Thank you for choosing Dr. Morgenstern Medical PLLC (Morgenstern Medical) for your medical care. We appreciate that you have entrusted us with your healthcare and we are committed to providing you with the best patient care possible. Below you will find information related to the services we offer (“Services”) and several policies and agreements that are collectively referred to as the “Terms and Conditions” or “TAC” including:

1. Summary of Morgenstern Medical’s Financial Policies
   II. Financial Policies and Patient Responsibilities
   III. Privacy Policy
   IV. Laboratory Billing information
   V. Declaration for Five Towns Neurology Patients
   VI. Medical Cannabinoids Patient Agreement
   VII. Long-term Controlled Substances Therapy for Chronic Pain Patient Agreement
   VIII. All Patients Declaration
   IX. Medical Advice Acknowledgement, Recommendations and Against Medical Advice Acknowledgement and Waiver
   X. E-mail/Electronic Communication Consent
   XI. Assignment of Benefits & LTD. Power of Attorney
   XII. Binding Arbitration
   XIII. Authorization for Release of Health Information Pursuant to HIPAA
   XIV. Severability
   XV. Electronic Signature Policy

Please read each component of the Terms and Conditions and click “agree” below and/or on our online form to provide an electronic signature that indicates that you understand and agree to the entire TAC. You may use of our Services only if you agree to the Terms and Conditions. A hard copy or email copy is available upon request and is also posted online at https://doctormm.com/terms.

By agreeing, you understand and agree to the information disclosed. If you have questions or do not understand the information below, consult with the attending physician before signing this agreement. Please do not sign this agreement if you do not understand the information and agree to the entire agreement.

Signature:___________ Date: ______________  

[Please note: Your agreement to the Terms and Conditions of this agreement will be provided via a related online form and all Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

Healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you better understand your responsibilities as a patient. We will do our best to assist you with understanding your proposed treatment and in answering questions related to submitting your insurance claim for reimbursement.

Your health insurance policy is a contract between you and your health insurance company or your employer. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals, pre-certifications, pre-authorizations, limits on outpatient charges, and any requirements for specific physicians, labs and/or hospitals to use. You should be knowledgeable of any deductibles, copayments, and/or coinsurance. This applies to all payors regardless of whether or not our physicians participate.

If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of- pocket fees, and coverage limits.

A COPY OF THIS POLICY IS AVAILABLE UPON REQUEST. It is also posted online at doctormm.com/terms.

INSURANCE COVERAGE

Please provide us with your current insurance plan information at the time of each visit and notify us of any changes. We will request a copy of your insurance card to copy or scan and keep on file for our records.

Please be aware of and provide any required referrals or authorizations in advance of the appointment or service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification.

Our doctor(s) belong to many insurance plans but participation differs by doctor. You can see a list of plans that our physicians participate with on our website (https://doctormm.com/insurance). Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the costs of care. If you would like a cost estimate, we would be happy to provide one. We will also help you find out if you have out-of-network benefits. Refer to our out-of-network policy below for more details.

Please let us know at any time if you do not want us to submit a claim to your plan.

ADDRESS CHANGE

It is important that we have your correct address information on file. Please advise us anytime there is any change to your address, telephone or other contact information.

CO-PAYMENTS/CO-INSURANCES/DEDUCTIBLES

You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time of service.

OTHER BILLS

You may receive services at Morgenstern Medical such as anesthesia, radiology testing, pathology, or other services. These doctors provide vital services and are involved in your care even though they may not be present at the time and you may not see them face-to-face. There may be additional charges for these services.

PAYMENTS

Payment is due at the time services are provided or upon receipt of a statement from our billing office. We accept payment in the form of cash, check, money order or credit card (American Express, MasterCard, Visa and Discover). Returned checks are subject to a fee of $20.00. We do not accept traveler’s checks.

NON-MEDICAL FEES

Additional fees may apply to the following:
• Returned Checks
• Billing charge for late payments
• Copying of medical records
• Completion of disability or other forms
• Certifications with state agencies

CREDIT CARD OR DEBIT CARD NUMBER ON FILE

Due to your insurance processing bills in a certain way there may be a portion of that bill that is your responsibility. WE REQUIRE YOU LEAVE A CREDIT OR DEBIT CARD NUMBER ON FILE so that we can balance your bill for the portion that is your responsibility as soon as it is due. Your responsibility includes and is not limited to the amount of any checks that your insurance elects to send to you that is related to a bill or claim that is submitted to your insurance for services provided by Morgenstern Medical. By providing this information you provide authorization for Morgenstern Medical to charge your credit card or debit card for full account balances and to save this number on file for future transactions.

Having your credit card or debit card number on file will ensure that you will not get charged a $25.00 billing fee for late payments.

As a service to our clients, we may provide a courtesy, such as a bill pay reminder call or email, a call prior to processing payments on a credit or debit card number that is on file, and possibly other important calls that may be placed using a prerecorded message. By providing your cell phone number, you consent to receiving such calls at this number.

MISSED APPOINTMENTS

Generally, Morgenstern Medical requires a 24 hour (1 business day) cancellation notice for most office visits. Procedures and surgeries may require 48 hours (2 business days) or more. Please note that weekends and holidays are not considered business days. If you miss your appointment, or do not cancel with the required notice, additional fees may apply:

• Office Visit: $50
• Second Office Visit $75
• New Patient Visit: $75
• Procedure/Surgery: $75.00

OUT-OF NETWORK PROVIDERS

If the doctor is not in your insurance plan, the following apply:

• Full payment is due at the time of service for routine visits.
• Payment expected on the date of service may be an estimate of your total charges.
• You will be quoted an estimated fee before services/procedures are performed.
• A deposit is required prior to the date of service for elective surgeries and procedures.
• Even if you have out-of-network benefits, you are ultimately responsible for the full fee charged.
• Depending on your plan, a payment may be sent to you from your insurance to reimburse you for payments made to Morgenstern Medical. However, if Morgenstern Medical has not received this payment (ie the date of the visit) and we we will bill your credit card if and when we are made aware of the amount on the check. We may also bill an amount related to the co-pay. You should receive a receipt when we bill you. However, if you receive this payment, it is your responsibility to notify Morgenstern Medical immediately and obtain permission from us in writing or by email prior to depositing this check in your account.

NON-COVERED SERVICES: MEDICARE PATIENTS

Medicare may not cover some services your doctor recommends that are sometimes covered (e.g. cosmetic surgery). In these circumstances, you will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully.

NON-COVERED SERVICES: NON-MEDICARE PATIENTS

Any service not covered by your plan are your responsibility and must be paid in full at the time of service or upon receiving a bill.

REFUNDS

A refund is issued when an overpayment has been identified. If you feel a refund is due, please contact our billing office at 516-778-7533.

FAILURE TO PAY

If you do not pay your bill, your account may be sent to an outside collection agency. If your account is sent to a collection agency, you will need to contact them directly to settle your balances.

WAIVER OF INSURANCE BILLING FOR SELF-PAY PATIENTS

Any Service provided by Morgenstern Medical, such as evaluations related but not limited to treatment with Medical Cannabinoids, is a Service (‘Service’) that may not be covered (“Non-Covered”) by health insurance. Alternatively, there may be components of a Service that are considered or believed by Morgenstern Medical to be eligible for coverage (“Eligible Service”) and other components of the Service that are not eligible (“Non-eligible Service”) for coverage by health insurance. This may include but is not limited to concierge services, state filing services and or other Non-eligible Services. I agree to pay in full by cash, Credit or debit card at the time the above-indicated Services are rendered, and understand that the rates may vary, ranging from at least $250 for new patients and $150 for follow-up visits up to approximately 100% of the UCR value provided at Fair Health Inc. (which may be found at http://fairhealthconsumer.org) or greater. I understand that any rate provided to me for any Service, here or via any medium and/or at any time, represents a general rate, only an estimate and not a guarantee, can change over time and vary based on individual circumstances, does not apply to every case, but, that, if and when applied, it may represent a discounted rate as a result of self-payment at the time of service. In the event that the above-indicated Service is being billed as a self-payment, I understand that it is being provided outside of any insurance arrangements, waive insurance billing by Morgenstern Medical, and agree that I will not submit insurance claims for the Service. I also understand that any bill for Services and self-payment represent a variable-rate that is contingent on the bill not being submitted to a health insurance by Morgenstern Medical, and that if Morgenstern Medical shall elect to submit one or more bills to an insurance, the billed amounts including prior bills may change and be applied retroactively. Should Morgenstern Medical submit bills for Services to an insurance, I also understand that prior bills and payments may or may not be considered null and void and that prior payments made as self-payments may be refunded and/or converted into a credit applied towards my total balance. This may also depend on whether Morgenstern Medical accepts any payment from a provider, even after Morgenstern Medical submits a bill for a Service. I understand that whether an insurer agrees to pay, pays or does not agree to pay Morgenstern Medical for some or all services and whether Morgenstern Medical accepts or does not accept payment, whether partially or payment in full for bills submitted to an insurer, this process may result in the total amount that I am billed and/or responsible to pay being greater than a prior payment, a refunded amount or a prior credit. I also understand that I may be responsible to pay some or all of a balance for a visit related to a component of a visit that is a Non-eligible Service, even if an Eligible Service has been already been paid for that took place and/or was associated with Services related to the same date, encounter and/or visit. This agreement and waiver is intended to supersede any insurance contract which otherwise might be applicable to myself, my dependent or any individual on whose behalf I am executing this agreement.

POLICY AND FEE CHANGES

These policies and fees are subject to change. We will do our best to keep you informed of any modifications.

We know medical care can become expensive. If you have concerns about your ability to pay, you can contact us for help in managing your account. If you have questions about these policies, feel free to ask any of our Managers for more details or call the billing office at the number listed on your billing statement.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

I understand that Dr. Morgenstern Medical PLLC (“Morgenstern Medical”), my treating physicians and their respective designees, will use and disclose my health information for all purposes necessary for treatment, payment and health care operations, including but not limited to release of information requested by my insurance company (or carrier) and any information necessary for discharge planning purposes.

ASSIGNMENT OF INSURANCE: I hereby authorize my insurance benefits to be paid directly to Morgenstern Medical. I understand I am financially responsible for non-covered services. I authorize the release of any medical or other information necessary to process insurance claims on my behalf.

FINANCIAL LIABILITY: I have been provided a copy of the Morgenstern Medical financial policies and agree to the specified terms. I hereby agree to pay all charges due (or to become due) to Morgenstern Medical for care and treatment, including co-payments and deductibles as provided under my plan. Benefits, if any, paid by a third party, will be credited on account. I understand that I will be responsible for any charges if any of the following apply:

• My health plan requires prior referral by a Primary Care Physician (PCP) before receiving services at Morgenstern Medical and I have not obtained such a referral or I receive services in excess of the referral, and/or
• My health plan determines that the services I receive at Morgenstern Medical are not medically necessary and/or not covered by my Insurance plan, and/or
• My health plan coverage has lapsed or expired at the time I receive services at Morgenstern Medical, and/or
• I have chosen not to use my health plan coverage, and/or
• The physician I see does not participate with my health care plan.

ANCILLARY SERVICES: I understand I may receive certain ancillary medical services while I am at Morgenstern Medical; such as, anesthesia, interpretation of cardiac tests, imaging services (e.g., x-rays, MRIs) and pathology specimen examination. I understand that some physicians may not provide services in my presence, but are actively involved in the course of diagnosis and treatment. I hereby authorize payment directly for these services under the policy(s) or plan(s) issued to me by my insurance carrier. I understand that I may incur additional charges as a result of these ancillary services; I agree to pay all charges due with respect to such services to the extent the charge is due after credit is given for benefits paid on my behalf by any third party payor.

CANCELED OR NO-SHOW APPOINTMENTS: I understand that, based on the policy of individual physician offices, I will incur a cancellation fee if I do not provide the 24 hour notice of cancellation, or if I do not keep my appointment and have not canceled.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

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.

We are Committed to Your Privacy

Morgenstern Medical is committed to maintaining the privacy of your health information. We use a secure electronic health records, servers or computer databases at our location or through partnerships with third party technology providers to store your health information including information collected from electronic surveys, questionnaires, forms, encounters or other communications. The third party providers must provide evidence that they are HIPAA compliant and/or act as Business Associates when applicable.

We will only use or disclose (share) your health information as described in this Notice. You will be asked to sign an acknowledgement that you have received this Notice.

Who Follows This Notice

All employees, medical staff, trainees, students, volunteers, and agents of Morgenstern Medical follow these privacy practices.

Using and Sharing Your Information

This section describes the different ways that we may use and share your information. We will usually contact you for these purposes by phone, but if you have given us your email address or permission to send a text message, we may contact you that way. We mainly use and share your information for treatment, payment, and health care operation purposes. This means we use and share your health information:
• with other health care providers who are treating you or with a pharmacy that is filling your prescription;
• with your insurance plan to collect payment for health care services or to get pre-approval for your treatment; and
• to run our business, improve your care, educate our professionals, and evaluate provider performance.

Sometimes we may share your information with our business associates, such as a billing service, who help us with our business operations. All of our business associates must protect the privacy and security of your health information just as we do.

We may also use or share your information to contact you:
• about health-related benefits or services.
• about your upcoming appointments.
• about fundraising.
• to see if you would like to take part in research projects.

If you do not wish to be notified of research projects you may be able to participate in, or contacted for fundraising you can contact us to opt out by emailing [email protected] or calling us at 516-778-7533,

Special protections may apply if we use or share sensitive health information. This includes HIV- related information, mental health information, alcohol or drug abuse treatment information, or genetic information.

For example, under New York State Law, confidential HIV-related information can only be shared with persons allowed to have it by law, or persons you have allowed to have it by signing a specific authorization form. If your treatment involves this information, further explanation is available on NYS department of health website.

We are also allowed, and sometimes required by law, to share your information in other ways. We have to meet many conditions in the law before we can share your information for the following reasons. Some examples of each include:
• Public health and safety: reporting diseases, births, or deaths; reporting suspected abuse, neglect, or domestic violence; to avoid a serious threat to health or public safety; monitoring product recalls; and reporting information for safety and quality purposes.
• Research: analyzing health record projects that have been approved by our institutional review board (IRB) and are of low risk to your privacy; preparing for a research study; studies that only involve decedents’ information.
• Judicial and administrative proceedings: responding to a court or administrative order.
• Workers’ compensation and other government requests: workers’ compensation claims payment or hearings; health oversight agencies for activities authorized by law; special government functions (military, national security).
• Law enforcement: with a law enforcement official to identify or find a suspect or missing person.
• Comply with the law: to the Department of Health and Human Services to see if we are complying with federal privacy law.
• Disaster relief situation: sharing your location and general location for the purpose of notifying your family, friends, and agencies chartered by law to assist in emergency situations.
• To organizations that handle organ, tissue, or eye donation or transplantation.
• To a coroner, medical examiner, or funeral director as needed to do their jobs.
• Incidental to a permitted use or disclosure: calling your name in a waiting area for an appointment and others in the waiting area may hear your name called. We make reasonable efforts to limit these incidental uses and disclosures.

In the following situations, we may use or share your information, unless you object or if you specifically give us permission. If for some reasons you are not able to tell us your preferences, for example if you are unconscious, we may share your information if we believe it is in your best interest.
• For our patient directory.
• With your family, friends, or others involved in your care or payment for your care.

In the following situations, we will only use or share your information if you give us permission:
• For marketing purposes
• Sale of your information or payments from a third party
• Most sharing of psychotherapy notes
• Any other reasons not described in this Notice You can revoke (take back) that permission, except when we have already relied on it, by contacting the Privacy Officer.

Your Rights When it comes to your health information, you have certain rights. You may:
• Review or get an electronic or paper copy of your medical record, including billing records. You may be charged a reasonable cost based fee which will not be higher than 75 cents per page for paper copies or a reasonable cost for the provision of electronic media for electronic records (plus postage if you request your records to be mailed). Records will be provided within 3 to 10 days of your request. We will let you know about any delay. You can also access your health information directly using our secure patient portal, my.patientfusion.com.
• Request confidential communications. You can ask us to contact you in a certain way, for example, by cell phone. We will say “yes” to all reasonable requests.
• Ask us to limit what we use or share for your treatment, payment, and healthcare operations. We are not required to agree to your request, but we will review it. When you pay for services out-of-pocket, in full, and ask us not to share the information with your insurance plan, we will agree unless a law requires us to share that information.
• Ask us to correct your medical record if it is inaccurate or incomplete. We may say “no” to your request, but we will tell you why in writing within 60 days.
• Get a list of those with whom we have shared information. You can ask for a list (accounting) of the times we shared your information and why for the six years prior to your request. Not all disclosures will be included in this list, such as those made for treatment, payment, or health care operations. You have the right to get this list one time every 12 months without charge, but we may charge you for the cost of providing additional lists during that time.
• Get a copy of this privacy Notice. Just ask us and we will give you a copy in the format you would like (paper or electronic).
• Choose someone to act for you. This “personal representative” can exercise your rights and make choices about your health information. Generally, parents and guardians of minors will have this right for the child, unless the minor is permitted by law to act on their own behalf.
• File a complaint if you feel your rights have been violated. You may provide any complaints to the Office Manager of Morgenstern Medical. We will not retaliate or take action against you for filing a complaint.
• Request additional privacy protections with respect to your electronic medical record.

Our Responsibilities
• We are required by law to maintain the privacy of your protected health information.
• We will notify you if a breach occurs that may have compromised the privacy or security of your identifiable information.
• We must follow the practices described in this Notice and give you a copy of it.
• We reserve the right to change the terms of this Notice and the changes will apply to all information we have about you.
The new Notice will be available upon request and on our website at www.doctormm.com.

Questions or Concerns
If you have a question or wish to exercise your rights described in this Notice, please contact us by phone at 516-778-7533 or via email to [email protected]. Most requests to exercise your rights must be made in writing.

AUTHORIZATION FOR OBTAINING CONFIDENTIAL RECORDS

I authorize Morgenstern Medical and its representatives to obtain my complete medical records including but not limited to:

• Psychotherapy records (If this authorization is for the use and/or disclosure of psychotherapy records, it cannot be combined with any other authorization).
• HIV/AIDS/AIDS-related illnesses
• Drug/Alcohol Treatment/Evaluation
• Lab reports
• Diagnostic imaging reports
• Developmental disabilities
• Immunization records
• Physical therapy records

I hereby authorize Morgenstern Medical to disclose and verify me as a patient to any law enforcement agency, my physician(s), Child Protective Services, cannabinoids dispensary/co-op, pharmacy or any source of referral such as a website (e.g. Zocdoc.com). This consent is subject to written revocation only, at any time except to the extent that action has already been taken on the basis of this consent. I give Morgenstern Medical, its representatives and the attending physician permission to validate my status as a patient using referral sources including but websites such as and like cannabinoids Doctors or zocodoc.com and to contact me using electronic forms of communications on those sites.

I give permission for my medical records and file to be reviewed by another physician working with Morgenstern Medical. I understand that this might happen if the original doctor who evaluated me need a secondary opinion, is not available, off premise, has moved or terminated his/her practice.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

Thank you for choosing Morgenstern Medical for your medical care. Any laboratory services or specimens provided by Morgenstern Medical are sent to an outpatient laboratory such as Labcorp or Quest for processing. The outpatient laboratory is a service that is billed separately from your physician visit. The labs used by Morgenstern Medical participate with most insurance plans; however some plans have a specific laboratory facility preference. You should review your laboratory plan to understand your benefits as services provided may be subjected to hospital coinsurances and deductibles. It is your responsibility to understand your insurance plan benefits and to notify our staff or physicians of your preferred laboratory at each visit. Based on your request we will send your specimen to the laboratory your choice. Should you have questions our practice staff will either answer your question or direct you to your insurance carrier.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

 

By seeing a physician using electronic communications technologies you are agreeing to have a telemedicine consultation. Telemedicine is the practice of medicine using electronic communications technologies not limited to interactive audio, video, or data communications to transmit medical information. The providers, in exercising their professional judgment, reserve the right to deny care for any reason, including instances where provision of care would be medically or ethically inappropriate.

Getting treatment through a telemedicine consultation offers certain expected benefits and has certain potential risks. Expected benefits include easier and quicker access to medical care, and the ability to access care from many locations. For example, you can initiate a remote visit from your home rather than having to travel to an office location. Potential risks include the physician not being able to fully resolve your issue remotely, lack of physician access to your full medical records, which may, in rare instances, result in allergic reactions or other adverse drug interactions. Furthermore, a telemedicine consultation is different from a regular face-to-face consultation. Therefore, a diagnosis and treatment may be based solely on the information provided by you and/or your Treating Physician, and omitting medical information or misinforming a Provider may result in an inaccurate diagnosis and treatment.  Additionally, in the absence of an in-person, face-to-face, physical evaluation, the physician may not be aware of certain facts that may limit, delay, or affect the assessment or diagnosis of your condition and recommended treatment. Accordingly, the diagnosis you receive is limited, provisional and does not and should not replace a traditional doctor’s office visit; and therefore, you are proceeding with this tele-evaluation at your own risk and understanding.

 The laws that protect the confidentiality of medical information also apply to telemedicine. As such, information disclosed during the course of treatment is confidential. Additional risks and consequences from telemedicine are not limited to, the possibility, despite reasonable efforts on the part of your Provider, that, the transmission of medical information could be disrupted or distorted by technical failures; the transmission of medical information could be interrupted by unauthorized persons; and/or the electronic storage of medical information could be accessed by unauthorized persons. 

Disclaimer and Release

I hereby completely and irrevocably release Morgenstern Medical of any and all errors and omissions, known or unknown, foreseen or unforeseen, knowingly or unknowingly, as well as all claims, actions or damages arising from or in connection with the telemedicine consultation, online consultation, conclusions or recommendations provided by Morgenstern Medical its physicians. Furthermore, I agree that the Morgenstern Medical has no liability or responsibility for the accuracy or completeness of the medical information submitted to them or for any errors in its electronic transmission. As a condition to receiving the online consult service, I have read and acknowledge that I have given this consent of my own free will.

Care Options

You have other options for care. You can obtain care in a traditional in-person care setting, such as seeing your Primary Care Physician or visiting an urgent care center. By agreeing to have a telemedicine consultation, you acknowledge that you have reviewed these benefits, risks, and alternatives, and you agree that you consent to a telemedicine consultation. You have the right to withdraw your consent at any time by ending this telemedicine consultation session.

Finally, I understand that there are potential risks, limitations and benefits associated with any form of medical treatment, and that despite the efforts of my Provider, my condition may not be improve, and in some cases may even get worse. Therefore, I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

ACKNOWLEDGEMENTS, AGREEMENTS, DISCLOSURES AND INFORMED CONSENT

I understand that medical cannabinoids is a medicine used in treating the suffering caused by serious and debilitating medical conditions. Serious and debilitating medical conditions include and may not be limited to: Cancer, HIV/AIDS, Epilepsy, Multiple Sclerosis, Parkinson’s disease, ALS (Lou Gehrig’s disease), damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity (any spinal cord injury), Inflammatory Bowel Disease, Huntington’s disease, and any type of neuropathy. Additionally, medical cannabinoids is used in the treatment of other chronic or persistent medical symptoms that:

• Substantially limits the ability of the person to conduct one or more major life activities as defined in the Americans with Disabilities Act of 1990 (Public Law 101-336)
• If not alleviated, may cause harm to the patient’s safety or physical or mental health

I agree NOT TO DRIVE a car or operate dangerous or heavy machinery while using cannabinoids. I understand that the use of medical cannabinoids may affect my coordination, motor skills and cognition in ways that could impair my ability to drive and agree not to operate heavy machinery, drive or engage in potentially hazardous activities.

I understand that the use of cannabis may ADVERSELY affect one’s health. If this occurs I will stop using cannabis and will schedule an appointment to be further evaluated by a physician to determine another form of treatment for relief of my health problems. I assume all risks for usage.

I understand that SIDE EFFECTS may occur while I am taking medical cannabinoids. Side effects of medical cannabinoids can include but are not limited to: abnormal ova, addictive behavior, aggressiveness, alterations in the perception of time and space, altered body temperature, anxiety, altered libido, altered perceptions, anxiety, confusion, confusion, decreased brain blood flow, decreased coordination, delayed reaction time, difficulty in completing complex tasks, dizziness, dry mouth, dysphoria, Euphoria, fetal exposure in pregnancy. hallucinations, headache, impairment of motor skills, impairment to short term memory, inability to concentrate, increased talkativeness, increased weight gain, infertility, loss of physical coordination, low blood pressure, lung irritation, menstrual abnormalities, nausea, nystagmus, overeating paranoia, psychotic symptoms rapid heart rate, reduced muscle strength, reduced testicular size and testosterone, sedation, suicidal thoughts, suppression of the body’s immune system and tremor.

I understand that some patients become dependent on cannabinoids. This means they experience withdrawal symptoms when they stop using cannabinoids. Signs of withdrawal symptoms can include: Feelings of depression, sadness, irritability, insomnia, restlessness, agitation, loss of appetite, trouble concentrating, sleep disturbances and unusual tiredness.

I understand that chronic use of medical cannabinoids can lead to laryngitis, bronchitis and general apathy.

I understand that although cannabinoids does not produce a specific psychosis, the possibilities exists that is may exacerbate schizophrenia in persons predisposed to that disorder.

I agree to tell the attending physician if I have ever had symptoms of depression, been psychotic, attempted suicide or had any other mental problems. I also agree to tell the attending physician if I have ever been prescribed or taken medicine for any of the conditions stated above. Furthermore, I understand that the attending physician does not suggest nor condone that I cease treatment and or medication that stabilize my mental or physical condition.

I understand there are few known interactions between cannabinoids and medications other than herbs. However, very few interactions between herbs and medications have been studied. I agree to tell my attending physician if I am using any herbs, supplements or other medications.

I am aware that a Notice of Compliance has not been issued under the Food and Drug Regulations concerning the safety and effectiveness of Marijuana as a drug. I understand the significance of this fact.

I am aware that medical cannabinoids has not been approved under Federal Regulations and I understand that medical cannabinoids has not been deemed legal under federal law.

I understand some users might develop a tolerance to cannabinoids. This means higher and higher doses are required to achieve the same benefit. It is recommended for patients to have an intermission with the drug for at least 3 weeks every 3-4 months. If I think I may be developing a tolerance to cannabinoids, I will notify the attending physician.

I understand the benefits and risks associated with the use of cannabinoids are not fully understood and that the use of cannabinoids may involve risks that have not been identified. I accept such risk.

I understand should respiratory problems or other ill effects be experienced in association with the use of medical cannabinoids, I agree to discontinue its use and report any such problems or effects to my primary care doctor and the attending physician. Although smoking cannabinoids has not been linked to lung cancer, smoking cannabinoids can cause respiratory harm, such as bronchitis. Many researchers agree that cannabinoids smoke contains known carcinogens (chemicals that can cause cancer) and that smoking cannabinoids may increase the risk of respiratory diseases and cancers in the lungs, mouth and tongue. I understand that medical cannabinoids smoke contain chemicals known as tars that may be harmful to my health. I understand that there are many methods of intake that substantially reduce the harmful effects of smoking such as vaporizers, edibles, drops, etc.

I understand Marijuana varies in potency. The effects of cannabinoids can also vary with the delivery system. Estimating the proper cannabinoids dosage is very important. Symptoms of cannabinoids overdose include, but are not limited to nausea, vomiting, hacking cough, disturbances to heart rhythms, numbness in the limbs, anxiety attacks and incapacitation.

If I start taking medical cannabinoids, I agree to tell my attending physician and primary care doctor if I: Start to feel sad or have crying spells, lose interest in my normal activities, have changes in my normal sleeping patterns, become more irritable than usual, lose my appetite, become unusually tired, withdraw from family and friends, or any other side effect that is not to your liking.

I agree that if I am a female patient that I will contact my attending physician and primary care doctor if I become or are thinking about becoming pregnant. I acknowledge that the use of medical cannabinoids creates pass-through problems to a fetus during pregnancy and to a baby during breastfeeding.

I understand that using cannabinoids while under the influence of alcohol is not recommended. Additional side effects may become present when using both alcohol and cannabinoids.

I should not be driving a vehicle while using cannabinoids and that I can get a DUI for driving under the influence.

Medical cannabinoids is not regulated by the USFDA and therefore may contain unknown quantities of active ingredients, impurities and or contaminants.

I am not permitted to smoke within 1,000 feet of any daycare or school. If I reside near those institutions, I must use my medicine within the privacy of my own home.

I agree to obtain medical FOLLOW- UP at my personal medical doctor’s office and to return to Morgenstern Medical for FOLLOW- UP, as recommended by the physician. I understand that interaction with healthcare providers is in the best interest for my continuity of care.

I agree to follow up with the attending physician at Morgenstern Medical with supporting medical records pertaining to my medical conditions.

I understand that it is my responsibility to see a physician to assess the possible continuance of cannabis use beyond the term of approval.

I am responsible for my own medications and am aware that lost, stolen, eaten or misplaced medicinal cannabinoids will not be replaced without exception.

I understand the attending physician, staff and or representatives of Morgenstern Medical are neither providing, dispensing nor encouraging me to obtain medical cannabinoids. I also acknowledge that the attending physician, staff and or representatives of Morgenstern Medical will NOT in any official capacity ne providing or discussing information regarding dispensary, co-op, delivery service or any other way to obtain cannabinoids.

I understand the importance of taking personal responsibility in the management of my condition. I understand the importance of legal responsibility with both federal and state law for taking medicinal cannabinoids appropriately. Under no circumstance will I share, sell or trade medicinal cannabinoids.

I understand that I will be subject to random urine and or blood drug testing to ensure compliance. Results may be forwarded to a primary care physician.

I am responsible for making my follow-up appointments for medication refill. It is my responsibility to schedule an appointment no less than 4 days prior to needing additional medication.

If a medication trial is unsuccessful, the remaining medication must be returned to a dispensary prior to receiving any new authorizations.

I will be compliant with medical and other forms of recommended therapy including mental health if deemed necessary by Morgenstern Medical.

I understand that Medical Marijuana may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, and that I must keep them out of reach of such people.

I understand that renewals are contingent on keeping scheduled appointments. Please do not phone for authorization after hours or on weekends.

I understand that any treatment is initially a trial, and that continued treatment is contingent on evidence of benefit.

It is understood that failure to adhere to these policies may result in cessation of therapy with medicinal cannabinoids by this physician or referral for further specialty assessment.

I certify that I have read this document and declare under penalty of perjury that the information contained herein it true, correct and complete. I acknowledge that any manipulation, alteration or falsification of this form, the Morgenstern Medical letter of recommendation will result in the immediate termination of any legal right to my use of medical cannabinoids. Furthermore, Morgenstern Medical will report any of the above mentioned activities to the appropriate local authorities.

The physician, staff and representatives of Morgenstern Medical are addressing specific aspects of my medical care and, unless otherwise stated, are in no way establishing themselves as my primary care physician/provider. Furthermore, the undersigned, my heirs, assigns, or anyone else acting on behalf, hold the physician and his/her principals, agents and employees, free of and harmless from any responsibility for any harm resulting to me and/or other individuals as a result of my medical cannabinoids use.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

 

RELEASE OF LIABILITY

I attest that the information on this form is correct and any medical history presented or discussed with the doctor is all factual and complete to the best of my knowledge. I do not plan or intend to use my Physician’s recommendation for the purpose of illegally obtaining medical cannabinoids.

I understand that I must be a New York State resident to obtain an approval or recommendation for the use of medical cannabinoids under the New York State Assembly Bill A06357E (Compassionate Care Act signed in to law by Governor Cuomo on July 4th, 2015.

I affirm that I have a serious medical condition that is debilitating and negatively affects my quality of life. I have found or am interested in finding out whether or not medical cannabinoids provides substantial relief and improvement in my condition.

I understand that the cannabis plant is not regulated by the United States Food and Drug Administration and therefore may contain unknown quantities of active ingredients, impurities and/or contaminants. I understand the potential risks associated with an elevated daily consumption of medical cannabinoids including risks with respect to the effect on my cardiovascular and pulmonary systems and psychomotor performance, risks associated with the long-term use of cannabinoids, as well as potential drug dependency. I am aware that the benefits and risks associated with the use of cannabinoids are not fully understood and that the use of cannabinoids may involve risks that have not been identified. In requesting an approval or recommendation for the use of medical cannabinoids, I assume full responsibility for any and all risks involved in this action.

I understand that medical cannabinoids smoke contains chemicals known as tars that may be harmful to my health. Recent research indicates that vaporizing cannabis may eliminate exposure to tar. Should respiratory problems or other ill effects be experienced in association with its use, it should be discontinued and reported to the physician immediately.

I also understand that the use of medical cannabinoids may affect my coordination and cognition in ways that could impair my ability to drive, operate machinery, or engage in potentially hazardous activities. I assume full responsibility for any harm resulting to me and/or other individuals as a result of my use of cannabis.

New York State Assembly Bill A06357E (Compassionate Care Act), provides for the possession for the personal medical purposes of the patient with a physician approval or recommendation. It should be made clear that the physician, staff and representatives of this practice are not providing medical cannabinoids, nor are they encouraging any illegal activity in my obtaining medical cannabinoids.

I, the undersigned, hereby request a consultation by the physician for purposes of determining the appropriateness of medicinal cannabinoids treatment. I acknowledge that using cannabis as a medicine will be or has been explained to me and that any questions that I have, if they have not already been answered to my satisfaction, will have the opportunity been answered to my complete satisfaction within reason. If they are not answered at a visit, your doctor may request that you submit your questions in writing via email. The physician, staff, and representatives are addressing specific aspects of my medical care, and unless otherwise stated are in no way establishing themselves as primary care provider. Should an approval be made for my medicinal use of cannabinoids, I understand that there is a renewal date specified by the physician depending on the condition.

I understand that it is my responsibility to see the physician to assess the possible continuance of cannabis use beyond the term of the approval.

Furthermore, the undersigned, or anyone acting on my behalf, hold the physician and his/her principals, agents, and employees, free of and harmless from any liability resulting from the use of medical cannabinoids, to the extent permitted by law.

I further understand that by signing below, I am authorizing the release of any part of this record, except for identifying information, for use in data analysis of medical cannabinoids treated patients.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

MEDICAL MARIJUANA PATIENT DECLARATION

I hereby declare that I have completely and truthfully disclosed all information regarding my medical condition and attest that I do not intend to use my medical recommendation for the purpose of illegally obtaining, growing or distributing medical cannabinoids. I attest that I am not a member, employee or agent of any media or law enforcement agency. It is illegal to film or record in this office with a video camera, cell phone or any other recording device be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor confidentiality. I am aware that my recommendation can be revoked at any time and legal actions will be taken if I have perjured or misrepresented myself or my condition, my intentions or falsified any medical records to the physician. I also hereby authorize Morgenstern Medical or its representative to discuss my medical condition with Marijuana Doctors for verification purposes only.

I acknowledge I have been informed of the nature of a recommended treatment, including but not limited to, any recommendation regarding medical cannabinoids; The risks, complications and expected benefits of any recommended treatment, including its likelihood of success and failure; Any alternatives to the recommended treatment, including the alternative of no treatment, and their risks and benefits. The physician may request that I visit another physician or specialist to further substantiate my condition.

If I have not been informed of any of the above I understand that I should notify The attending physician who will promtly and fully explain to me the nature and purpose of medical cannabinoids treatment, including its benefits and possible side effects.

 

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

The purpose of this agreement is to protect your access to controlled substances and to protect our ability to prescribe for you. The long-term use of such substances as opioids (narcotic analgesics), benzodiazepine tranquilizers and barbiturate sedatives is controversial because of uncertainty regarding the extent to which they provide long-term benefit.

There is also the risk of an addictive disorder developing or of relapse occurring in a person with or without an addiction. The extent of this risk is not certain. Because these drugs have potential for abuse or diversion, strict accountability is necessary when use is prolonged. For this reason the following policies are agreed to by you, the patient, as consideration for, and on condition of, the willingness of the physician whose signature appears below to consider the initial and/or continued prescription of controlled substances to treat your chronic pain.

All controlled substances must come from a physician at Morgenstern Medical, or during his absence, by the covering provider, unless specific authorization is obtained for an exception. (Multiple sources can lead to untoward drug interactions or poor coordination of treatment.)

All controlled substances must be obtained at the same pharmacy, where possible. Should the need arise to change pharmacies, our office must be informed.

You are expected to inform our office of any new medications or medical conditions, and of any adverse effects you experience from any of the medications that you take.

The prescribing physician has permission to discuss all diagnostic and treatment details with dispensing pharmacists or other professionals who provide your health care for purposes of maintaining accountability

I understand that these drugs should not be stopped abruptly, as an abstinence syndrome will likely develop.

Unannounced urine or serum toxicology screens may be requested, and your cooperation is required. Presence of unauthorized substances may prompt referral for assessment for addictive disorder.

Prescriptions and bottles of these medications may be sought by other individuals with chemical dependency and should be closely safeguarded. It is expected that you will take the highest possible degree of care with your medication and prescription. They should not be left where others might see or otherwise have access to them.

Original containers of medications should be brought to each office visit.

Since the drugs may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, you must keep them out of reach of such people.

Medications may not be replaced if they are lost, get wet, are destroyed, left on an airplane, etc. If your medication has been stolen and you complete a police report regarding the theft, an exception may be made.

Early refills will generally not be given.

Prescriptions may be issued early if the physician or patient will be out of town when a refill is due. These prescriptions will contain instructions to the pharmacist that they not be filled prior to the appropriate date.

If the responsible legal authorities have questions concerning your treatment, as might occur, for example, if you were obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to our records of controlled substance administration.

I agree NOT TO DRIVE a car or operate dangerous or heavy machinery while using a controlled substance. I understand that the use of a controlled substance may affect my coordination, motor skills and cognition in ways that could impair my ability to drive and agree not to operate heavy machinery, drive or engage in potentially hazardous activities.

I understand that the use of controlled substances may ADVERSELY affect one’s health. If this occurs I will schedule an appointment to be further evaluated by a physician to determine another form of treatment for relief of my health problems. I assume all risks for usage.

I understand that SIDE EFFECTS may occur while I am taking a controlled substance. Side effects of controlled substances include side effects of opioid administration not limited to sedation, dizziness, nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression, physical dependence and addiction, less common side effects may include delayed gastric emptying, hyperalgesia, immunologic and hormonal dysfunction, muscle rigidity, and myoclonus. Abruptly stopping opioids can also lead to serious side effects and withdrawal. Opioids are a common cause of overdose leading to severe disability and/or death. Common side effects of benzodiazepines include sedation, dizziness, weakness,and unsteadiness. Other side effects include drowsiness depression, loss of orientation, headache, sleep disturbance, confusion, irritability, aggression, excitement, and memory impairment, physical dependence and addiction. Suddenly stopping therapy may be associated with withdrawal symptoms which including depression, agitation, and insomnia. If benzodiazepines are taken continuously for longer than a few months, stopping therapy suddenly may produce seizures, tremors, muscle cramping, vomiting, and sweating. Benzodiazepines are a common cause of overdose leading to severe disability and/or death. In order to avoid withdrawal symptoms, the dose of benzodiazepines should be tapered slowly. I understand that other controlled substances may have similar side effects that at times can be serious leading to serious disability and loss of life and that this is not a comprehensive list of side effects.

I also understand that combining these medications with other medications or supplements including those that are available over the counter can increasing the likelihood of experiencing a side effect and that no medication or supplement should not be taken without consultation with a physician.

I understand that none of these medications should ever be combined with alcohol. I understand that taking alcohol, opioids or benzodiazepines together could result in death.

I understand that if any side effect takes place even those that don’t seem bad they may progress to being severe. I agree that if side effects take place that are concerning I will not wait to see a physician but I will call 911 or seek immediate medical attention especially if the side effects include any worsening problems, breathing problems, chest pain, palpitations or fast beating heart, swelling of the mouth or tongue, weakness, high-fevers, vomiting, severe symptoms, or experiencing more than one of: skin rash, itching, wheezing, breathing difficulty, swelling, vomiting or feeling dizziness after taking a medication.

I agree to tell the attending physician if I have ever had symptoms of depression, been psychotic, attempted suicide or had any other mental problems.

I understand some users might develop a tolerance to controlled substances. This means higher and higher doses are required to achieve the same benefit. It is recommended for patients to have an intermission with the drug for at least 3 weeks every 3-4 months. If I think I may be developing a tolerance to a controlled substance, I will notify the attending physician.

I agree that if I am a female patient that I will contact my attending physician and primary care doctor if I become or are thinking about becoming pregnant. I acknowledge that the use of controlled substances creates pass-through problems to a fetus during pregnancy and to a baby during breastfeeding.

I will not be driving a vehicle while using controlled substances and understand that I can get a DUI for driving under the influence.

I agree to obtain medical follow up at my personal medical doctor’s office and to return to Morgenstern Medical for follow up as recommended by the physician. I understand that interaction with healthcare providers is in the best interest for my continuity of care.

I am responsible for my own medications and am aware that lost, stolen, eaten or misplaced controlled substances will not be replaced without exception.

I understand the importance of taking personal responsibility in the management of my condition. I understand the importance of legal responsibility with both federal and state law for taking controlled substances appropriately. Under no circumstance will I share, sell or trade controlled substances.

I understand that I will be subject to random urine and or blood drug testing to ensure compliance. Results may be forwarded to a primary care physician.

I am responsible for making my follow-up appointments for medication refill. It is my responsibility to schedule an appointment no less than 4 days prior to needing additional medication.

If a medication trial is unsuccessful, the remaining medication must be discarded in accordance with local law. While flushing medication down the toilet is effective it may not be legal according to local law. You may be permitted to bring your medication to a local fire department or pharmacy to have them discard the medication in accordance with the law.

I will be compliant with medical and other forms of recommended therapy including mental health if deemed necessary by Morgenstern Medical.

I understand that controlled substances may be hazardous or lethal to a person who is not tolerant to their effects, especially a child, and that I must keep them out of reach of such people.

I understand that renewals are contingent on keeping scheduled appointments. Please do not phone for authorization after hours or on weekends.

I understand that any treatment is initially a trial, and that continued treatment is contingent on evidence of benefit.

It is understood that failure to adhere to these policies may result in cessation of therapy with controlled substances by this physician or referral for further specialty assessment.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

 

1. I hereby declare that I have completely and truthfully disclosed all information regarding my medical conditions. I attest that I, and any visitors that will accompany me at my visit, are not members, employees or agents of any media or law enforcement agency. It is illegal to film or record in any office associated with Morgenstern Medical with a video camera, cell phone or any other recording device be it a still image, video or audio. This is a direct violation of HIPAA regulations and patient/doctor confidentiality. I am aware that my recommendation can be revoked at any time and legal actions may be taken if I have perjured or misrepresented myself or my condition, my intentions or falsified any medical records to a physician.

2. If I am a current patient or a former patient of Five Towns Neurology or Dr. David Steiner, I acknowledge that Morgenstern Medical and its representatives did not solicit me to be a patient. I established this visit on my own without any contact or solicitation from or with Morgenstern Medical. 

 

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

I acknowledge that Morgenstern Medical has informed me, I understand and/or I agree to all of the following:

1. About the side effects and dangers associated with all medications including and not limited to prescribed, over-the-counter medications, and supplements I have been prescribed and/or that I am using (“Medications”) that may directly or indirectly cause serious permanent disability, injury, or death (“Injury”). I understand Injury may occur from Medications causing side effects and/or physiological effects that may cause or contribute to an event including and not limited to a heart attack or stroke that may result from increased or decreased heart rate and increased or decreased blood pressure and that these effects are commonly caused by many over-the-counter and prescribed medications. I understand many medications can have an unanticipated effect and may even have an effect that is the opposite of what is meant to treat (for example, an anti-depressant can or may alter my ability to perform tasks requiring attention or skill such as driving or operating machinery. I also understand that all Medications may indirectly cause Injury through an interaction with another medication including and not limited to decreasing the effectiveness of another medication or increasing the likelihood that another medication will cause a side effect.
2. I have entered all of my Medications and read, understand and followed all instructions provided about my Medications on the Medline Plus Website at https://medlineplus.gov/druginformation.html and at the Drugs.com and the Drug Interactions checker on Drugs.com at https://www.drugs.com/drug_interactions.html (“Drug Information”). This includes and is not limited to all Medications side effects and drug interactions. I have no questions for Morgenstern Medical related to Drug Information.
3. Prior to starting, stopping, altering the dose, administration form, or frequency of any Medications (“Changing Medications”)—unless specifically directed by another health care provider—I agree to review Drug Information for any Medications and, if I have any questions, I will email, call and leave a voice mail message (“Contact”) if I do not speak to a physician, informing Morgenstern Medical of any questions related to Changing Medications. If I do not get an immediate response to a question, I will contact my primary care doctor to ask them the question. I also understand that if I do not receive a response from Morgenstern Medical within a 24 hour period, and do not Contact Morgenstern Medical a second time within 24 hours to ask the question a second time, I am acknowledging that I have read and understand the Drug Information and have also received an answer from another qualified health care provider and no longer have any questions related to Drug Information or Changing Medications.
4. Notwithstanding the information above, I have also been provided with education associated with my visits including the a) general risks of all Medications not limited to a fast or irregular heartbeat, high blood pressure, low blood pressure, dizziness, falls, slowed reaction times, drowsiness, addiction, short-term memory loss, trouble concentrating, confusion, decreased or increased anxiety, lung irritation that may occur from Medications. b) general risks and contraindications of Medications for people with pre-existing conditions including and not limited to worsening pre-existing disease of the major organs of the body brain, heart, lung, liver or risk to pregnancy, or individuals with a history of psychotic disorder or substance abuse c) risks of driving under the influence of any psychotropic d) the risks of combination of Medications not limited to the combination of alcohol, benzodiazepines, cannabis, or opioids alone and/or with each other e) to never share any Medications f) to only obtain medications at state licensed facilities due to risks including and not limited to contamination g) that for any Medications being used, it is important that they are certain that it does not impair concentration, coordination or cause drowsiness prior to driving, using machinery or carrying out activities that require sustained attention h) to obtain patient drug handouts for any medication they are already taking, or that is prescribed by a provider at this office and i) Advised to carefully review side effects and drug interaction information routinely and retain copies for my own record.   j) I must constantly monitor for side effects of medication and to report these side effects if they occur. To notify us immediately if any changes in their medical condition, medications or if they experience any side effects from any medications. To call primary care physician for non-serious medical questions.
5. To call 911 and/or obtain care at an emergency room if: a) I have serious symptoms—or side effects—not limited to chest pain, shortness of breath, weakness, paralysis b) I feel suicidal or homicidal—I feel like I might hurt or kill myself or others, c) I feel psychotic symptoms d) I have signs of toxicity or d) I have any symptom but am unsure if a symptom and/or a side effect is considered dangerous or serious
6. Morgenstern Medical’s role was explained during my visit as being limited in scope—unless defined otherwise in writing—to symptomatic treatment of the patient’s condition and/or as a second opinion to treat a condition after it has been diagnosed and that Morgenstern Medical is not a substitute for a primary care doctor or other specialists that treat the patient’s conditions and that the patient also needs to have a primary care doctor to manage any medical problems.
7. Unless otherwise informed in writing, Morgenstern Medical recommends that I: a) obtain an in-person physical examination b) follow up without any further reminder from Morgenstern Medical within 1 – 3 months with Morgenstern Medical and with your primary care physician, and that; c) If any recommendations (“Recommendations”) are made including and not limited to one for a follow up appointment, obtaining a lab test, diagnostic test or related to Medication adjustment, that I will promptly follow Recommendations without delay, will make private arrangements to remind myself to follow Recommendations and that Morgenstern Medical will not be responsible to remind me to follow any Recommendations.
8. Unless otherwise advised in writing, such recommendations must be obtained urgently and as soon as possible. I understand that Recommendations have medical health and/or other benefits associated with them and that not following any Recommendation and/or any delay in following a Recommendations is considered to be a refusal of care and is being done against medical advice (collectively “Refuse Care”). I understand if I Refuse Care it is at my own insistence and without the authority and against the advice of Morgenstern Medical, that it may result in additional pain and suffering, permanent disability, risks to an unborn fetus, risks to family members, serious injury and/or death, and I accept full responsibility for any decision including all risks and consequences resulting from my refusal of care and will indemnify and not hold Morgenstern Medical, its administration, personnel  or its officers, agents, or employees responsible for any bad things that happen to the patient because of my refusal.

 Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

Morgenstern Medical Communication via Email and Text Messaging.

We recognize that many patients find e-mail and text messaging (Electronic Messaging) to be a convenient manner to communicate with your doctor. Similarly, we consider this to be an essential component of providing the best care with our patients.  

I understand and authorize Morgenstern Medical to contact me via Electronic Messaging not limited to text messages sent through Electronic Messaging including and not limited to SMS, MMS, and email or other electronic forms directly or through a third party provider. I also authorize Morgenstern Medical to contact me using other technologies in not limited to Electronic Messaging, land line phone, mobile phones, mobile applications (not limited to Zoom, Skype or FaceTime), Voice Over Internet Protocol (VOIP) or video conferencing software (collectively “Communication Tools”) and understand that any or all forms of Communication Tools used to communicate (“Communicate”, “Communication”) may contain personal health information (“PHI”).

I understand that communication via any Communication Tools may not be a completely secure method of communication. Information could potentially be sent to the wrong person, may not be the most timely method of communication and it is dependent on technology which may or may not work all time or technology may exist on a network or recipients device that could listen to or record private conversations.

I understand that for all forms of Communication, especially the Communication Tools mentioned above, should I choose to communicate with my provider I acknowledge and consent a) that it should not be used for emergencies or for communicating time sensitive information. In the event of a medical emergency you should contact 911 or go to the nearest Emergency Department. To communicate emergent or time sensitive information I should directly contact the office of the healthcare provider. I understand that all communications will generally be processed during routine business hours. In the event I do not receive a response, I understand that I should contact the office directly. I understand that due to situations outside of the control of the physician, clinicians and office practices, internet and email service and other Communication may be interrupted or not work at any given time. The physicians, clinicians and office practices are not responsible for technical Communication failures. Again, if you do not receive a response to your Communication, please call the office directly during business hours.

I agree that I will not share, distribute, release or sell my healthcare provider’s e-mail address or other contact information. I understand that Communication with a physician outside of a scheduled office visit through Communication Tools is not a substitute for medical care and evaluation. I must arrange for an office appointment or video conference office visit to assure appropriate care b) I understand that I am to provide my full name and contact information in all Communications, e.g., full name, address, phone number(s). 

I understand and accept that my provider may route my Communications to other members of the staff for informational purposes or for expediting a response. I authorize my provider to send and designate staff to receive and read my Communication. Whenever possible, e-mails originating from Morgenstern Medical will attempt to use encryption technologies to prevent interception of e-mails by inappropriate parties.

However, I acknowledge that many commonly used Communications devices not limited to email services and mobile phones are not secure and fall outside the security requirement set forth by the Health Insurance Portability and Accountability Act (HIPAA) for the transmission of protected information. Therefore, I understand there is a risk that my health information may be obtained by others not affiliated with my provider. I authorize my provider to transmit my PHI via email and other Communication Tools even though they may not be secure and private and may be subject to loss or exposure.

I understand that I can opt-out of receiving emails containing personal health information protected by HIPAA below. I may also do so by contacting the office at 516-778-7533 or by email at [email protected] and receiving written or e-mailed confirmation from the office. I also understand that sending email to my doctor containing personal health information (such as questions about medication, testing etc.) after opting out will indicate that I am opting back in to receiving future e-mail containing personal health information. I also understand that even if I opt-out of receiving e-mails containing personal health information, I agree to receive other e-mails including non-personal health information such as information related to billing or future appointments.

I acknowledge and accept that my healthcare provider can terminate the Communication Tools used for Communication at any time. I understand that I am responsible for notifying the physician if I chose to discontinue the use of email or other Communication Tools if or if my contact information not limited to my email address has changed.

 

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

I request that payment of authorized insurance benefits be made either to me or on my behalf to all providers who treat me and authorize the holder of medical and other information about me to release information needed to determine these benefits or benefits for related services.

I irrevocably assign to you, my medical provider and/or Morgenstern Medical (collectively Morgenstern Medical, you or your), all of my rights and benefits under my insurance contract for payment for services rendered to me. I authorize Morgenstern Medical to file insurance claims on my behalf for services rendered to me and this specifically includes filing arbitration/litigation in your name on my behalf against the PIP carrier/health care carrier. I irrevocably authorize Morgenstern Medical to retain an attorney of your choice on my behalf for collection of your bills. I direct that all reimbursable medical payments go directly to Morgenstern Medical, my medical provider. I authorize Morgenstern Medical to act on my behalf. I consent to your acting on my behalf in this regard and in regard to my general health insurance coverage pursuant to applicable state and federal laws. In the event the insurance carrier responsible for making medical payments in this matter does not accept my assignment, or my assignment is deemed invalid, I execute this limited power of attorney and appoint your collection attorney as my agent to collect payment for your medical services directly against the carrier in this case including filing an arbitration demand or lawsuit. I specifically authorize that attorney to file directly against that carrier in my name or in your name as a medical provider rendering services to me. I authorize Morgenstern Medical and or your assigned to obtain medical information regarding my physical condition from any other health care provider, including hospitals, diagnostic centers, etc., and I specifically authorize such health care providers to release all such information to Morgenstern Medical about me, including medical reports, X-ray reports, narrative reports, and any other report or information regarding my condition.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

I understand that any dispute between myself, my heirs, or other associated parties on the one hand and Morgenstern Medical, its health care provides, or other associated parties on the other hand,  for alleged violation of any duty arising out of or related to any claim for medical or hospital malpractice, for premises liability, or relating to delivery of services or items, and for questions of arbitrability irrespective of legal theory, must be decided by binding arbitration under New York law and not by lawsuit or resort to court process.

The term medical or hospital malpractice should be interpreted broadly and shall include and not be limited to all claims in tort, contract, lack of informed consent, or other legal theories which in any way pertain to claims or unnecessary, unauthorized, improper, negligent, or incompetent rendering of medical treatment.

I agree to give up my right to a jury trial and accept the use of binding arbitration.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law, Law in the State which I reside and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996  (HIPAA), I understand that: 

1. This authorization includes disclosure of HEALTH INFORMATION and may include information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV RELATED INFORMATION (collectively referred to as “PHI”) unless I  revoke this authorization as in Item 4. In the event the health information described below includes any of these types of information, I specifically authorize release of such information to the person(s) and/or in public in response to a review or other information that is posted online as  indicated in Item 9.
2. This authorization, including those in Item 1, includes the disclosure of information publicly including responses to REVIEWS, DISCUSSIONS or WRITINGS that are made IN-PRINT or ONLINE including, as an example, but not limited to the INTERNET, FACEBOOK, GOOGLE, YELP (collectively referred to as “Reviews”) unless I  revoke this authorization as in Item 6. I understand that from time to time, Morgenstern Medical may choose to respond to Reviews that may include the disclosure of PHI or may be a response to PHI that is disclosed by a patient or a third-party.
3. If I revoke authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information as in line Item 6, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If  I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division  of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 
4. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may  revoke this authorization except to the extent that action has already been taken (“Action Taken”) based on this authorization. I also understand that any public disclosure of my PHI in a “Review” by myself or third-parties subsequent to my revocation, will constitute a reauthorization and that a response made at any date, even subsequent to the expiration date of an authorization, to any Review made during a period of authorization will constitute an Action Taken as mentioned above.
5. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.  
6. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 
7. THIS AUTHORIZATION AUTHORIZES ANY HOSPITAL, HEALTH PROVIDER, AGENCY, OR OTHER ENTITY TO SHARE, DISCUSS OR DISCLOSE MY HEALTH INFORMATION OR MEDICAL CARE WITH MORGENSTERN MEDICAL AS LISTED IN ITEM 8 BELOW . 
8. Name and address of health provider or entity to release this information: Morgenstern Medical, 1979 Marcus Ave, #210, New Hyde Park, NY 11042 
9. THIS AUTHORIZATION AUTHORIZES MORGENSTERN MEDICAL TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH AN ATTORNEY, GOVERNMENTAL AGENCY OR OTHERS SPECIFIED BELOW, INCLUDING:

a. Any Health Insurance company, Health Care Provider or health agency

b. As in Item 2 above, I am providing authorization for public disclosures to made in response to “Reviews.” I understand that this includes any publication, in writing or on the internet not limited to online forums, chats, message boards, website or online reviews including but not limited to on Facebook, Google, Yelp.

c. Any other party, individual or entity (Party), that I ask Morgenstern Medical to disclose information to via communication not limited to conversation, phone, fax, electronically, or in writing (Communication). I understand and agree that evidence of a request vaia Communication via email, fax or, a record of Communication by documentation will be sufficient to establish my official authorization. Party shall include and is not limited to any friends, family members, employers, insurance companies, disability agencies or the agents of the Party (Agent). I understand that an Agent may also request information in relation to a my health information or a disclosure made to the Party and by agreeing to share information with a Party I am also authrizing the information to be shared with an Agent of the Party whether or not I have included the name of the Agent in my Communication and without any limitations beyond those provided already during prior Communication with Morgenstern Medical respect to the Party. 

10. Specific information to be released: Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,   referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Alcohol/Drug Treatment, Mental Health Information, Discuss Health Information, HIV-Related Information and/or to discuss health information with my attorney, or a governmental agency. 
11. Reason for release of information includes and is not limited to information that is made at request of individual, a healthcare provider, insurance, governmental agency and/or a public discussion or review about Morgenstern Medical. 
12. This authorization will be expire and automatically be renewed on an annual basis unless a :
13. If not the patient, name of person signing form agrees and certifies his/her authority to sign on behalf of patient.

Signature:___________ Date: ______________

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

Modifications to Terms and Conditions

Morgenstern Medical may in its sole discretion, without prior notice to you, revise these Terms and Conditions at any time. Should these Terms and Conditions change materially, Morgenstern Medical will update the Effective Date noted above and post a notice regarding the updated Terms and Conditions on the Websites. The amended Terms and Conditions will also appear when the Service is accessed by you and you will need to acknowledge your agreement to the amended Terms and Conditions prior to being able to continue to use the Service. If you do not agree to the terms of the amended Terms and Conditions, your sole and exclusive remedy is to discontinue your use of the Websites and Services and you will be deemed to have terminated these Terms and Conditions. Amended Terms and Conditions will be effective as of the Effective Date unless otherwise stated. By accessing or using the Websites and the Services after such changes are posted you agree and consent to all such changes.

Severability

 If a court or other tribunal of competent jurisdiction should hold any term or provision of this Agreement to be excessive, invalid, void or unenforceable, the offending term or provision shall be deleted or revised to the extent necessary to be enforceable, and, if possible, replaced by a term or provisions which, so far as practicable, achieves the legitimate aims of the parties.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

I understand that the Terms and Conditions are requested and conducted electronically using forms, electronic records and/or Electronic Signatures. I consent that whenever expressly required or permitted by Morgenstern Medical, I shall be bound by its Electronic Signature and by the terms, conditions, requirements, information and/or instructions contained in any such Electronic Records. I understand that individual electronic actions not limited to typing my name, checking on a checkbox, or entering information stored as an image such as a signature image created by using an electronic pen, finger, or mouse, may all individually and/or collectively represent an Electronic Signature.   I understand that by providing an Electronic Signature one time, I am providing one or more signatures and/or my initials to the end of each section of the Terms and Conditions or anywhere in the Terms and Conditions where the term Signature or initials is referenced or listed not limited to Signature, Signed, initials, or a representation of a line. These elements may appear independently, enclosed in brackets or underlined. I understand that these elements may be replaced by a representation of my Electronic Signature when the executed Terms and Conditions are printed.

I understand that from time to time Morgenstern Medical might need to provide a signed copy of all, part and/or a section of the Terms and Conditions (collectively “Signed Copy”). I authorize Morgenstern Medical to reproduce a Signature and/or initials represented with any font, text or image, not limited to the electronic representation of my signature on one or more parts of the Terms and Conditions and send them to third-parties in accordance with the Terms and Conditions.

By completing these forms, I understand further that I am giving my consent to electronic disclosures and to the use of electronic signatures. I understand that I am not required to to receive notices and disclosures or counter-signed documents for the Terms and Conditions to be executed. If you prefer to receive a copy of a signed disclosure, you may make a request in writing.  You may also request to receive paper copies of Terms and Conditions, and you may withdraw your consent at any time via written notification in accordance with these Terms and Conditions.

 

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

Patient Agreement

Please read the Morgenstern Medical Terms and Conditions and consider printing a copy for your records.

Name of individual agreeing to terms and conditions [Electronic Entry]

Relationship to patient [Electronic Entry]

Today’s date [Electronic Entry]

[Electronic Checkbox Entry] I agree to the Terms & Conditions.

Signature:___________ Date: ______________  

[Please note: All Signature Lines and Dates in the Terms and Conditions will be executed by Electronic Signature as in Section XV. ]

 

Submit [Electronic Button Entry]