Financial/Office Policy Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida (813)

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1 Brandon B Family MEDICAL CARE Financial/Office Policy The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make your visits as convenient as possible. By signing below you confirm that you have read this policy and understand that: It is the patient s responsibility to inform the office of any address or telephone changes. The patient s account must be kept current. All self-pay or insurance co-payments, co-insurances and deductibles will be collected at the time of service. Payable by cash, check (with driver s license) or credit card. If the patient does not have their payment(s), the appointment will be rescheduled. Due to time allowed for each appointment patients may be asked to schedule another appointment for issues other than the reason of the original appointment. A returned check will result in a minimum service charge of $25.00 and checks will not be accepted for future payment(s). Unpaid returned checks will be turned over to the state attorneys office. An Office visit is required for all forms that need addressed. Patient is responsible for any financial fees, co pays and/or deductibles at the time of service. In addition, there is a $30.00 minimum for all forms (FMLA, medical reports, physical forms, disability forms or any special reports requested). Medical records copy fee $1.00 per page for copies up to 25 pages and $0.25 per page for copies of 26 pages and greater. There is a minimum of thirty business days to request medical record copies and sixty business days for archived records. A request for review of your medical record(s) requires an appointment with a minimum of thirty-business days notice and sixty business days for archived records. Twenty-four hour notice must be given to reschedule or cancel appointment to avoid cancel/no show charge. If the proper notice is not given there is a charge of $20.00 for a (15) minute appointment, a $40.00 charge for a (30) minute appointment, and $30.00 for an urgent appointment. Saturday appointments are all urgent and any no show or cancellation will have a $30.00 charge. Saturday and Monday cancellations must be done by close of business day on Friday. There is no phone service on Saturdays, answering service only. Prescription refills require a seven (7)-business day notice. No narcotics called in after hours by any on call physician. Page 1 of 2 Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida (813)

2 If the insurance requires a referral, it is the patients responsibility to get all information to the primary care doctor for processing within seven (7) business days. If the correct time is not allowed the patient may need to reschedule. Appointment is required to request a referral with a specialist. IF OU HAVE HEALTH INSURANCE COVERAGE * PHOTO ID REQUIRED Claims will be submitted, however we must emphasize that as medical providers, the relationship is with our patients, NOT the insurance companies. Although we attempt to verify benefits with insurance policies, please be advised this is only an estimate of the coverage based on the information given at the time of inquiry and not a guarantee of payment. It is the patient s responsibility to inform us of any changes in their insurance. Not all services are covered benefits with all insurance plans. It is the patient s responsibility to be aware of the service(s) provided, and their covered benefit(s) under the insurance policy. The patient is responsible for any non-covered charges not payable by the insurance policy. Although filing insurance claim(s) is a courtesy extended to the patient, all charges incurred are the patient s responsibility. Any unpaid balances older than 30 days may be subject to a 1.5% interest per month. If a patient s account is turned over to a collection agency, the patient will be responsible for any costs incurred in collection of the balance, which will include collection agency fees, court cost, and attorney fees. In the event that a patient does not meet their financial obligation, the patient will be discharged from the practice. I, have read and understand the Financial/Office Policy of Brandon Family Medical Care and agree to meet all financial obligations. I understand that this policy cannot be altered and if I do not agree with the office policy, I understand that I will need to find another primary care physician. Print Name of Patient Patient/responsible party Date Signature Responsible Party Print Name Page 2 of 2 Revised Revised Revised Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida (813)

3 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVAC PRACTICES & PERMISSION TO SHARE HEALTH INFORMATION I have received a copy of the Brandon Family Medical Care Notice of Privacy Practices. PRINT NAME_ Signature Date NOTIFICATION OF FAMIL AND FRIENDS I hereby authorize Brandon Family Medical Care to disclose my health information to the following persons: 1) 2) 3) 4) Signature RESTRICTIONS ON THE USE & DISCLOSURE OF OUR HEALTH INFORMATION As further described in the Brandon Family Medical Care Notice of Privacy Practice, I understand that I may request certain restrictions on the use and disclosure of my health information. I request the following restrictions. Brandon Family Medical Care is not required to agree to my requests. 1) 2) 3) Signature_ DATEEXP DATE OFFICE STAFF WITNESS

4 PATIENT HISTOR FORM LAST NAME _ FIRST NAME: DOB: DATE Review of Systems (2 pages) Circle es or No. General Symptoms NOW PAST (Comments) Genitourinary NOW PAST (Comments) Weight change N N Change in stream N N Chills N N Nocturia (getting up at night) N N Sleep Disorder N N Urinary frequency > 8 times/day N N Eyes Double vision Glaucoma Cataracts N N N N N N Musculoskeletal Bone pain Muscle pain Joint pain N N N N N N Ear/Nose/Throat/Mouth Hearing changes Sore throat Sinus problem N N N N N N Skin Rash Lumps or bumps Moles, skin tags N N N N N N Cardiovascular Chest pain Irregular heartbeat Swelling in ankles N N N N N N Neurological Tremors Dizzy spells Numbness/tingling N N N N N N Psychologic Are you generally happy? N N Do you feel depressed? N N Do you feel anxious? N N Do you feel safe in your home? N N Endocrine Excessive thirst N N Too hot/cold N N Tired/sluggish N N Respiratory Wheezing Frequent cough Shortness of breath Gastrointestinal Abdominal pain Nausea/vomiting Indigestion/heartburn N N N N N N N N N N N N Hematologic/Lymphatic Swollen glands Blood clotting problem Bruising N N N N N N Sexual History Change in sex drive? Sexual performance satisfactory? (i.e. sexual trauma) N N Allergic/Immune Last Exams or Lab tests: Please enter date (mo/yr) Hay Fever N N Dental: Eye : Drug allergies N N Pelvic: _ PAP smear: Food N N Mammogram: Cholesterol: Colonoscopy:_ Stool Tested: Prostate _ PSA test: _ Living Will? es No Advanced Directive? es No Doctor s signature: ( Please Complete Side )

5 Medical Medical History None (High Blood Pressure, Diabetes, Cancer, Heart Disease, etc.) Surgical Pregnancy History ear Sex Complications None (Tonsillectomy, Appendectomy, Hysterectomy, Hernia, etc - Please enter year surgery was done if known) Allergies to medications? None (If es, please explain type of reaction, i.e. hives, wheezing, upset stomach, swelling, etc.) Last Immunizations: FLU / / PNEU // Tetanus / / // Current prescription medicines: None Name of drug mg dose # tablets # times per day Additional current prescription medicines: Name of drug mg dose # tablets # times per day Current Non-Prescription Medicine (Aspirin, Tylenol, Ibuprofen, Aleve, vitamins, anti-acids, herbals.) Family History Father: Living - Age: Deceased, Age at Death (Cause) Mother: Living - Age: Deceased, Age at Death (Cause) Siblings: Number Living Number deceased (Cause) List other illnesses in your family (Example - Diabetes, heart disease, colon, breast, or prostate cancer, arthritis, depression etc) ( Family Member) (Illness ) ( Family Member) (Illness) (Family Member) ( Illness) = = _= _ Social History Caffeine es No If yes, how much? Smoke? es No If yes, how much? # of packs/day _ # of years When did you stop smoking? Alcohol? es No If yes, how much? OCCUPATION. Retired Significant prior industrial or agricultural exposures? es No MARITAL STATUS MARRIED SINGLE DIVORCED WIDOWED NUMBER OF CHILDREN None Exercise regularly? es No If yes, what and how frequently?

6 BRANDON FAMIL MEDICAL CARE PATIENT INFORMATION PATIENT NAME MI LAST NAME ADDRESS (REQUIRED) CITSTATE ZIP HOME PHONE CELL PHONE WORK PHONE_ DATE OF BIRTH SEX SS# RACE (REQUIRED) DRIVERS LICENSE_ MARITAL STATUS_ (PHOTO ID REQUIRED) address Can we leave a message at home es No Can we leave a message at work es No (circle one) (circle one) GUARANTOR/SPOUSE/PARENT INFORMATION REQUIRED GUARANTOR/SPOUSE/PARENT NAME_ ADDRESS TELEPHONE NUMBERCELL PHONE POLIC HOLDER S INFORMATION REQUIRED POLIC HOLDERS NAME ADDRESS TELEPHONE NUMBER CELL PHONE SOCIAL SECURIT NUMBER DATE OF BIRTH_ EMPLOER NAME EMPLOER PHONE NUMBER EMPLOER ADDRESS PATIENT S RELATIONSHIP TO POLIC HOLDER (CIRCLE): SELF SPOUSE CHILD OTHER: INSURANCE COMPAN (INSURANCE CARD REQUIRED, PRESENT TO FRONT DESK) DO OU CURRENTL HAVE AN ADVANCE DIRECTIVE ES NO HOW DID OU HEAR OF US _ I AUTHORIZE BRANDON FAMIL MEDICAL CARE TO RELEASE AN MEDICAL INFORMATION NECESSAR TO PROCESS CLAIMS, COORDINATE CARE, REFERRALS, AND FOR QUALIT MANAGEMENT AND/OR UTILIZATION ACTIVITIES. I AUTHORIZE PAMENT OF MEDICAL BENEFITS TO BRANDON FAMIL MEDICAL CARE FOR SERVICE S RENDERED. SIGNATURE: DATE

7 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION I hereby authorize _ Phone# Fax # and its entities, its officers or agents to permit inspection, copying and/or release of health information compiled in the ordinary course of business in connection with the following: Patient Name: Date of Birth: Address: Telephone #: Social Security #: I further understand and acknowledge that in complying with my request for release, such disclosure will require Brandon Family Medical Care to disclose, as provided under applicable federal law, Protected Health Information, as defined in 42 C.F.R. 160 et seq. Information to be disclosed: Complete Health Record Consultation Reports Radiology Reports Discharge Summary Progress Notes Abstract/Pertinent Information History & Physical Exam Laboratory Tests Emergency Department Record (Please Specify) I UNDERSTAND THIS MA INCLUDE INFORMATION RELATING TO THE FOLLOWING UNLESS EXPRESSL EXCLUDED B CHECKING THE BOX (ES) BELOW: Acquired Immunodeficiency Syndrome (AIDS) or infection with Human Immunodeficiency Virus (HIV) Psychiatric Care (Behavioral Health) ¹ Treatment for Alcohol and /or Drug Abuse² Genetic Testing Sexually Transmitted Diseases (STDs) This information is to be disclosed to: I understand there may be a charge for copying my records as provided under federal and state law. I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked in writing, this authorization will expire 60 days from the date of execution. A photocopy or FAX of this document is valid as the original. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosures of the above information to the extent indicated and authorized herein: Signature or Patient or Legal Representative Date: Witness: _Date: The patient information requested above may not be further disclosed to any party under any circumstances except with the patient s express written consent or as otherwise permitted by law. The information may not be used except for the need specified above. (Form updated 2/11/10) ¹Except psychotherapy notes as provided under federal and state laws. ²PROHIBITION ON REDISCLOSURE: This information ha been disclosed from records whose confidentiality is protected by federal and state law. Federal Regulation (42 CFR Part2) prohibit the receiver of these records from making any further disclosure of this information except with the specific written consent of the person who it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose. Brandon Family Medical Care, P.A. 414 West Robertson St. Brandon, FL Phone: (813) Fax: (813)

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