Healthy Living Clinic, LLC Phone:(321) / FAX:(321)

Transcription

1 IDENTIFYING INFORMATION Patient Enrollment Form PATIENT NAME: SEX: MALE FEMALE DOB: / / SS# MO DAY YEAR CONTACT HOME PHONE: WORK PHONE: Preferred method of communication Mail Home Phone Mobile Home Work Phone ADDRESS STREET CITY STATE ZIP CODE DEMOGRAPHICS ETHNICITY: Not Hispanic or Latino Hispanic or Latino Decline to specify PREFERRED LANGUAGE: RACE (S): American Indian Asian Black or African American Native Hawaiian or Pacific Islander White Declined to specify NEXT OF KIN NAME: RELATION TO PATIENT: PHONE NUMBER: ADDRESS STREET CITY STATE ZIP CODE INSURANCE /NAME OF INSURRED / POLICY COPAY AMT DEDUCTIBLE EFECTIVE DATE EXPIRATION DATE ADDRESS: STREET CITY STATE ZIP CODE

2 SECONDARY INSURANCE (if applicable) NAME OF INSURANCE: POLICY# DEDUCTIBLE NAME OF INSURED RELATIONSHIP TO PATIENT: Parent Spouse Caregiver Friend Other RESPONSIBLE PARTY INFORMATION (if Different than above) NAME: ADDRESS: CITY STATE ZIP PHONE: CELLULAR HOME WORK PRIMARY EMPLOYER ADDRESS: CITY STATE ZIP PHONE: RELATIONSHIP TO PATIENT: Parent Spouse Caregiver Friend Other I authorize payment directly to the billing office of this physician/clinic for the medical and / or surgical benefits, if any, otherwise payable to me for services. I understand that I am financially responsible for the charges not covered by my insurance. Payment of deductibles and co-payments is expected at the time of service. Cash, Check, MasterCard, American Express, and Discover Cards are acceptable methods of payment. Insurance claims for each service date will be submitted to your insurance company, after which time the responsibility for payment will become yours. In the event this account is placed with a collection agency you will be responsible for collections fees and/or attorney fees. DATE: SIGNATURE OF PATIENT / GUARDIAN:

3 Patient Enrollment Form PATIENT NAME: Please read and initial each line. If you have questions, please ask us at the front desk for assistance. 1. I have given the office my current and correct insurance information. 2. I understand that I could be charged $25 for a missed appointment (no show) if a 24-hour notice of cancellation is not given. 3. I understand that I could possibly be discharged from the practice for failing to give 24 hour cancellation notice for three or more scheduled appointments. 4. I understand that my co-payment is due at each visit. 5. I understand that I may be responsible for charges related to the completion of forms and letters. The cost to complete this letters is $ I understand that I will be charge$ for any bounce check. NOTICE: I attest that the above information is correct to the best of my knowledge. I authorize the release of any medical or other information necessary to process the claim. I also request payment of insurance benefits either to myself or to the party who accept assignment. I authorize payment of insurance benefits to the physician or supplier for all services rendered. I also understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered or fees associated with my care. I also agree that I am responsible for any collection fees should my account be turned over to a collection agency. DATE: SIGNATURE OF PATIENT / GUARDIAN:

4 AUTORIZATION FOR RELEASE OF INFORMATION PATIENT NAME: DOB: / / SS# MED REC# MO DAY YEAR ADDRESS: CITY STATE ZIP PHONE: CELLULAR HOME WORK I herby authorize to release information from my medical record as indicated below to: NAME: ADDRESS: CITY STATE ZIP PHONE: FAX: Please send only the following information: INFORMATION TO BE RELEASED:I understand that documents authorized to be released by me include, but are not limited to, family histories, medical histories, reports of clinical findings and all diagnoses. laboratory test results, X-ray results, reports of examination, and/or evaluation, and any hospital admission or discharge reports. My parental rights have not been terminated. (In the case of signing for a minor child) I specifically authorize the release of information relating to: Mental health (including psychotherapy notes) SIGNATURE OF PATIENT OR LEGAL GUARDIAN DATE PURPOSE OF THIS DISCLOSURE: Changing Physicians Consultation / 2 nd Opinion Continuing Care Legal School Insurance Worker s Compensation Other / Specify: 1. I understand that this authorization will expire in 90 days 2. I understand that I may revoke this authorization at any time by notifying Healthy Living Clinic, LLC in writing, and it will be effective on the date notified except to the extend action has already been taken in reliance upon it. 3. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal privacy regulations. 4. I understand that in compliance with Florida regulations I will pay the charge for copying clinic medical records is $1 per page up to 25 pages and 15 cents for each additional page.

5 CONSENT TO PHOTOGRAPH INSTRUCTIONS This is a consent document that has been prepared to help inform you concerning permission to take photographs and to use these images for a purpose as defined within this consent document. INTRODUCTION Medical photographs may be taken before, during, and or after a procedure or treatment. Consent is required to take such images. CONSENT TO TAKE PHOTOGRAPHS I hereby authorize Erich Arias, M.D. and/or his associates to take photographs for professional medical purposes. Patient Signature Date (Or Legal guardian) I decline consent to take photographs Patient Signature Date (Or Legal guardian)

6 Patient MEDICAL HISTORY PATIENT NAME: DOB: LAST FIRST MI LIST YOUR REASONS FOR COMING TO SEE THE DOCTOR TODAY SEX: MALE FEMALE SOCIAL HISTORY SMOKING Yes No, if so How many cigarettes / pack a day: ALCOHOL Yes No, if so How many drinks a day: PAST MEDICAL HISTORY (Major events, hospitalizations, surgeries): LIST YOUR MEDICAL & PSYCHIATRIC PROBLEMS LIST YOUR PAST SURGERIES OBSTETRICS & GYNECOLOGY HISTORY (If Applies to you): ALLERGIES FAMILY HEALTH HISTORY 375 S. Courtenay Parkway Suite 7A, Merritt Island, FL 32952

7 PREVENTIVE CARE INFLUENZA VACCINE (all adults) Yes No if so when: PNEUMOCCOCAL VACCINE (> 65 years) Yes No if so when: TETANUS VACCINE (Every 10 years) Yes No if so when: COLONOSCOPY (> 50 years) Yes No if so when: MAMMOGRAPHY (> 50 years) Yes No if so when: PAP SMEAR (> 21 years) Yes No if so when: BONE DENSITY TEST (> 65 years) Yes No if so when: LUNG CANCER SCREEN Yes No if so when: ABDOMINAL AORTIC ANEURYSM Yes No if so when: OTHER VACCINES Yes No if so which one: years ; 30 pack year history, smokers, quit 15 years 65-75years who ever smoked PLEASE LIST MEDICATIONS THAT YOU TAKE Please list your medications, doses and supplements. If you have a list of your medications please provide a copy to us. DATE: SIGNATURE OF PATIENT / GUARDIAN: 375 S. Courtenay Parkway Suite 7A, Merritt Island, FL 32952