Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL (SEGURO SOCIAL)

Transcription

1 7887 North Kendall Drive Suite 210 Miami, Florida office fax Patient Information NAME SOCIAL SECURITY # (NOMBRE) LAST/APELLIDO FIRST/PRIMER INITIAL (SEGURO SOCIAL) Address (Direccion) (Correo electronico) City State Zip (Cuidad) (Estado) (Codigo postal) HOME PHONE ( ) CELLPHONE ( ) (Telefono de la casa) (Telefono celular) Sex F M Age Birthdate Married Single Widowed Divorced Minor (Sexo) (Edad) (Fecha de nacimiento) (Casado) (Soltero) (Viudo) (Divorciado) (Menor) Patient Employer/School Occupation (Empleador) (Occupacion) Employer / School Address Employer /School Phone ( (Direccion de empleo) ) (Telefono de empleo) Primary Care Physician (PCP) Phone# ( ) (Medico primario) (GYN) Phone# ( ) (Ginecologo) Emergency Contact Phone ( (Contacto en caso de emergencia) ) REFERRAL SOURCE Please let us know how you heard about our physician and/or facility. Place a check mark ( ) in the box beside the most appropriate response below. (Por favor haganos saber como supo de nuestro medico y/o la instalacion. Coloque una marca ( ) en la casilla junto a la respuesta mas apropiada de las siguientes opciones.) Referring physician Phone# ( (Referido por un medico) ) Current or former patient Newspaper advertisement Yellow pages (Paciente nuestro) (Anucio en el periodico) (Seccion amarilla) Friend/family member Online internet search Television advertisement (Amigo/familiar) (Internet) (Anucio en la television) Other (Otras) Please provide any additional comments related to your response above. (Sirvase proporcionar cualquier comentario adicional relacionado con su respuesta anterior.)

2 Vascular and Spine Institute Patient Information Page 2 of 2 Person Responsible for Account (Persona responsable por cuenta) PRIMARY INSURANCE Last name (apellido) First name (primer nombre) Initial Relation to patient Birthdate Social security # (Relaccion al paciente) (Fecha de nacimiento) (Seguro Social) Address (if different from above) Phone ( (Direccion si differente a la del paciente) ) Insurance Carrier Policy# Group# (Compania de seguro) (Numero de póliza) (Numero de grupo) ADDITIONAL INSURANCE Is patient covered by additional insurance? YES NO Policy Holder (Paciente tiene otro tipo de seguro?) Insurance Carrier Policy # Group# (Compania de seguro) (Numero de póliza) (Numero de grupo) PRIVACY POLICIES The privacy of your health information is of paramount importance to us. To that end, we have established and implemented Privacy Practices to protect your information consistent with the Office of Civil Rights, U.S. Department of Health and Human Services. These practices are outlined in the Vascular and Spine Institute Privacy Policies document. Place a check mark ( ) in the box below indicating your acknowledgement of receipt and understanding of our privacy policies. (La privacidad de su informacion de salud es de extrema importancia para nosotros. Por esa razon, nosotros hemos establecido e implementado la Politica de Privacidad para proteger su informacion siguiendo lo establecido for la Oficina de Derechos Civiles y el Departamento de Salud y Servios Humanos de los Estados Unidos. Estas practicas se describen en nuestro document de Politica de Privacidad. Por favor, coloque una marca ( ) indicando que usted he recibido y entendido nuestra politica de privacidad.) I have received a copy of the Vascular and Spine Institute s Privacy Policies and I understand my health information rights. (Yo he recibido una copia de la Politica de Privacidad De Vascular and Spine Institute y yo entiendo mis derechos relacionados a my informacion de salud.) ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Vascular and Spine Institute all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Vascular and Spine Institute may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. (Yo certifico que yo, y/o mis dependientes tenemos covertura de seguro con y asigno directamente a Vascular and Spine Institute todos los beneficios. Yo entiendo que soy completamente responsible por todos los cargos por atencion medica recibida, sea o no pagados por mi seguro. Yo autorizo el uso de mi firma en todos los documentos que se necesiten enviar al seguro. Vascular and Spine Institute puede compartir mi informacion de salud con la anteriormente mencionada compania(s) de seguros con el proposito de obtener pagos por servicios recibidos, y determiner beneficios de seguro, o beneficios por determinado servicio. Este consentimiento terminara en el momento el actual plan de tratamiento termine, o al ano de haber firmado este document.) Signature of patient, parent guardian or personal representative (Firma del paciente, padre o persona responsable por el paciente) Please print name of patient, parent, guardian or personal rep. (Nombre del paciente, padre o persona responsable por el paciente) Date (Fecha) Relationship to patient (Relaccion con el paciente)

3 VASCULAR AND SPINE INSTITUTE Phone: (305) Fax: (305) Authorization to Release Private Health Information to Oscar Sosa, M.D. and/or Osmany DeAngelo, D.O. Patient Name: Date of Birth: Social Security #: I request and authorize: Name of person or organization releasing information Street Address City State Zip Code Telephone Number Fax Number to release health information of the patient name above to: Oscar Sosa, M.D. and/or Osmany DeAngelo, D.O North Kendall Drive, Suite #210 Miami, FL This request and authorization applies to: Health care information relating to the following treatment, condition or dates: Labs Performed on EKG Performed on X-Ray Reports Performed on Immunizations Performed on All Records Other: A specific authorization is required to release information regarding the following: (Please sign if this information is to be included) Sexually Transmitted Disease (STD) and/or HIV/AIDS testing Yes No Signature Drug, Alcohol or Mental Health Information Yes No Signature The requested information will be used for: Continuation of Care Medical Consultation Other I understand that this information is a confidential part of my medical record and by signing this authorization I am allowing the release of the medical information requested to Dr. Oscar Sosa, M.D. and/or Osmany DeAngelo, D.O. I may revoke this authorization at any time, in writing, before the information has been released. Signature of patient or personal representative / Relationship to patient Witness: Date: THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT WAS SIGNED.

4 Vascular and Spine Institute CONSENT TO TREATMENT I, while a patient of a physician in the employment of Oscar Sosa, M.D., Osmany DeAngelo, D.O., and the Vascular and Spine Institute, Inc. hereby consent to and authorize the performance of all appropriate procedures and courses of treatment, the administration of all anesthetic, and any and all medication and technical procedures which in the judgment of the physicians(s) attending and consulting may be considered necessary or advisable for my diagnosis and/or treatment. In addition to the above: o I agree to abide by those regulations designed to enhance the care and safety of patients. o I consent to the appropriate disposal by Oscar Sosa, M.D. and/or Osmany DeAngelo, D.O. of any specimens or other bodily materials removed during technical procedures or for testing purposes. o I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees have been made as to the results of any therapies and/or procedures(s). PATIENT'S VALUABLES Oscar Sosa, M.D., Osmany DeAngelo, D.O., and the Vascular and Spine Institute, Inc., does not accept responsibility for any personal property (monetary or sentimental). ASSIGNMENT OF MEDICAL INSURANCE BENEFITS I hereby authorize and request payment of insurance benefits otherwise payable to me, to be made directly to Oscar Sosa, M.D., Osmany DeAngelo, D.O., and the Vascular and Spine Institute, Inc., attending consulting physicians and other allied health professionals deemed necessary by my physicians(s). Where MEDICARE and/or MEDICAID benefits are applicable, I certify that the information given by me in applying for payment under Title XVIII or XIX of the Social Security Act is correct and request that these payment(s) of authorized benefits be made on my behalf to Oscar Sosa, M.D, Osmany DeAngelo, D.O., and/or the Vascular and Spine Institute, Inc. I further authorize the release of any medical or personal information necessary to process this or a related claim to my insurance carrier or to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers. GUARANTEE OF PAYMENT For and in consideration of services rendered, I guarantee payment of any and all charges incurred which are not covered or allowable by my insurance, or Medicare and/or Medicaid, if any includes any denial of payment due to lack of medical necessity or pre-certification/ authorization (as may be determined by a review organization); affiliation with an HMO; or constraint imposed as a condition of my insurance coverage. It is further agreed that if this account be referred for collection, I will pay the costs of collection including a thirty-five percent (35%) collection agency fee imposed on the total outstanding account balance, reasonable trial and appellate attorney's fees. An itemized bill is available from Patient's Accounts upon request. RELEASE OF INFORMATION I authorize any individual/organizations to release copies of information in their possession, acquired in the course of my examination and treatment, to Oscar Sosa, M.D. and/or Osmany DeAngelo, D.O., and the aforementioned insurance carriers in connection with the outpatient visit occurring/concerning prior to my visits, treatment and/or consultations to Oscar Sosa, M.D. and/or Osmany DeAngelo, D.O., for the purpose of any insurance, Medicare or Medicaid Payments. PATIENT PRIVACY POLICY I acknowledge receipt of the facility s Privacy Policy and Patient Bill of Rights. I acknowledge that I have read and understand each of the provisions appearing on this page and by my signature consent and agree to such provisions individually and collectively. Signature of Patient or Personal Representative or Legal Guardian / Relationship to Patient Date Signature of Guarantor Signature of Insured (If different than patient) Signature of Witness

5 7887 North Kendall Drive Suite 210 Miami, Florida office fax CONSENT FOR HIV AND HEPATITIS B AND/OR C TESTING I hereby consent to voluntary testing for Human Immunodeficiency Virus (AIDS/HIV Virus) and Hepatitis B and/or Hepatitis C. This consent authorizes the drawing of body fluids or oral swab for HIV and Hepatitis B and/or Hepatitis C testing. CONSENT FOR RELEASE OF INFORMATION I authorize the facility s physicians to disclose complete information concerning their medical findings and treatment of the undersigned, from the initial office visit until the date of conclusion of such treatment to those individuals who, in their determination, are required to receive such information for the purpose of medical treatment, medical quality assurance and peer review. I authorize the release of health information to include diagnostic tests and general medical history, to be used for pending surgery at the facility. CONSENT FOR PHYSICIAN APPROVED OBSERVER IN SURGERY I authorize the facility s physicians to determine when the presence of an observer is necessary for the purpose of rendering technical advisory assistance to the physician, educational purposes and/or to support the patient. UNPLANNED TRANSFER/ADMISSION TO OTHER FACILITY I authorize the physicians to determine when the transfer or admission to another facility is medically necessary. VASCULAR AND SPINE INSTITUTE IS REGULATED AND PURSUANT TO THE RULES OF THE BOARD OF MEDICINE OF THE STATE OF FLORIDA AS FORTH IN RULE CHAPTER 64B8, FAC. PRINT PATIENT NAME: PATIENT SIGNATURE: WITNESS: DATE: TIME: