_~ Faculty Group Practice Patient Demographic Form Ee Name (Legal Last, Fir, Mi and 2 Chosen Names t mand address } EPSTE iJ eFF ee eVaACOn © eT ta peut tev é ALO FAG Mas).com Steer | New yore | “KY L1LO©3. | Work | Maral Status | wSiagle c Married 0 Divorced © Widewed 0 Separated Panier © Other | Coumery of Orig Relatonship to Paice tgs. lk Date of Banh ili j[l-20-S3 ee TRust CO. a) Work Pho yeevVAcat on me | Cell "Coe to Pao Referring Physcian 5 Name De. BRUCE MOSKOW i =| Physician Address | Poa Pet less. o4 D360 Pay * Ketatsamshap to Insred | Name of Subscriber (if other than patient) Seif OSpoue 0 Chad 0 Otter Subscriber s Gender | Date of Beth Employer of Subscriber (-30-S3/ Ry signing below. 1 acknow lodge that the information | provided is correct to the best of my abiliry i ae Dae: FF) II 18 Date | | Paticnt Signature Guarantor Signature (if other than patient; Form Revised: 3/23/2017 EFTA00304446

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Amn, Department of Plastic Surgery Wr Lngoe = ont a —_ forViem: aici aan - Medical History: © None : Ei SRG a tac snc yee acme cates eet Ome Ov Surgical History ~ Please list dates, if any: None Allergies - Piease list Reactions: Onone Otter © Other: Oe R Social History: Highest Level of Education: Occupation es ————— Martial Statuttnieaens: Single Ontaried Ooivorces Owidowes Opantnered EFTA00304447

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peor teeth the procedure code(s) that corresponds tothe procedure that anticpata tobe Sere aha Zo Procedure tahes place. You can contact youriomrenc company (9a cane you ker th back your insurance cari) and provide then with theece(ea ine can let you know what their rate is. This will also allow the insurance company to benefits. de, ate that these codes are not guaranteed tobe billed until alter the procedhan Performed they might change ifthe physician deems necessary whik performing the mace wl ot be chee pP=d sccated with your procedure Thisiea pre-set amount tine in which you will not be charged Any follow up office visits that are related to the procedure performed ° for deed Fer Pasiod most minor procedures that are performed in the office is 10 days from ° donc a atve Peto for most sunical procures performed inthe hospital i 90 days from the date of service. thas Sodan Pe procedure injection x-ray or lice vi regarding «separate lau, performed within cee the 3 7Om lirance company anda copayment, coinancs or dchecble nape once the claim is processed per the insurance. Only post-operative office visits alone are not billable. After the 10 of 90 day period, all visits are billable in full. INTIAL THAT | HAVE READ AND UNDERSTAND ALL ABOVE STATED EFTA00304448

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co-payments and ceductities as provided under any. paid by a third party, will be Credited on account. "derstand that | wit be responsitie or any charges if any ofthe tosowing eat me during my hospital stay oF any services fumished to me by those providers. pats dariane ens eam td er ifomaton abot mato rience o Meds ands, ‘nformation needed to determine these benefits or benetits fer retated contay CANCELED OR NO.SHOW APPOINTMENTS: | understand that, based on the policy of individual physician oftices, | mey canted, nnn F140 prove te required notice ot cancaaton. #1 aor hanp oy cope Say canceled. 'have been provided the Faculty Group Practice Policies. understand the information fully sted above i = EFTA00304449

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EFTA00304450

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giggeus iat i 3h? g Henitl | ve | lin ith lel il cf EFTA00304451

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Personal Representative’s Name (if applicable Pemonal Representative's Authority (4, parent, guardian, health care proxy): ellen Effective as of 11/01/2017, EFTA00304452

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MyChart ACCESS YOUR HEALTH INFORMATION ONLINE EFTA00304453

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Adult MyChart at NYU Langone Prony Access Reavest and Authorization Form Requirements and Procedures . remanent MyChart t NYU Langone record of an adult may be granted bythe paint or his/her legs representative. . Than ihe Person requesting access and the patient or his/her legal representative must sign this form. . doy gst have hisher own MyChart at NYU Langone account because the patents chart il he accomed through the proxy’s MyChart at NYU Langone record. | understand that: . MyChart at NYU Langone is intended as a secure online source of confidential medical information. * MyChart at NYU Langone is not to be used in an hb . itt share my MyChart at NYU Langone ID and password with another person that person may be abe to view . eases 2 MyChart at NYU Langone is provided by NYU Langone Medical Center as a convenience to it Padents and that NYU Langone Medical Center has the right to deactivate access at any me for my teaven somrtecad eas form wil establish a MyChart at NYU Langone record for the patient and prezy. Retum pmapreter arated td mao orokoke 3 already a MyChart at 'U Langone account, you will receive MyChart at NYU Langone message when sre tional aes rod eae pcs Ss Fea NY nee authorization form is received. NYU Langone. Name: TECERSY EH or pink: 20-53. “S3_Emit:_jeevacatonSaqmal.cam Address/Phone #:_F EAST FET ST,_ NY, ALY joto1) 215-350-985, s ; S12 eae aa / Proxy Signature Relationship to Patient Date acknowledge that I have read and understand this Request and sein, 10 its terms and choose to designate the person named above as my MyChart # NYU Langone Proxy, thereby allowing my proxy to access my MyChart at NYU Langone medical eos Name: Date of Birth: EFTA00304454

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oussoael NAN 018359 Gey Ave yneyap yum son2e1d ayn “Aso}e20qR|@ 329I05 10U Op nok J “seed Asoyes0qe} YoY MOUX YOU OP NOA 4 “Ailiqsuodsas s uaned ayy Sinite} ‘Soyovesoqe) 2ypeds azynn Swwa;ted pasenod yeys avinbeu sued aouesNsu) SIUCINSUY INOA 3303U09 aseaid ‘39/95 0} SIG ©} Pea} UE soUNapINT sEY MoyO4 0

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am, \NYULan ENTER Nansorg Wyss Department of Plastic Surgery 30S East 330d Street New York, NY 10016 Fel. 212-263-3030 Fax 212-263-8492 Peat Panes, nant tet Ter and bar Zin othe arse Praconars Amanda Young, itary Moone, yamecrnee Nicole Sweeney. | understand that failure te consent to these wil give NYU Plastic Surgery the right to decline my treatment. Jer Print Patient/ Guardian Name Relabonstup to Patient EFTA00304456

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This Medicare card shows if you have Part A, Part B or both, tt Is for your use only. Show your card when you get health services. Use your name and claim number as shown on this card any time you write or talk to Medicare. Cut out and keep this card. important: Turn over to read more. (BI835-C080816 nD AADC 199 Pe? Tooees Sens ASE Sten ST THOMAS, Vi 00802 MoabtMaeual!aleton alo ME daa A Pye EFTA00304457

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aaee ERERRG 002609 rosorer Oosoer - EPSTEIN 108 RED HOOK QUARTER 8-3 & T THOMAS VI 00862-9000 i ! HT =i ii} one EFTA00304458

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eer ew pao eran ea Oe Seleseueien at oo Aad pen rn cee Cane OHA tems O00 wanes anes aes coe mk ses aan A Oe pee tome tne, tA Pret Oe Os seme Geememesene Pesos yk py EFTA00304459