Account ID

Patient Information

Registration : LLOYD M. LOFT MD

I the undersigned give my authorization to treat and assign directly to LLOYD M. LOFT MD , all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am ultimately financially responsible for all approved and covered charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. I understand that payment is expected at the time of service.

I acknowledge receipt of the Practice's Notice of Privacy Practices. I authorize the Practice to use and disclose my health information for purposes of treating me, obtaining payment for services rendered to me, and conducting healthcare operations.

Please attach all pertinent insurance ID cards for photocopying.

Physician Family Physician Referring Physician

Guarantor (Person to be billed, if different than patient)

Phone

115 EAST 57TH STREET, SUITE 60 Phone: 212-832-1699 X Email:loftentmd m l. om

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Date Other ID Internal Use

Last Name First Name Middle Gender Birthdate Social Security #

Address

Marital Status

Home:

Address 2

Work:

Email:

City State Zip Code Employer Name & Address Occupation

Cell:

Emergency Contact Pharmacy Pharmacy Phone

Medical Insurance Name & Address Policyholder Relationship Policy ID Group ID

Last Name First Name Middle Gender Marital Status Birthdate Social Security #

Address Home: Work: Email:

City State Zip Code Employer Name & Address Occupation

Patient's or Authorized Person's Signature

Signature Signature Date

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Last Name First Name

Address

City State Zip Code

Home:

Employer Name & Address Occupation

GenderMiddle Marital Status Birthdate Social Security #

Work: Email:

Chart ID

HIPAA Approved ContactsLast Name

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1. First Name Middle Gender Birthdate Social Security # Relationship

Address City State Zip Code Home: Work:

Last Name First Name Middle Gender Birthdate Social Security # Relationship

Address City State Zip Code Home: Work:

Cell:

Cell:

Age

How did you hear of us?

LLOYD M. LOFT MD PC

N YO , NY 10022

Copay

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PATIENT HEALTH HISTORY In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. This is very important information. Please fill out every item. It is important for your doctor to know you have carefully reviewed every area of this form. This information will be entered into the computer and you are welcome to a copy of the report if you wish.

Patient’s Last Name_______________________________First___________________________MI______

Sex Male Female Date of Birth: _________________________________________________

Name of Primary Care Physician: ___________________________________________________________

Pharmacy Preference (include location):______________________________________________________

REASON FOR TODAY’S VISIT:___________________________________________________________

PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING: Name of Medication Dosage How Often Taken

ARE YOU ALLERGIC TO ANY MEDICATION? Yes No. If yes, please list below: Name of Medication Type of Reaction

SURGERIES AND HOSPITALIZATIONS. Have you ever had any problems with anesthesia (being numbed or put to sleep)? Yes No If yes, please list type of problems:___________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ List any surgeries you have had (including dates): ________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________ Have you ever been hospitalized for non-surgical reasons? Yes No If yes, list hospitalizations: _________________________________________________________________ ________________________________________________________________________________________

CURRENT OR MOST RECENT OCCUPATION:_____________________________________________

Lloyd M. Loft M.D., P.C. 115 East 57th Street Suite 600

New York, NY 10022

T: 212-832-1699 F: 212-832-7881

Information for Patients

Thank you for choosing our practice for your ear, nose and throat specialty care. We

would like to provide you with some information regarding additional tests and office

procedures that the doctor may order or perform as part of your evaluation.

These tests include:

1. EAR: (Audiogram, Cerumen Removal) A battery of tests used to evaluate a

wide range of complaints including hearing loss, ear wax, infections and

dizziness.

2. NOSE: (Nasal Endoscopy) A diagnostic procedure used to evaluate a wide

variety of conditions and symptoms of both the nasal cavity and sinuses.

3. THROAT: (Laryngoscopy) A diagnostic procedure that evaluate the throat,

larynx and vocal cords.

If your office visit includes any of these procedures or ancillary tests then the invoice that

we send to your insurance company will include a charge for both the office visit in

addition to a separate charge for the diagnostic procedure or test. Some insurance carriers may code ear related diagnostics, nasal endoscopy and laryngoscopy as surgical procedures even though they are routine diagnostic tests commonly performed in the office. Many insurance carriers will require a copayment that is due at

the time of the office visit, however, there may also be required annual deductibles and

co-insurance for the office procedure or ancillary tests. The explanation of benefits form

that you receive from your insurance carrier will detail how the claim was processed and

will specify any required coinsurance and deductibles that you are responsible for under a

section usually called “Patient Responsibility.”

Please sign below to indicate that you have read and understand your financial

responsibility regarding office tests and procedures. If you have any questions, please feel

free to discuss them with our billing manager.

_________________________________ __________________

Patient/Guardian Signature Date

_________________________________

Print Name

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