend and certify patients for the Medical Marijuana program who meet the state's criteria. To be certified in the Medical Marijuana program, patients must have one of the following conditions: cancer, amyotrophic lateral sclerosis (ALS), Parkinson's disease, multiple sclerosis, damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity, epilepsy, inflammatory bowel disease, neuropathy, PTSD, or Huntington's disease associated with severe or chronic pain, severe nausea, seizures, or severe or persistent muscle spasms, or chronic pain. Marijuana-related visits are solely for the purpose of certifying medical marijuana in the state of New York, and is not for the purpose of treating any conditions except through medical marijuana. Gomez Neurology's medical marijuana visits are cash only and we do not accept any insurances for its certification. If you wish to be seen for your neurological problem, please call the office at for details. The process of making an appointment Dr Gomez requires copies of your last two medical visits (dated in the last 12 months), showing your exact diagnosis before your you can be considered for the program. Medical records may be faxed to our office at (888) or ed to us at DO NOT MAIL IN YOUR MEDICAL RECORDS, AS THEY WILL BE DESTROYED UNREAD. If you prefer, you can complete a Release Of Information form which is attached to this . This completed form gives us permission to seek these records from your specified physicians for you. Once we have received your medical records and they've been reviewed and it appears that you would be a good candidate for the medical marijuana program, our office will call to schedule an appointment. Medical marijuana-related office visit costs: There are two payment plans you can choose from. The first, is a total of $275: $100 (non refundable) upon scheduling your appointment, and the remaining $175 at the initial appoitment. Or, if you prefer, there is a payment plan. Please contact your scheduler at Gomez Neurology for further details. Payment methods include cash or credit card. Yearly re-certification visit is $70.
6 Medical Marijuana FAQ What forms medical marijuana are allowed? The Commissioner currently approved forms include liquids and oil for vaporization via inhaler, oral spray, inhaler, tincture and capsules to take orally. Under the law, smoking and edibles are not permitted. Do I have to pay the state to register as a patient or as a caregiver? Yes, there is a non-refundable application fee of fifty dollars ($50) that will be billed to you at a later date. When can I expect my registry identification card to arrive? Once your application to register has been submitted successfully and approved, please allow approximately 3-5 business days to receive your Patient or Caregiver Registry Identification Card via mail. Once you have received your registry ID card you may visit a registered organization's dispensing facility to obtain medical marijuana products. Which dispensing facilities may I use? A certified patient may receive medical marijuana products from any dispensing facility of any Registered Organization in New York State. Will every dispensing facility sell the same types of Medical Marijuana? No. There are only two New York State-mandated products for Medical Marijuana (one with an equal ratio of THC to CBD, and one with a low-thc-high-cbd ratio) that must be offered by each Registered Organization. Each Registered Organization will also offer other products that have varying ratios of THC to CBD. How much medical marijuana can be dispensed at a visit? Registered Organizations may dispense up to a 30-day supply of medical marijuana to a certified patient or designated caregiver. Can I use my out-of-state medical marijuana identification card to purchase medical marijuana in New York State? No. Only certified patients with a New York State registry identification card may purchase approved medical marijuana products in New York State.
7 How does the DOH ensure the quality of the products produced by the registered organizations? The Department requires independent laboratory testing for every brand of product to be tested for any contaminants and to ensure product consistency. Where will patients find the prices of Medical Marijuana? Patients should contact the Registered Organization directly to obtain final prices, taking into account the dosing recommendations of their physician. The total amount that a patient pays depends upon a patient's individual dosing needs and the resultant total quantity purchased. Important links from the New York State Medical Marijuana Program About and News & Updates Frequently Asked Questions Patient/Caregiver Information Laws & Regulations Registered Organizations CONTACT GOMEZ NEUROLOGY AT Call: ext 111 or reply to this to send a HIPAA compliant reply. Contact the New York State Medical Marijuana Program Call: mmp@health.ny.gov
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