Fran, Medical Assistant Kim, Office Manager, Referral Coordinator, Billing Specialist



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GFP GARDENS FAMILY PRACTICE Phone (561) 627-7433 Fax (561) 775-1055 Welcome To Gardens Family Practice! We are happy to have you join our family and would like to give you some general information regarding our office and staff. Our office is located at: 3365 Burns Road, Suite 217 Palm Beach Gardens, FL 33410 Our office hours are: Monday-Tuesday-Thursday 8:30am-4pm Friday 8:30am- Noon We are on Service from 12N-1pm each day Our Doctor: Our Staff: OFFICE POLICIES Prabha Viralam, M.D. Board Certified Family Practice Physician Nick, Receptionist Fran, Medical Assistant Kim, Office Manager, Referral Coordinator, Billing Specialist WE SEE PATIENTS BY APPOINTMENT ONLY WE MUST HAVE 48 HOURS NOTICE ON ALL REFERRALS MEDICATIONS WILL BE REFILLED THROUGH YOUR PHARMACY, PLEASE CALL THEM AND THEY WILL FAX THE REQUEST TO OUR OFFICE. PLEASE CALL A FEW DAYS BEFORE YOUR MEDICATION RUNS OUT. APPOINTMENTS ARE SCHEDULED AS FOLLOWS: URGENT/SAME DAY ILLNESS/WITHIN 3 DAYS ESTABLISH W/DR/WITHIN ONE MONTH WELL EXAM/ WITHIN ONE MONTH Our staff is always available to answer any question you may have. On Monday mornings, Please limit calls to urgent matters only. We handle each request to the best of our abilities and as efficiently as possible. AS A COURTESY TO OTHERS, PLEASE DO NOT USE CELL PHONES IN OFFICE! Prabha Viralam, MD & Staff

Gardens Family Practice Prabha Viralam M.D 3365 Burns RD., #217 Palm Beach Gardens, FL 33410 Telephone: (561) 627-7433 Fax: (561) 775-1055 PATIENT INFORMATION DATE SOCIAL SECURTY # LAST NAME FIRST ADDRESS CITY STATE ZIP HOME PHONE WORK CELL DATE OF BIRTH AGE MALE FEMALE MARITAL STATUS: M D S W INSURANCE INFORMATION PRIMARY POLICY HOLDER (IF OTHER THEN SELF) PRIMARY POLICY HOLDERS (IF OTHER THEN SELF) DATE OF BIRTH PRIMARY POLICY HOLDERS SOCIAL SEC. # (IF OTHER THEN SELF) NAME EMERGENCY CONTACT INFORMATION PHONE NUMBER ALT PHONE NUMBER PRIMARY LANGUAGE SPOKEN AT HOME

PRABHA VIRALAM M.D Gardens Family Practice Board Certified in Family Practice Dear Patient: Due to the high cost of medical billing, payment is requested at the time of treatment, unless payment plan arrangements are made with the doctor or billing manager, your signature indicated agreement with the following stipulations: 1. Payment in full at time of visit. (If no insurance coverage at all) including applicable insurance copayment. Patients with indemnity coverage (80/20 plans) will be responsible if deductible has not been met and/or their 20% at time of service. 2. If payment is not received by your insurance company for any reason within 90 days, you will be responsible for the full amount due. 3. The signing party will incur all costs including collection fees, court costs, and reasonable attorneys fees, if payment not received as described. 4. Any secondary or supplemental insurance claims that need to be filed will be done as a courtesy to our patients. All remaining balances after claims are processed are the sole responsibility of the patient! 5. Managed care subscribers (HMO, PPO, POS) Florida State Law requires payment by your insurance carrier to the participating provider within 60 days of the submission of the medical claim. If the claim is not paid, your insurance company has broken its contractual agreement. Since this is your insurance; If the claim is not paid by your insurance carrier, then it is your responsibility to pay the claim or have it paid by the insurance company. Thank you very much for your understanding and cooperation. CONSENT FOR TREATMENT. I voluntarily consent to the rendering of medical care by Dr. Prabha Viralam. I understand that I am under the care and supervision of my attending physician and it is the responsibility of the staff to carry out the instructions of the physician. AUTHORIZATION TO RELEASE INFORMANTION: I authorize Dr. Prabha Viralam to release any and all information acquired in the course of my examination and/or treatment for the purpose of insurance, workman s compensation or Medicare benefit payments. Patient Signature: Date:

Gardens Family Practice Prabhavathi K. Viralam We need you to know your past medical records to best understand how we can help you. The information you give us on this form will be kept confidential, for our files, in this office only. The information will not be released to anyone else unless you request the release in writing. Date 1. What is your full name? Last First MI 2. Do you have any Drug Allergies? 3. When was your last Medical check up? Month Day Year 4. Why are you here to see the Doctor? 5. What are if any significant illness or injury s you had in you life time? Illness or Injury When 6. Have you ever been hospitalized or had any surgeries in your life time? Hospitalization/ Surgeries When 7. Please list any medication s you are on currently. Gardens Family Practice 3365 Burns RD Suite 217 Palm Beach Gardens Florida 33410

8. Review of Systems (circle below only the conditions that you know you have) ENT: Eye disease Glaucoma Glasses Sinus trouble Hay fever Nosebleeds Ringing in the ears Deafness Postnasal drip Broken ear Drum Lungs: Coughing blood Persistent Cough Shortness of Breath Asthma Frequent Chest Infections Pneumonia Pleurisy Emphysema Heart: Heart trouble Murmurs Enlarged Heart Irregular Heart Beat Fluttering Chest Pains Severe Swelling Heart Attack High Blood Pressure Intestines: Difficulty Swallowing Indigestion Ulcer liver Disease Cirrhosis Hepatitis Gallbladder Trouble Vomiting Blood Black Bowel Movement Hemorrhoids Blood in the Bowel Movements Yellow or Jaundice Kidneys: Painful Urination Frequent Urination Waking in the Night to Urination Pus Blood Stones Albumin Loss of Control with Cough or Laugh Prostate Trouble in Men Do you have impotency or Ejaculation problems Nervous System: Headaches Convulsions Epilepsy Head injury Fainting Paralysis Double Vision Blurred Vision Staggering Unconsciousness Persistent Numbness 10. Miscellaneous History Have you had a Blood Disorder or Bleeding problems? YES NO Do you take Aspirin? YES NO Menstrual Periods: Began at age Ceased at age Occurs Every Days Lasts Days Pain in Periods Number of Pregnancies Number of Births Gardens Family Practice 3365 Burns RD Suite 217 Palm Beach Gardens Florida 33410

11. Social History: Do you smoke or ever smoked How Much How Long When did you Stop Smoking? Do you Drink Alcohol or ever Drank Alcohol How Much Long When did you Stop Drinking Alcohol? How History of Alcoholism? Yes No History of Drug Abuse? Yes No If so What? Work History? Has you job had you exposed to anything? 12. Family History: Mother Living Age or Died at Age Cause of death Father Living Age or Died at Age Cause of death Brothers - Number living Number Deceased Died at Age Cause of death Sisters - Number living Number Deceased Died at Age Cause of death CIRCLE ONLY THOSE CONDITIONS ANYONE IN YOUR FAMILY HAS HAD? Heart Trouble Diabetes Gout Tuberculosis Cancer High Blood Pressure Glaucoma Kidney Disease Heart Disease GARDENS FAMILY PRACTICE 3365 BURNS RD PALM BEACH GARDENS FLORIDA 33410

Gardens Family Practice Privacy Notice This notice describes how medical information about you may be used and disclosed also, how you can get access to this information. Please review it carefully. Gardens Family Practice Privacy commitment to you We understand that the information about you and your family is personal. We are committed to protecting your information. This notice tells you how Gardens Family Practice uses and discloses information about you. It tells you about your right and about Gardens Family Practice requirements about medical information. Understanding the information that Gardens Family Practice has You provided certain information to Gardens Family Practice when you needed services from us. This information included you name, address, date of birth, phone number, social security number and health insurance policies. It may also have included health information. For some medical treatments, other health care providers send additional medical information such as doctor s statements, x-rays or lab test results. Your health information rights You have the following rights regarding the health information that Gardens Family Practice has about you. (Note: These rights may me limited by Florida law or by court orders.) You have the right to see and obtain a copy of your health information. An exception is psychotherapy notes. Another exception is information that is needed for a legal action relating to Gardens Family Practice. You have the right to ask Gardens Family Practice to change health information that is incorrect or incomplete. Gardens Family Practice may deny your request under certain circumstances. You have the right to request a list of the disclosures that Gardens Family Practice has made of your health information. Beginning in April 2003. You have the right to request a restriction on certain uses or disclosers of your health information Gardens Family Practice is not legally required to agree with your request. You have the right to request that Gardens Family Practice communicates with you about your health in a way or at a location that will help you keep the information confidential. You have the right to receive a paper copy of this notice. You may ask Gardens family Practice staff to give you another copy of this notice. Privacy law s requirements Gardens Family Practice is required by law to Give you this notice of Gardens Family Practice legal duties and privacy practice regarding the information that Gardens Family Practice ahs about you. Follow the terms of this notice Not use or disclose any information about you without your written permission, except for the reason given in this notice. You may take away your permission at anytime, in writing, except for the information that Gardens Family Practice disclosed before you stopped your permission In the future, Gardens Family Practice may change its privacy practices. If its privacy changes significantly Gardens family Practice will provide a new notice to you. How Gardens Family Practice uses and discloses health care information There are some services Gardens Family Practice Provides through contracts with other agencies and private companies. For example, the Gardens Family Practice billing services sends your insurance claims. When services are contracted, Gardens Family Practice may disclose some or all of your information to other agencies or companies so that they can perform the job for Gardens Family Practice has asked them to do. To protect your information, Gardens Family Practice requires the other agencies or company to safeguard the information in accordance with the law.

The following categories describe different ways that Gardens Family Practice uses and discloses your health information. For each category, we will explain what we mean and give an example. For payment: Gardens Family Practice may use and disclose information about you so that it can pay for the health services that you received. For example, when you receive services at Gardens Family Practice, the provider sends a claim for payment to the insurance for payment. The claim includes information that identifies you, as well as your diagnoses and treatment. For medical treatment: Gardens Family Practice may use or disclose information about you to ensure that they receive necessary medical treatment and service. For example, V may send you reminders about medical appointments. For healthcare operations: Gardens Family Practice may use disclose information about you to ensure that they receive quality care. For example, Gardens Family Practice may contact with a company that reviews records to check on the quality care that you received and the outcome of that care. To other government agencies Providing Benefits or Services: Gardens Family Practice may give information about you to other government agencies that are giving you benefits or services. The information must be necessary for you to receive those benefits or services. To keep informed: Gardens Family Practice may mail information to you about you health and wellbeing. Examples are information about managing a disease, information about your managed car choices, and appointment reminders for your medical services. For Research: Gardens Family Practice may disclose information about you for a research project that has been approves by a review board, as permitted by Florida law. The review board must review the research project and its rules to ensure the privacy of your information. As required by law: Gardens Family Practice will disclose information about you when required by law or court order. For more information: If you have questions and would like additional information, you may contact Gardens Family Practice at (561) 627-7433. To report a problem If you believe your privacy rights have been violated You can file a complaint with Gardens Family Practice by contacting Privacy Officer. There will be no retaliation for filling a complaint or grievance. Effective Date The privacy practice described in this notice will be affective April 14, 2003 Notice of privacy practice acknowledgement and consent I have received a copy of the Gardens Family Practice notice of Privacy Practice. Signature: Date: Consent: I consent ton the use and sharing of my health records for treatment, payment and operation purposes as described in the notice of Privacy s Practices. I know that if I do not consent, you can not provide services to me. Signature: Date:

Request For Release Of Medical Records *Please Fax Or Mail At Your Earliest Convenience* TO: I Hereby Request That Medical Records Be Released To: Gardens Family Practice Prabha Viralam MD 3365 Burns RD Suite 217 Palm Beach Gardens, Fl 33410 Phone 561-627-7433 Fax 561-775-1055 Date Patients Signature Print Name Social Security Number Date Of Birth Gardens Family Practice 3365 Burns RD Suite 217 Palm Beach Gardens Florida 33410

GARDENS FAMILY PRACTICE 3365 BURNS RD STE: 217 PALM BEACH GARDENS, FL 33410 CONSENT TO RELEASE INFORMATION TO FAMILY To Whom It May Concern: This letter is to certify that I give permission to Dr. Prabha Viralam, or any member of her staff to give any or all of my personal medical information to. This includes consults from other physicians, test results and any information pertaining to my medical care. Print Name Signed Date Witnessed Gardens Family Practice 3365 Burns RD Suite 217 Palm Beach Gardens Florida 33410

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