PATIENT INFORMATION
PLEASE COMPLETE ALL FIELDS Patient’s Last Name Suffix
DATE
First Name
Middle Name
Gender: q Male q Female Social Security Number
Race
Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred Language
Mailing Address Home Address Home Ph.(
Date of Birth
)
Cell Ph. (
Country
Zip Code
City
State
County
Country
Zip Code
City
State
County
)
Work Ph. (
Primary Care Physician Employment Status
Marital Status
)
Ext
Email Address
Referring Physician
q Full-Time
q Part-Time
q Retired
Employer
Retired Date Occupation
WHO IS FINANCIALLY RESPONSIBLE FOR THE PATIENT (GUARANTOR) Spouse
Self Last Name
Parent
Other
Gender
First Name
SSN
Date of Birth
Home Ph.(
Street Address
Middle Name )
Country
Employment Status q Full-Time
q Part-Time
Cell Ph. (
)
Zip Code
q Retired
Work Ph. ( City
) State
Retired Date
Employer Name Policy Holder Information (if Different from Patient). If same as responsible, please check here q Spouse
Self Last Name
Parent
Other
Gender
First Name
SSN
Date of Birth
Home Ph.(
Street Address
Country
Employment Status q Full-Time
q Part-Time
q Retired
Middle Name )
Cell Ph. ( Zip Code
)
Work Ph. ( City
) State
Retired Date
Employer Name Emergency Contact (Parent / Guardian if patient is a minor) Name Home Ph.(
Relationship )
Cell Ph. (
)
Work Ph. (
)
PLEASE HAVE YOUR INSURANCE CARD AND DRIVER’S LICENSE READY FOR THE RECEPTIONIST. PAYMENT FOR PROFESSIONAL SERVICES IS DUE AND PAYABLE WHEN SERVICE IS RENDERED. PLEASE FILL OUT REVERSE SIDE.
MM3503 FRONT (08/11)
PLEASE REVIEW AND PROVIDE SIGNATURE CONSENT FOR EVALUATION OR TREATMENT The undersigned hereby consents to evaluation or treatment the assigned healthcare provider may deem necessary to the patient name above.
PATIENT, PARENT, LEGAL GUARDIAN OR AUTHORIZED REPRESENTATIVE
DATE
INSURANCE ASSIGNMENT I hereby authorize my insurance benefits to be paid directly to Florida Hospital Medical Group. I 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
DATE
FOR MEDICARE PATIENTS ONLY MEDICARE PART B SIGNATURE AUTHORIZATION - LIFETIME 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. I 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 NAME
PATIENT SIGNATURE
MEDICARE B #
DATE
ADVANCE 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.)
SIGNATURE
DATE MM3503 BACK (08/11)
AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (MEDICAL RECORD) PLEASE READ THE ENTIRE FORM, ALL 3 PAGES, BEFORE SIGNING BELOW. Individual (name and information of person whose health information is being disclosed): Patient Name:
Date of Birth: ________________________
Address: ______________________________________ City: __________________ State:_____ Zip:___________
You may use this form to allow limited access to and use of your health information by certain persons for certain purposes. Your choice on whether to sign this form will not affect your ability to get medical treatment, payment for medical treatment, or health insurance enrollment or eligibility for benefits.
By signing this form, I voluntarily authorize, give my permission and allow use and disclosure (including paper, oral and electronic interchange): OF WHAT: (initial one) ______ ALL MY HEALTH INFORMATION including information about sensitive conditions (if any). Health information includes, but is not limited to, all records and other information regarding my health history, treatment, hospitalization, tests, and outpatient care, and also educational records that may contain information about my health. This includes my specific permission to release any and all of the following information: a. Drug, alcohol, or substance abuse b. Psychological, psychiatric or other mental impairment(s) or developmental disabilities (excludes “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501) c. Sickle cell anemia d. Birth control and family planning e. Records which may indicate the presence of a communicable disease or noncommunicable disease; and tests for or records of HIV/AIDS or sexually transmitted diseases or tuberculosis f. Genetic (inherited) diseases or tests g. Copies of educational tests or evaluations, including Individualized Educational Programs, assessments, psychological and speech evaluations, immunizations, recorded health information (such as height, weight), and information about injuries or treatment. ______ ONLY THE INFORMATION INDICATED BELOW (initial next to all that you want disclosed): _____ History and Physical _____ Operation Reports _____ Discharge Summary _____ Radiology Reports & Images _____ Pathology Reports _____ EKG Reports _____ Progress Notes _____ Consultation Reports _____ Lab Results _____ Physician’s Orders _____ Drug, Alcohol or Substance Abuse Records _____ Family Planning Records _____ Prenatal Records _____ Mental Health Records (excluding “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501) _____ Diagnostic Test Reports (specify type of test): _____ Other (please specify): ______ Note: Information created before or after the date of this form may be disclosed, unless you specify a date range of records here: From (mm/dd/yyyy): ______________________ To (mm/dd/yyyy) : ______________________.
FROM WHOM: Persons/organizations providing the information: (Complete w/Address)
TO WHOM: Persons/organizations permitted to receive my information: (Complete w/Address)
PURPOSE: (check all that apply) ❐ My medical treatment and related services and products ❐ To evaluate and improve patient safety and the quality of medical care provided to all patients ❐ Payment (as defined in HIPAA at 45 CFR 164.501) ❐ Eligibility for certain health care services (e.g., hospice)(please specify: ) ❐ Eligibility for clinical trials (if limited, please specify here:
)
❐ Scientific research with proper Institutional Review Board approval or waiver ❐ Personal Health Record for my use ❐ Personal use ❐ Other, please specify:
EFFECTIVE PERIOD: This authorization/permission form will remain in effect until (check one): ❐ The day I withdraw my permission or the date of my death ❐ A specific date (mm/dd/yyyy): ❐ A specific event. Please specify:
REVOKING YOUR PERMISSION: I can revoke my permission at any time by giving written notice to the person or organization to whom I originally gave this form. In addition: • • • •
I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above. I understand that there are some circumstances in which this information may be re-disclosed to other parties and no longer protected by federal privacy laws (see page 3 for details). I understand that refusing to sign this form does not stop disclosure of my health information that is otherwise permitted by law without my specific authorization or permission. I have read all pages of this form and agree to the disclosures above from the types of sources listed.
X_____
Signature of Patient or Patient’s Legal Representative
Date Signed (mm/dd/yyyy)
_____ Print Name of Legal Representative (if applicable) Check one to describe the relationship of Legal Representative to Patient (if applicable): ❐ Parent of minor ❐ Guardian ❐ Other personal representative (explain: This form is invalid if modified. You are entitled to get a copy of this form after you sign it.
Further Explanation of This Form Laws and regulations require that some sources of personal information have a signed authorization or permission form before releasing it. Also, some laws require specific authorization for the release of information about certain conditions and from educational sources.
Definitions: In this form, the term “treatment,” “healthcare operations,” “psychotherapy notes,” and “protected health information” are as defined in HIPAA (45 CFR 164.501). Note on Mental Health Records: If you are requesting a copy of your mental health records with this form, Florida allows such access, unless such access is determined by your physician to be harmful to you. For more information, see Florida Statute 394.4615(10). “To Whom”: •
If you specified a healthcare provider in the “TO WHOM” section above, this permission would also include physicians, other health care providers (such as nurses) and medical staff who are involved in your medical care at that organization’s facility or that person’s office, and health care providers who are covering or on call for the specified person or organization, and staff members or agents (such as business associates or qualified services organizations) who carry out activities and purpose(s) permitted by this form for that organization or person that you specified.
•
If you specified an organization other than a healthcare provider in the “TO WHOM” section above, this permission would also include that organization’s staff or agents and subcontractors who carry out activities and purpose(s) permitted by this form for that organization that you specified.
Revocation: You have the right to revoke this authorization and withdraw your permission at any time regarding future uses by giving written notice. You should understand that organizations that had your permission to access your health information may copy or include your information in their own records. These organizations, in many circumstances, are not required to return any information that they were provided nor are they required to remove it from their own records. Re-disclosure of Information: Any health information about you may be re-disclosed to others only to the extent permitted by state and federal laws and regulations. You understand that once your information is disclosed, it may be subject to lawful re-disclosure, in accordance with applicable state and federal law, and in some cases, may no longer be protected by federal privacy law. Limitations of this Form: This form does not obligate your health care provider or other person/organization listed in the “From Whom” or “To Whom” section to seek out the information you specified in the “Of What” section from other sources. Also, this form does not change current obligations and rules about who pays for copies of records.
COMMUNICATION USE AND DISCLOSURE AUTHORIZATION Section A: Please complete the following information for all requests 1. Today’s date: 2. Patient name: 3. Date of Birth:
4. Patient #:
5. Address: I hereby request the following regarding the use of my PERSONAL HEALTH INFORMATION: 1. You may leave the following messages on answering machines:
q q q q
Referral Information Prescription refill information Test results Other:
2. You may discuss information regarding my treatment and care with the following family members and/or friends: 3. You may contact me regarding my treatment and care at the following numbers: Signature of Patient or Guardian
Date
Signature of Staff Person and Title Printed Name of Staff Person and Title
MM3521 (09/11)
Written Acknowledgement of Receipt Of Florida Hospital Medical Group’s Notice of Patient Privacy Practices PLEASE REVIEW AND PROVIDE SIGNATURE
By signing this Written Acknowledgement, I hereby expressly acknowledge my receipt of FHMG’s Notice of Patient Privacy Practices.
Patient, or Legal Representative, Signature Printed Patient, or Legal Representative Name Relationship to Patient Date Acknowledgement NOT obtained because: Patient, or legal representative, declined to accept Notice of Patient Privacy Practices: Patient received Notice of Patient Privacy Practices, but refused to sign Acknowledgement. Other (briefly describe)
Employee Signature Employee Printed Name Date
MM3522 (11/11)
FINANCIAL RESPONSIBILITY STATEMENT Thank you for choosing us as your health care provider. We are committed to providing excellent health care services to our patients. As part of our professional relationship, it is important that you understand our financial policy. • It is your responsibility to provide us with your most current insurance and billing information. • Co-payments, co-insurance and deductibles are due at the time of service. For co-insurance, we will estimate the amount you owe. You will be responsible for the balance after your insurance company pays your claim. We accept cash, checks, Visa, and MasterCard. • You will receive a statement from our billing office, Florida Hospital Medical Group. Payment for your balance will be due upon receipt of the statement. If you are unable to pay the balance in full, you must contact the billing office to make payment arrangements. • If you undergo surgery, your insurance company will be billed for Florida Hospital Medical Group professional services. The hospital or surgical center will be billed for operating room fees and there are additional fees for anesthesia. Some surgical procedures may require a second surgeon to assist and your insurance company will be billed separately on his behalf. Any inquires should be addressed to that surgeons’ billing department. Deposits that are paid to Florida Hospital Medical Group are only applied to his fee for performing the surgery. • Form Fees – Forms that you request to be filled out for FMLA, short/long term disability and all other insurance forms will be subject to a $25.00 fee per form.
I have read and understand this financial policy. PATIENT NAME:________________________________DATE:____________/______________________ Signature of Responsible Party
