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New Patients
Welcome to West Side ENT. We look forward to meeting you.
To save time and in order that we may expedite your visit, we ask that you either fill out your medical history form online on our secure server, or download it and complete the new patient medical history form below (PDF) and bring it with you for your appointment (see links below). You’ll require a PDF reader program such as Adobe Acrobat Reader to open this document. Mac computers have a PDF reader built-in (Preview).
We also ask that you be prepared to provide your credit card information at the time of service. This information is kept on file in the event of a discrepancy in payment, or as payment for coinsurances or deductibles as they are assigned to you by your insurance company at the time your claim is processed. For more info, read about our Complimentary Benefits Check.
Patient confidentiality is of the utmost importance to us. Therefore, your personal account information will never be distributed, nor will it be processed without your prior written consent.Thank you for your cooperation.
A. Online Registration Form
B. Download Medical History From (PDF)
C. Online Sleep-Breathing Form
D. Online Patient Survey
General Office Information
Our Financial Policy
HIPAA Privacy Information
Our E-mail policy
Disclosure Statement
Patient Financial Policy
At West Side ENT, we are committed to providing you with the best possible medical care, and this also means that our highly trained and knowledgeable staff will work with your insurance to maximize your coverage so you don't have to. Listed below are the services we provide:
· Complimentary Benefit Checks:
We'll call your insurance for you PRIOR to your first visit with us to provide you with an estimate of the charges that will and will not be covered by your insurance.
· Fast and Accurate Claims Processing:
We will complete, and submit all of your insurance forms for you electronically (or on whichever form that is appropriate)—even if we don't participate with your insurance plan.
· Appeals and Pre-certification Services For All Covered Services:
We take pride in managing your claims with 99% accuracy on timely filing and appeals submission processes to ensure that your claims are paid correctly to ensure that any administrative mistakes made by your insurance or by our office doesn't end up costing you unnecessarily. We also Pre-certify your prescriptions, procedures, and any other ancillary services that require pre-certification by your insurance company.
· Acceptance of Multiple Assignment of Benefits:
Currently, we accept discounted plan fees from over 25 major insurance companies including: Aetna, Cigna, Empire BC/BS, Oxford and United Healthcare (access our full list from our Insurance Participation section).
For your added convenience we also offer:
· Multiple Payment Methods:
We accept cash, checks, MasterCard, Visa or American Express.
· Pay by Phone Option:
Avoid any late fees by paying your bills by phone. Just call us with a credit card number and we can process it right away.
· Insurance Review & Analysis From Our "In-House" Claims Experts:
If you're ever confused about how your insurance claim/payment was processed, our friendly and knowledgeable Claims Coordinator will be happy to review these items with you at any time.
· No Confusing or Unexpected Bills:
Because we're ready to provide you with your financial
information prior to services, you'll rarely have to deal with
any confusing or unexpected bills few months after your
visit with Dr. Park.
Exceptions to this would be in case of:
1) Incorrect information:
Despite measures to ensure accuracy, sometimes your insurance benefits department will give us outdated or incorrect information at the time of service, in which case, the estimate we gave you may be different than what was actually covered when your claim is processed.
2) Insufficient Data:
If we were not given accurate and timely information (i.e. subscriber ID, primary insured's name, employer information etc) at the time of service to bill your claim properly
3) Other Physician's Office's Administrative Delays:
We'll be happy to contact your primary care physician prior to services if your insurance requires a referral from him/her for you to receive specialist services. However, we will not take responsibility for their inability or inaccessibility in delivering these referrals to us in a timely manner (most offices require a 48-72 hour turn around time for referrals so please contact them in advance).
4) Non-payment of claims by your carrier:
If your claims are still unpaid after 45 days (Prompt Pay period as mandated by New York State Insurance Commission).
There is a $3.00 billing fee in addition to a 1%/ $3.00 a month late pay interest for any outstanding balances still remaining in your account beyond the 30 days from the date of service (i.e. co-pays, coinsurance or deductibles)
A fee of $25.00 will be added to the amount balance for returned checks.
HIPAA Privacy Notice
NOTICE OF PRIVACY PRACTICES
Effective Date: April 14, 2003
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.
At West Side ENT, we respect the confidentiality of your medical information and will protect that information in a responsible manner. We have a comprehensive privacy program in place that meets the requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations, the government legislation that sets standards for the privacy of medical information.
West Side ENT follows all state privacy laws to which we are subject that do not conflict with the HIPAA Privacy Regulations. However, if a state privacy law conflicts with the HIPAA Privacy Regulations yet provides greater privacy rights or protections than the HIPAA Privacy Regulations, we will follow that state law.
We must follow the privacy practices that are described in this notice while it is in effect. We reserve the right to change our privacy practices and the terms of this notice at any time, as long as the changes are permitted by law. Before we make a significant change to our privacy practices, we will change this notice and send the new one to our current patients. This new notice will be effective for all medical information that we maintain, including medical information we created or received before the changes were made.
Additionally, please know that West Side ENT is required by law to maintain the privacy of your medical information and to give you this notice regarding your rights, our privacy practices and legal duties concerning your medical information.
Definition of Medical Information
When we refer to medical information in this notice, we mean information that is individually identifiable health information. This includes demographic information collected from you or created or received through your health plan, your employer or a health care clearinghouse.
This information relates to: (1) your past, present or future physical or mental health or condition; (2) the provision of health care to you or (3) past, present or future payments for the provision of health care to you.
Uses and Disclosures of Medical Information
This section provides you with a general description and examples of the ways your medical information is used and disclosed. Our uses and disclosures are not limited to these examples.
Treatment: Your medical information may be used or disclosed to a physician or other health care provider in order for them to provide you with treatment.
Payment: Your medical information may be used or disclosed
* for billing, claims management and collections activities.
* to get our claims payments from your insurance carrier
* to determine your eligibility for benefits.
* to conduct risk adjustment activities.
* to obtain "precertification" or "pre-authorization" from your
insurance carriers for medically necessary procedures or
services.
* to obtain information regarding your premiums, deductibles
or co-insurances..
Health Care Operations: Your medical information may be used and disclosed in connection with our health care operations, including
* quality assessment and improvement activities and protocol
development.
* conducting or arranging for medical review, legal services,
auditing and fraud and abuse detection and compliance
programs.
* business management and general administrative activities,
including management activities relating to privacy, patient
service and resolution of internal grievances.
Additional Disclosures: Your medical information may be disclosed to other persons or entities that assist us in conducting our payment, health care operations and business activities. We will not disclose your medical information to those persons or entities unless they agree to keep it protected.
Health-Related Services: Your medical information may be used to send you appointment reminders or to communicate with you for purposes of treatment, or to direct or recommend alternative treatments, therapies, health care providers or settings of care.
To Your Family and Friends: Your medical information may be disclosed to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care.
Your name, location and general condition or death may be used or disclosed to notify or assist in the notification of (including identifying or locating) a person involved in your care.
We will provide you with an opportunity to object to such uses or disclosures, unless, based on professional judgment, we may reasonably infer from the circumstances that you do not object to such uses and disclosures.
If you are not present, or in the event of your incapacity or an emergency, we will use our professional judgment in deciding whether disclosing your medical information would be in your best interest.
Disaster Relief: We may use or disclose your medical information to a public or private entity authorized by its charter or by law to assist in disaster relief efforts.
For the Public Benefit: Your medical information may be used or disclosed as authorized by law for the following purposes:
* as required by law
* for public health activities, including disease and vital statistic
reporting, child abuse reporting, FDA oversight and to employers
regarding work-related illness or injury
* to report adult abuse, neglect or domestic violence
* to health oversight agencies
* in response to court and administrative orders and other lawful
processes
* to law enforcement officials pursuant to subpoenas and other lawful
processes concerning crime victims, suspicious deaths, crimes
on our premises, reporting crimes in emergencies and for
purposes of identifying or locating a suspect or other person
* to coroners, medical examiners and funeral directors
* to organ procurement organizations
* to avert a serious threat to health or safety
* in connection with certain research activities
* to the military and to federal officials for lawful intelligence,
counterintelligence and national security activities
* to correctional institutions regarding inmates
* as authorized by state workers' compensation law
Your Written Authorization Is Required: Other uses and disclosures of your medical information that are not described above will only be made with your written authorization. You may give us written authorization to use or to disclose your medical information to anyone for any purpose.
You may revoke your authorization at any time. However, your revocation will not affect any use or disclosure that you permitted prior to your revocation.
Your Individual Rights
Access to Your Information: You have the right to inspect or obtain a copy of the medical information about you that is contained in a "patient chart/folder" . A "patient chart/folder" generally contains medical and insurance information as well as other records that are maintained by or for us, or used by or for us to make decisions about you.
We may ask you to submit your request in writing and to provide us with the specific information we need in order to fulfill your request. We reserve the right to charge a reasonable fee for the cost of producing and mailing the copies to you. In certain situations, we may deny your request to inspect or obtain a copy of the requested information. If we deny your request, we will notify you in writing and may provide you with an opportunity to have the denial reviewed.
Accounting of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes other than treatment, payment, health care operations or those authorized by you as well as for certain other activities that occurred up to six years before the date of your request. However, you will not be able to obtain a list of disclosure instances that occurred prior to April 14, 2003; the date this notice is effective. Any list we send you will include the date(s) of the disclosure, to whom it was made, their address, if known, a brief description of the information disclosed and the purpose of the disclosure. If you request this accounting list more than once in a 12-month period, we may charge you a reasonable administration fee for these additional requests.
Restrictions on Use or Disclosure: You have the right to request that we restrict the use or disclosure of your medical information in connection with treatment, payment and health care operations. You also have the right to request that we restrict disclosures to persons involved in your health care or payment for your health care. We may ask you to submit your request in writing. We will review your request, but we are not required to comply with it.
Confidential Communication: You have the right to request that we communicate with you about your medical information by a different means or location. You must make your request in writing and state that the information could endanger you if it is not communicated by a different means or location. We must accommodate your request if it is reasonable and specifies the new means or location of contact. It must also allow us to collect on claims we filed on your behalf. This includes issuing explanations of benefits to the subscriber of the health plan in which you participate.
An explanation of benefits issued to the subscriber about the subscriber or others covered by the health plan in which you participate, may contain sufficient information to reveal that you obtained health care for which we received payment, even though we communicated with you in the confidential manner you requested. Once your request for confidential communications is in effect, all of your medical information will be communicated in accordance with your instructions.
Amending Your Medical Information: If you believe that the medical information contained in your "designated record set" is not correct or complete, you have the right to request that we amend it. We may require your request be in writing and that it explains why the information should be changed. If we make the amendment, we will notify you. In addition, if we make the change, we will make reasonable efforts to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that information.
Additional Copies, Questions or Complaints
Requests for Additional Copies and Questions Regarding Privacy and Individual Rights:
* You may request a copy of our notice at any time.
* If you view this notice on our website or receive it by e-mail, you are
also entitled to receive it in written form.
* You may request more detailed information about your rights and
privacy protections or learn how to exercise those individual
rights as described in this notice.
Complaints: If you believe that West Side ENT has violated your privacy rights, you may contact West Side ENT’s HIPAA compliance officer at 212-315-9058, or file a complaint with the Secretary of the U.S. Department of Health and Human Services. Complaints filed directly with the Secretary must: (1) be in writing; (2) contain the name of the entity against which the complaint is lodged; (3) describe the relevant problems; and (4) be filed within 180 days of the time you became or should have become aware of the problem. We will provide you with this address upon request. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. We support your right to the privacy of your medical information.
Our E-mail policy
E-mail is a convenient and commonly accepted way of communicating in today’s society. However, please note that the internet (including e-mail) is not secure, and anyone with malicious intent can intercept your private medical information. There are ways of using e-mail in secure settings (such as for banks), but that is in the works for the near future. We ask that you do not use e-mail for any substantial or urgent medical issues. E-mail in our office is only checked once daily, with the lowest level of priority.
Please call us directly for all your urgent or important needs, and reserve e-mail more for routine, non-urgent administrative issues.
Faxing over a phone line to another fax machine is also considered secure. Faxing to an e-mail account is not.
Disclosure Statement
Dr. Park has no financial interest of any kind in any of the ancillary or testing facilities that he recommends for his patients.
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