M E D I C A L
G R O U P
GENERAL INFORMATION
Name ________________________________________________________Date of Birth_____________________ INSURANCE ASSIGNMENT: I hereby authorize my insurance benefits to be paid directly to Florida Hospital Medical Group. Understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered.
PATIENT SIGNATURE/PERSONAL REPRESENTATIVE
DATE
LIFETIME MEDICARE AUTHORIZATION FOR MEDICARE PATIENTS ONLY:
I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare Claim. I permit a copy of this authorization to be used in place of the original. Request that payment of the authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to me.
PATIENT SIGNATURE/PERSONAL REPRESENTATIVE
DATE
ADVANCED DIRECTIVE: I understand that the terms of any Advance Directive that I have executed will be followed by the health care facility and my care givers to the extent permitted by law. Please check one of the following statements:
¨ I HAVE executed an Advance Directive.
(Living Will, Durable Power of Attorney, Designation of a Health Care Surrogate.)
Please provide copies of Advance Directive/Living Will to the receptionist to be included in your medical record
¨ I HAVE NOT executed an Advance Directive.
(Living Will, Durable Power of Attorney, Designation of a Health Care Surrogate.)
PATIENT SIGNATURE/PERSONAL REPRESENTATIVE
DATE
NAME OF PERSONAL REPRESENTATIVE (Please print)
RELATIONSHIP TO PATIENT FHMG-CFRM-01 6/15
M E D I C A L
GENERAL CONSENT FOR TREATMENT, EVALUATION, AND INFORMATION RELEASE
G R O U P
Patient Name:__________________________________________Date of Birth: _____________________ By signing below, I voluntarily agree to the following provisions of this form: Consent to Treatment
I allow Florida Hospital Medical Group (the "Practice") to provide health care services to me that may be deemed to be routine or otherwise necessary. I consent to evaluation or treatment that the assigned healthcare provider may deem necessary. This may include diagnostic, radiology and laboratory procedures, and medication administration. I understand that I have the right to refuse consent to any proposed procedure or treatment at any time prior to its performance. PHOTOGRAPHS I consent to the Practice taking and reproducing pictures of me in any form (e.g., photograph, film, tape, etc.) in connection with my diagnosis, care and treatment (including surgical procedures). These pictures will be used for purposes related to treatment, scientific and educational purposes, or Practice department functions, such as quality assurance or health care operations. Yes ______ No_______ GENERAL RELEASE OF INFORMATION I acknowledge that I have received a copy of the Practice's Notice of Patient Privacy Practices, which describes the permitted uses and disclosures of my protected health information related to my care by the Practice, and payment of my charges for the services received at the Practice. I specifically authorize the uses and disclosures of my health information described in the Practice's Notice of Patient Privacy Practices. I consent to release of my health information, including but not limited to psychiatric, substance abuse, communicable disease, genetic testing, venereal disease, and HIV information (referred to in this form as "Sensitive Conditions"), for medical purposes and for payment purposes to third parties including but not limited to federal or state health plans, insurance companies , collection agencies, employers or other organizations responsible for payment of my charges for the services received at the Practice. I also consent to release of this information for the Practice's day-to-day health care operational purposes. I understand that my health information may include information relating to my health condition, care, or payment for my care, including telephone numbers and other demographic information. AFFILIATED ENTITIES OF ADVENTIST HEALTH SYSTEM I consent to the use and release of all my health care information, including Sensitive Conditions, for treatment, payment and health care operations, among the affiliated entities of Adventist Health System referenced in the Practice's Notice of Patient Privacy Practices, as amended from time to time.
Page 1 of 2
FHMG-CFRM-04 6/15
HEALTH INFORMATION EXCHANGE Health information exchange allows health care providers to share health care information about patients electronically for several purposes, such as treatment, quality assurance and state law reporting requirements. I understand that if I go to the Practice for treatment, the physicians and/or their staff may get a copy of my medication history and other health care information electronically through various health information exchange connections with other health care providers. I understand I may request that my health care information not be shared through electronic health information exchange by following the directions in the Practice's Notice of Patient Privacy Practices. SUBSTANCE ABUSE I understand I can terminate this authorization for release of substance abuse health care information at any time, unless Adventist Health System and its affiliated hospitals, physicians and care providers have already acted in reliance on it. If not previously revoked, I understand this authorization will be reviewed annually. I further understand that I may decline to sign this authorization today by checking the box below. ¨ Decline
BY SIGNING BELOW, I AM AGREEING TO THE CONSENTS AND RELEASES DESCRIBED ON THIS FORM. I HAVE READ THIS CONSENT AND HAVE BEEN ABLE TO ASK QUESTIONS.
Printed Name of Patient
Signature of Patient
Legal Representative Printed Name
Legal Representative Signature
Legal Representative Relationship
Date
Page 2 of 2
FHMG-CFRM-04 6/15
M E D I C A L
G R O U P
PATIENT FINANCIAL RESPONSIBILITY
Name__________________________________________________________ Date of Birth__________________ • Our front desk staff will ask you for payment for any past due balances as well as your portion of the payment for today's service. • Payment is expected at time of service. This includes co-pays, co-insurances and deductibles.
• If you are unable to keep your appointment, it is important to notify us 24 hours prior to your appointment. This will allow us to free your appointment time for other patients. You may be charged a $25 no show fee for primary care visits and a $50 no show fee for specialty visits if you fail to notify us. You may also be charged a $100 fee if you fail to cancel and reschedule an elective procedure. • If you are scheduled for an elective non-covered service, an estimate of your portion of the payment will be provided to you. Payment will be expected at least 10 days prior to this procedure. If you have any outstanding balance, we will also expect payment 10 days prior to the procedure. Failure to make the required payments will result in the service being rescheduled. • Some insurances require that your labs be performed in a different location other than your doctor's office. If you choose to have the test performed at your physician's office, you will be expected to pay the fee for this service. Your insurance cannot be billed in those instances.
• If your insurance does not authorize a procedure or test and you choose to have the procedure or test done anyway, you will be expected to pay the fees for this service. Your insurance cannot be billed in those instances. • We do not extend professional courtesy discounts.
➤ If you have any questions, please call our Customer Service department at (407) 200-2711 or 1 (800) 741-8342 (Florida) or 1 (877) 720-7964 (outside Florida), Monday thru Thursday, 8:00 AM to 5:00 PM and Friday from 8:00 AM to 3:00PM. By Signing below, I acknowledge I understand the Patient Financial Responsibilities outlined above.
PRINTED NAME OF PATIENT
DATE
PATIENT’S SIGNATURE / LEGAL REPRESENTATIVE’S SIGNATURE
PRINTED LEGAL REPRESENTATIVES NAME AND RELATION TO PATIENT FHMG-CFRM-05 6/15
M E D I C A L
PATIENT INFORMATION
G R O U P
Please Print
Date: _________________
Patient's Name: Last____________________________________ First_________________Middle _________ Suffix ____ Gender: ¨ Male ¨ Female Social Security Number_______________________________ Date of Birth _______________ Marital Status________
Race: ¨ American Indian/Alaska Native ¨ Native Hawaiian/Pacific Islander
¨ Asian
¨ Black/African American
¨ White
¨ Other
Ethnic Group: ¨ Hispanic/Latino ¨ Non-Hispanic/Non-Latino ¨ Unknown Preferred Language___________________________Religion ________________________ Home Address_______________________________________________________________ Apt#____Zip Code_________ City________________________State______
Portal Pt. Access ¨ No ¨ Yes
Mailing Address (if different) ___________________________________________________ Apt#____Zip Code_________ City______________________________________________________State______ Preferred Contact Method: ¨ E-Mail ¨ Phone ¨ Portal Home Ph.(
)_______________________Cell Ph. (
Employment Status
¨ Full-Time ¨ Part-Time
Email Address ______________________________________ )____________________ Work Ph. (
¨ Student
) ___________________
¨ Retired Retired Date _________________________
Primary Care Physician__________________________________ Referring Physician ______________________________ Policy Holder: ¨ Yes
¨ No FINANCIALLY RESPONSIBLE FOR THE PATIENT (GUARANTOR)
¨ Self ¨ Spouse ¨ Parent
¨ Other ______________________________________________________ Gender ________
Last Name___________________________________________First Name__________________Middle Name __________ SSN_____________________________________________________________Date of Birth_________________________ Home Ph.(
)_______________________Cell Ph. (
)____________________ Work Ph. (
) ___________________
Home Address_________________________________________________________ Apt#______ Zip Code_____________ City_________________________________________State_________ Mailing Address (if different)_____________________________________________ Apt#______ Zip Code_____________ City_________________________________________State_________ Employment Status Policy Holder: ¨ Yes
¨ Full-Time ¨ Part-Time
¨ Student
¨ Retired
Retired Date__________________________
¨ No
EMERGENCY CONTACT (PARENT/GUARDIAN IF PATIENT IS A MINOR) Name _______________________________________________________________________________________________ Relationship _________________________________________________________________________________________ Home Ph. (
) __________________ Cell Ph. (
Where did you hear about us? ¨ Family ¨ Friend
) ____________________ Work Ph. (
) _______________________
¨ Insurance ¨ Internet ¨ Website ¨ Other
FHMG-CFRM-06 5/15
M E D I C A L
POLICY HOLDER ADDENDUM
G R O U P
POLICY HOLDER INFORMATION (IF DIFFERENT FROM PATIENT/GUARANTOR) ¨ Spouse ¨ Parent ¨ Other_______________________________________________________ Gender ______________ Last Name_____________________________________________First Name_________________ Middle Name_________ SSN_____________________________________________________________Date of Birth_________________________ Home Ph.(
)_______________________Cell Ph. (
)____________________ Work Ph. (
) ___________________
Home Address_________________________________________________________ Apt#______ Zip Code_____________ City_________________________________________State_________ Mailing Address (if different)_____________________________________________ Apt#______ Zip Code_____________ City_________________________________________State_________ Employment Status
¨ Full-Time ¨ Part-Time
¨Student
¨ Retired
Retired Date__________________________
FHMG-CFRM-06A 5/15
M E D I C A L
COMMUNICATION AUTHORIZATION
G R O U P
Stamp/Label Practice Name
Florida Hospital Medical Group (Practice) would like to communicate with you in the ways you prefer. By signing below, you allow us to disclose your Protected Health Information (PHI) as described on this form. PHI includes all information regarding your treatment and care. We may need to contact you for a number of reasons, including to provide information about your treatment or payment for your care. We may disclose your PHI in other ways if it is permitted by law and we determine such disclosure to be necessary under the circumstances. Patient name: _________________________________________________________ Date of Birth: _______________________________Today’s date: _________________ I hereby request the following regarding the use and sharing of my PHI: 1. Telephone messages: We may leave messages on answering machines or with individuals answering the phone at the numbers written in this section, including referral information, prescription refill reminders, appointment reminders, test results, and other information the Practice determines to be appropriate to leave on voice mail, or with the person answering the phone. Please write the number(s) you would like us to use on the line below or, if you do not want us to leave messages, write "none" or leave this blank:
2. Sharing PHI with family and friends: In addition to any individuals who may be handling messages left as allowed in Section 1 above, or individuals we may contact in emergencies or as otherwise allowed by law, you allow us to discuss PHI with the following family members, friends, or other individuals you list below and on any additional sheet attached to this form:
Printed name
Relationship
Printed name
Relationship
Street address
Street address
City, State, Zip
City, State, Zip
Phone number, including area code
Phone number, including area code Page 1 of 2
FHMG-CFRM-03 5/15
COMMUNICATION AUTHORIZATION 3. Email Communication: Sending your PHI by email carries risk. Most standard email does not provide a secure means of communication. There is a risk that PHI contained in an unencrypted email may be disclosed to, or accessed by, unauthorized individuals. Emails can be lost or misdelivered. Use of more secure communications, such as by phone, are alternatives that are available to you or the secure patient portal. 4. Sensitive Conditions: We may discuss sensitive conditions directly with you, either in person, by mail, or over the phone. If you allow us to disclose PHI regarding certain sensitive conditions, including, but not limited to HIV/AIDS, substance abuse, mental health, genetic testing, sexually transmissible diseases and tuberculosis by patient portal, telephone messages, or wireless calls as described on this form, please initial here: ___________________.
5. Wireless Calls and Texting: You consent to receive treatment and account-related calls from the Practice at the numbers you provided on the patient information form. Texts may be generated and sent using an automated notification system. Messaging may be prerecorded and delivered. You are not required to provide consent to receive calls or messages in order to receive healthcare services. Message and data rates may apply. To stop text messages, simply reply STOP to the text message. Do not use emails or texting to communicate with us regarding urgent or time-sensitive matters. In a medical emergency, call 911. It is your responsibility to make sure that only authorized people are allowed to access your email, phone messages, and mobile devices. If individuals other than you receive your PHI sent in the ways allowed on this form, they may share it with others and state and federal privacy laws will not protect it. You do not have to sign this form. If you do not sign, it will not affect the way we treat you. We will still communicate with you in person, by telephone, by mail, and as otherwise allowed by law. It is your responsibility to update this form should any changes occur prior to the annual renewal.
____________________________________________________ PATIENT NAME PRINTED
_____________________ DATE
_____________________________________________________________________________________ PATIENT/ LEGAL REPRESENTATIVE SIGNATURE
_____________________________________________________________________________________ Legal representative printed name and description of relationship (if applicable) You may request a copy of this form. Page 2 of 2
FHMG-CFRM-03 5/15
