461 West Oak Street Suite A • Kissimmee, FL 34741 • 407.846.8600 • MyHealthApple.com

Welcome to Family Health Care of Central Florida! Please complete, sign and date the attached forms, and submit them, along with your insurance card and I.D. to our check-in clerks when you sign-in for your appointment.

______Patient Information Sheet (to be completed by all patients, or their parent or guardian, please print legibly, sign & date)

______Financial Policy (to be completed by all patients, or their parent or guardian, please print legibly, sign & date)

______Medical History (front page only to be completed by all patients, or their parent or guardian; please print legibly, sign & date)

______Acknowledgement of Receipt of Notice of Privacy Practices (print your name, write your signature, fill-in the date)

______HIPPA Authorization Form (permission to share medical information with designated other . . . to be completed by all patients, or their parent or guardian, please print legibly, sign & date)

______Medical Records Release Form (to be completed by all patients, or their parent or guardian, please print legibly, sign & date)

______Living Will and Health Care Surrogate (Please read the enclosed information regarding the importance of a Living Will and Designated Health Care Surrogate. If you so desire, you may complete the enclosed Living Will and submit it to be filed with your medical records. Otherwise, please discuss any questions regarding this process with your nurse or health care provider. Thank you.)

______Driver’s License ( a scanned copy of the patient’ driver’s license or authorized I.D. must be filed in the medical record)

______Insurance Card(s) Please be sure to bring your current insurance card(s) with you to every appointment.

______Medications Please put all prescription and over the counter medications that you are currently taking in a zip lock bag and bring it with you to your healthcare visit. *REMINDER: 24 hours minimum notice is required to cancel any appointments. Otherwise, patients are subject to a $25 cancellation fee for missed or “no show” appointments.

If you have any questions prior to your visit, please feel free to contact: Rose Quintana Director of Operations 407.846.8600 ext. 1124 [email protected]

OR

Amanda Waskelis Director of Support Services 407.846.8600 ext. 1109 [email protected]

“Thank you for partnering with Family Health Care in maintaining your good health.” FHC0027 New PT Packet—Adult

FOR OFFICE USE ONLY:

PATIENT INFORMATION

INITIALS:______________

Last Name:______________________________First Name:______________________MI:____D.O.B.:____/_____/_____ Sex: M

F

SS#::______-_____-_____

Marital Status: Sin Mar Wid Div Sep

Age_____

Street Address:________________________________________________City:_____________State:_____Zip:_______ Home Phone: (______)_____-________ Cell Phone: (_____)_____-_______ Email:______________________________ Patient 2nd Address (if patient is a part-time Florida Resident):

Phone Number for this 2nd Address:(_______)______-________

Street Address:_______________________________________City:_______________________State:____Zip:_______ Preferred Pharmacy:______________________________________Phone #: (_______) ________-___________ *PLEASE PRINT LEGIBLY*

RESPONSIBLE PARTY INFORMATION

*PLEASE PRINT LEGIBLY*

The RESPONSIBLE PARTY is the person responsible for payment and/or care of the above listed patient. Please IDENTIFY the RESPONSIBLE PARTY as follows: __Patient Listed Above

__Parent

__Guardian

__Other____________________

r

Last Name:______________________________First:__________________________MI:____SS#:_____-____-________ Street Address:______________________________________City:_______________________State:_____Zip:_______ Home Phone: (______)_____-________ Cell Phone: (_____)_____-_______ Email:______________________________ Occupation:__________________Name of Employer:_____________________Business Phone:(_____)_____-_______ Spouse of Responsible Party Last Name:______________________First:_________________________

ext._____

Home Phone: (______)_____-________ Cell Phone: (_____)_____-_______ Email:______________________________ *PLEASE PRINT LEGIBLY*

EMERGENCY CONTACT INFORMATION

*PLEASE PRINT LEGIBLY*

The EMERGENCY CONTACT is the nearest relative, not living at the same address as the responsible party, to be contacted in case of a medical emergency or continued unsuccessful attempts in contacting the responsible party. Last Name:________________________________________First:______________________________________MI:____ Home Phone: (______)_____-________Cell Phone: (_____)_____-_______ Business Phone: (_____)_____-_________ *PLEASE PRINT LEGIBLY*

INSURANCE SUBSCRIBER INFORMATION

*PLEASE PRINT LEGIBLY*

The insurance SUBSCRIBER is the holder of the health insurance policy. PRIMARY INSURANCE COVERAGE Last Name:______________________First:_______________MI:____D.O.B.:____/____/____SS#:_____-_____-_______ Policy ID:_________________________Effective Date:_____/_____/_____Relationship to Patient:_________________ Name of Insurance Company:____________________________________ SECONDARY INSURANCE COVERAGE Last Name:______________________First:_______________MI:____D.O.B.:____/____/____SS#:_____-_____-_______ Policy ID:_________________________Effective Date:_____/_____/_____Relationship to Patient:_________________ Name of Insurance Company:____________________________________ ASSIGNMENT OF INSURANCE BENEFITS, RELEASE OF INFORMATION AND AUTHORIZATION FOR TREATMENT RELEASE OF BENEFITS & INFORMATION: I authorize my insurance benefits to be paid directly to the doctor. I am financially responsible for any balance due. I authorize the doctor or insurance company to release any information required for this claim. A copy of this is as valid as the original. ADVANCED DIRECTIVES: ONLY in the event of a severe accident or illness that renders a patient unconscious or unable to communicate, Advanced Directives are written instructions, from the patient to the healthcare providers, regarding various types of medical treatment in several representative situations so that the patient’s desires can be respected. The Advanced Directives also allow the patient to appoint someone to make medical decisions for them in the event they are unable to do so for themselves. As your healthcare provider, we need to know if you have executed an Advanced Medical Directive. Please check one:

_____ I have signed Advanced Directives that are already part of my medical records to be transferred to this medical practice. _____ I am willing to review the Advanced Directives, and consider completing and signing them. (Family Health Care provides this legal service at no cost to our patients. A nurse or healthcare provider will provide the document during your visit today.) _____ I am NOT INTERESTED in reviewing or completing my Advanced Directives at this time.

“To the best of my knowledge, the preceding information is accurate and complete.”______________________________________Date_____/_____/_____ SIGNATURE

FHC0027 New PT Info Packet—Adult—Patient Info

461 West Oak Street Suite A • Kissimmee, FL 34741 • 407.846.8600 • MyHealthApple.com

FINANCIAL POLICY The providers and staff of Family Health Care of Central Florida would like to welcome you to our practice. We strive to provide you with excellent medical care and our goal is to make your visits as convenient as possible. Please read this policy in its entirety, and sign below to confirm that you understand it: 

It is your responsibility to inform our office of any change in address, telephone number, e-mail address, or insurance coverage.



Your account is to be kept current - accordingly, all self-pay or insurance co-payments, co-insurances and deductibles will be collected at the time of service. Services are payable by cash, check, Visa and MasterCard.



If you do not have your payment(s), your appointment may be rescheduled .



You will only be sent a statement if your balance exceeds $5. Refunds will be issued within 4-8 weeks from the date requested, if there are no pending insurance claims.



It is your responsibility to be aware of what service(s) is being provided to you and if it is a covered benefit under your insurance policy.



Although filing your insurance claims is a courtesy extended to you, all charges are always your responsibility from the date services are rendered. We respectfully emphasize that as medical providers, our relationship is with you; not your insurance company, with whom we attempt to verify your benefits with your insurance policy.



A returned check will result in a $15 service charge and all future payments being required in the form of cash or credit card.



There is a $10 per page charge for the completion of paperwork (ex: disability, FMLA, etc.)



If original physical and vaccination records required for school enrollment are misplaced, original records will be recreated for a fee of $10 per form.



If an appointment is not cancelled or rescheduled 24 hours prior to the appointment time, there will be a charge of $25.00.



If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of said balance, which may include collection agency fees up to 35% of your outstanding balance, court costs and attorney fees.



For healthcare visits occurring during extended hours (after 5pm) or on Saturday mornings, and additional fee is charged. Some insurances may also apply an increase to the co-payment.



After hours calls to the provider may result in a charge to you and your insurance company.



You are responsible for any non-covered charges not payable by your insurance policy.



If temporary financial problems affect timely payment of your account, it is your responsibility to contact us promptly for assistance in the management of your account.

If you have any questions about the above information, please do not hesitate to contact us. I have read and understand the above Financial Policy and agree to meet all financial obligations.

_____________________________ Patient Name (please print)

________________________________________ Name of Responsible Party, IF other than patient (please print)

______________________________

_____/_____/_____

Patient Signature

Date

_________________________________________ Responsible Party Signature

_______/_______/_______ Date FHC0042 Financial Policy

MEDICAL HISTORY NAME:

Please complete FRONT PAGE ONLY.

AGE ALLERGIES

DATE____/____/____ FAMILY HISTORY Father

Mother

Siblings Children

Heart Disease High Blood Pressure

Stroke FAMILY HISTORY

Cancer

FATHER:

LIVING or DECEASED

Age:

Glaucoma

MOTHER:

LIVING or DECEASED

Age:

Diabetes

SIBLINGS:

LIVING or DECEASED

Age:

Epilepsy/Seizures Bleeding Disorder

Kidney Disease CHILDREN:

LIVING or DECEASED

Age:

Thyroid Disease Mental Illness Arthritis

HAVE YOU HAD ANY HOSPITALIZATIONS OR SURGERY? REASON

DATE

REASON

DATE

__/__/__

__/__/__

__/__/__

__/__/__

PAST MEDICAL HISTORY - ANY? ___Allergies/Hay fever ___Anemia ___Arthritis ___Bowel irregularity ___Bronchitis ___Chest Pain ___Chronic Rashes

___Diabetes ___Gallbladder disease ___Gout ___Headache/Migraines ___Heart murmur ___Heart palpitations ___Hepatitis

___Depression ___Dizziness/Fainting

___High cholesterol ___High triglycerides

HABITS Smoke now? Yes No Ever smoked? Yes No Packs daily? _______ How long? _______

Coffee: cups daily?____ Other caffienes?______ Exercise routine?_____ Sleep patterns?_______

Alcohol? Yes No Type? _______ Amount? _______ Diet:________________

Fat intake?___________ Salt intake?__________

Street drugs? Yes No Type:_______________ Contact with blood/body fluids @ work? Yes No Advanced Directive Living Will? If yes, please provide copy.

Yes No

What is your primary language? ________________ Have you ever been a victim of domestic violence?

Yes No

OTHER PERTINENT INFORMATION:______________

___Hypertension ___Nervousness ___Pneumonia ___Prostate disease ___Rheumatic fever ___Seizure disorder ___Sexual/Menstrual dysfunction ___Shortness of breath ___Ulcer

DATE OF LAST IMMUNIZATION ____/____/____Flu Vaccin ____/____/____Tetanus ____/____/____Pneumonia ____/____/____MMR ____/____/____PPD ____/____/____Other

WOMEN ONLY Menstruation: First at age:_______________________ ___days between periods ___period lasts ______days Flow is:

light

moderate

heavy

Date of last period:_____/_____/_____ Pregnant? Yes No Planning? Yes No Total # Pregnancies:_________ Full term? Yes No Number Living Children?_____ Age of youngest:_____ Type of Birth Control:____________________________ TO THE BEST OF MY KNOWLEDGE, THE PRECEEDING INFORMATION IS ACCURATE AND COMPLETE. Signature_______________________________Date_____/_____/_____ FHC0027 New PT Info Packet—Adult—Medical History

ATTENTION: THIS PAGE WILL BE COMPLETED BY YOUR HEALTH CARE PROVIDER. Thank you.

Patient Name:___________________________________________________________________________________ Allergies:___________________________________________________________________________________________ ___________________________________________________________________________________________________ Problem List

ICD-Code

Date

1.

___/___/___

2.

___/___/___

3.

___/___/___

4.

___/___/___

5.

___/___/___

6.

___/___/___

7.

___/___/___

8.

___/___/___

9.

___/___/___

10.

___/___/___

Indication/Result

Surgeries

Family History:_______________________________________________

Advance Directive Brochure Given Date: _____/_____/_____

Pneumovax:_________________________________________________ Flu Shot:____________________________________________________

Living Will in Chart:____________________

Smoker/Non-Smoker:__________________________________________ DATE OF LAST TEST:

DATE OF LAST TEST:

DATE OF LAST TEST:

DATE OF LAST TEST:

DATE OF LAST TEST:

DATE OF LAST TEST:

Colonoscopy

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

Mammogram

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

Pap

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

Other

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

____/____/____

TEST:

RX LIST START DATE:

UPDATE: ___/___/___

_____/_____/____ NAME OF MEDICATION

DOSE

SIG

UPDATE: ___/___/___

RX CHANGE? RX CHANGE?

UPDATE: ___/___/___

UPDATE: ___/___/___

UPDATE: ___/___/___

RX CHANGE?

RX CHANGE?

RX CHANGE?

PLEASE RETAIN THIS COPY OF THE PRIVACY PRACTICES NOTICE FOR YOUR RECORDS.

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on 04/15/03 and will remain in effect until it is amended or replaced by us. It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made. You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer, tion on contacting me can be found at the end of this notice.

Rose Quintana.

Informa-

TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION We will keep your health information confidential, using it only for the following purposes: Treatment: We may use your health information to provide you with our professional services. We have established “minimum necessary” or “need to know” standards that limit various staff members’ access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement. Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so. Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances. Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use your professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise. Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities. Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others. Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability. Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so. National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards or letters. HIPPA Notice of Privacy Practices This form does not constitute legal advice and covers only federal, not state, law.

YOUR PRIVACE RIGHTS AS OUR PATIENT Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian). There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be $1.00 for each page* and the staff time charged will be $15.00 per hour including the time required to locate and copy your health information. If you want the copies mailed to you, postage will also be charged. If you prefer a summary or explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure. Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied. Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care information. (When we make a routine disclosure of your information to a professional for treatment and/or payment purposes, we do not keep a record of routine disclosures: therefore these are not available.) You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can discuss non-routine disclosures going back 6 years starting on April 14, 2003. Information prior to that date would not have to be released. (Example: If you request information on May 15, 2004, the disclosure period would start on April 14, 2003 up to May 15, 2004. Disclosures prior to April 14, 2003 do not have to be made available.) Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement. (Except in emergencies.) Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing. ______________________________________________________________________________________________________ QUESTIONS AND COMPLAINTS You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us. In writing. Request a Complaint Form from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. ______________________________________________________________________________________________________ HOW TO CONTACT US

Practice Name: Family Health Care of Central Florida Privacy Officer: Rose Quintana, Director of Operations Telephone:

407.846.8600

E-Mail:

[email protected]

Address:

461 W. Oak Street Suite A Kissimmee, FL 34741

Fax: 407.846.2301

*After 25 pages, $.25 (25 cents) per page per FLA. STATUTE 61F6-26-003

HIPPA Notice of Privacy Practices This form does not constitute legal advice and covers only federal, not state, law.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement if you wish.

I acknowledge that I have received a copy of this office’s Notice of Privacy Practices. ______________________________________________________________________________________________ Please print your name here ______________________________________________________________________________________________ Signature ________________________________________________ Date

FOR OFFICE USE ONLY We have made every effort to obtain written acknowledgement of receipt of our Notice of Privacy from this patient but it could not be obtained because: _____ The patient refused to sign. _____ Due to an emergency situation it was not possible to obtain an acknowledgement. _____ We weren’t able to communicate with the patient _____ Other (Please provide specific details) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

___________________________________________________ Employee signature

________________ Date

HIPPA Acknowledgement of Receipt of the Notice of Privacy Practices This form does not constitute legal advice and covers only federal, not state, law.

461 West Oak Street Suite A • Kissimmee, FL 34741 • 407.846.8600 • MyHealthApple.com

HIPPA AUTHORIZATION FORM (permission from patient/patient’s legal guardian to share personal medical information) (Please print legibly.)

LAST NAME OF PATIENT:__________________________FIRST NAME:_________________ PATIENT’S DATE OF BIRTH:_____/_____/_____ PATIENT’S STREET ADDRESS:____________________________________Apt./Ste. #______ CITY, STATE, ZIP:_____________________________,______ _____________ I,

____________________________________________, hereby authorize Family Health Care of name of patient

Central Florida and/or any medical facility to release any and all medical information and test results that pertain to me, to the following individual(s): Name:_____________________Phone # :(_____)____-_______Relationship to Patient:________________ Name:_____________________Phone # :(_____)____-_______Relationship to Patient:________________ Name:_____________________Phone # :(_____)____-_______Relationship to Patient:________________ I authorize Family Health Care of Central Florida or the medical facility to contact the individual(s) listed above to convey any pertinent information to me, in the event that I an unable to be reached by the facility. I understand that I may revoke/cancel this authorization by notifying Family Health Care of Central Florida, in writing, of my intent to revoke authorization, or change the name(s) of the individual(s) to whom information is to be released.

_______________________________________ Signature of Patient

_____________________ Date

OR, if applicable -

_______________________________________ Signature of Legal Guardian or Personal Representative of Patient’s Estate

_____________________ Date

_____________________ __ Description of Authority to Act for the Patient

___________________________________ Name of Witness

_____________________ Witness Signature

_____________________ Date

461 West Oak Street Suite A • Kissimmee, FL 34741 • 407.846.8600 • MyHealthApple.com AUTHORIZATION FOR THE USE & DISCLOSURE OF INDIVIDUALLY INDENTIFIABLE HEALTH INFORMATION

ATTN. NEW PATIENTS: COMPLETION OF HIGHLIGHTED AREAS IS REQUIRED IN ORDER FOR Family Health Care of Central Florida to attain copies of your medical records from your previous physician. Thank you.

PLEASE PRINT Full Name:____________________________________________________

SS#:_______-_____-_______

Phone #:(_________)___________-________________________________

DOB_______/______/______

REASON FOR RELEASE REQUEST: (please check one)

__X _ 1. Insurance Requirement _____2. Moving away from this area _____3. Dissatisfaction with service If you checked #3, please elaborate briefly on how you feel we may have served you better:______________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________  Please check here if you would like to be contacted by our operations manager to further express your concerns, which may be of use to us in our efforts to continually improve our customer service. This is an authorization under the Privacy Rules of the Health Insurance Portability and Accountability Act of 1996. I authorize Family Health Care of Central Florida, my physician and/or administrative staff to: (check those which apply) 1 a)_____Release my patient protected health information _____Check here if transferring out of this practice. I hereby freely give my permission to: Family Health Care of Central Florida - 461 W. Oak Street Ste. A, Kissimmee, FL 34741 to release protected health information to: (complete address & phone numbers needed to avoid delays) Name of Dr./Institution:___________________________________ Phone: (______)______-_________ Street Address:__________________________________________ Fax: (______)______-_________ City, State, Zip:__________________________________________ 1 b)_ X __Obtain my patient protected health information: I hereby freely give my permission to: Name of former Dr./Institution:____________________________________ Street Address:__________________________________________________ City, State, Zip:_________________________, __________ ____________ Phone: (______)______-_________ Fax: (_____)________-___________ release protected health information to: Family Health Care of Central Florida, 461 W. Oak Street, Ste. A, Kissimmee, FL 34741 Fax # 407-846-2301 2.

The information to be used or disclosed is as follows: (specifically and meaningfully describe the protected health information to be used or disclosed such as date of service, type of service, level of detail to be released, origin of information, etc.) __Please release ALL of my medical records to the Family Health Care of Central Florida

3.

4. 5.

6.

This protected health information is being used or disclosed for the following purposes: (List specific purpose here. You may simply state “At the request of the individual” if the request is being made by the patient, and the patient does not want to state a specific purpose.)__”At the request of the individual.”________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ This authorization expires on (upon) _____/_____/_____.(insert date/event) I understand that I may revoke this authorization at any time, by notifying, in writing the practice Privacy Officer at 461 W. Oak Street Suite A, Kissimmee, FL 34741. Except to the extent that: (a) action has been taken in reliance on this authorization; or (b) if this authorization is obtained as a condition for obtaining insurance coverage; other law provides the insurer with the right to contest a claim under the policy I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

________________________________________ Signature of Patient or Patient Representative

_____________________________ Date

_________________________________________ Print Name of Patient or Patient Representative

_________________________ ____ Relationship to Patient

FHC0026 Medical Records Release Form

Witness Initials_________