Existing Patient Form

East Florida Premium Medical Care

7421 N. University Drive, Suite 314 Tamarac Fl 33321
Phone: 954 724 724-3440 Fax: 954 724 3494

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NOTICE OF PRIVACY PRACTICES-SHORT FORM
East Florida Premium Medical Care

Our practice is committed to educating our patients about healthcare issues that affect them. As a result, we are providing you with general information about Privacy Rule, a federal regulation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) along with brief overview of our Notice of Privacy. Our practice is complying with HIPPA’s regulations.
What is HIPPA and how does the Privacy Rule affect you?
When the Health Insurance Portability and Accountability Act (HIPPA) was passed in August of 1996, this gave the federal government the ability to mandate how healthcare plans, providers, and clearinghouses store and send a patient’s personal information as it relates to healthcare. The privacy rule was created to protect your rights as a patient of our practice, and we are required by law to be compliant with this regulation. Under the Privacy Rule you are guaranteed access to your medical records, allowed control over how your protected health information is used and disclosed and allowed to take action if your privacy is compromised by following the practice’s policy. Our practice is dedicated to maintaining the privacy of your personal information.
What is Individually Identifiable Health Information (IIHI)?
Any health information you provide our practice, including your mailing address. IIHI is any information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment, and/or that identifies you as an induvial.
What is Individually Identifiable Health Information (IIHI)?
Any health information you provide our practice, including your mailing address. IIHI is any information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment, and/or that identifies you as an induvial.
What is the Notice of Privacy Practice?
Our practice has an official Notice of Privacy Practice posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice of Privacy Practices at any time. It will be posted, and a copy is provided in our waiting room and you can take a copy of the current notice at any time.
What is Individually Identifiable Health Information (IIHI)?
Any health information you provide our practice, including your mailing address. IIHI is any information that is created and retained by our practice or received by another healthcare provider that relates to treatment, payment, and/or that identifies you as an induvial.
What is the Notice of Privacy Practice?
Our practice has an official Notice of Privacy Practice posted in our waiting room informing our patients about their rights surrounding the protection of your IIHI and our obligations concerning the use and disclosure of your IIHI. This notice applies to all records created or retained by our practice. We can update our Notice of Privacy Practices at any time. It will be posted, and a copy is provided in our waiting room and you can take a copy of the current notice at any time. The following categories describe the different ways in which we may use and disclose your IIHI:
What are your rights concerning your individually Identifiable Health Information (IIHI)?
What have rights regarding the IIHI that we maintain with you. In our Notice of Privacy, you can view the policies and procedures you will need to follow for the areas listed below. 1.Confidential Communications 2.Requesting Restrictions 3.Inspection and Copies 4.Amendment 5.Accounting of Disclosures 6.Right to a Paper Copy of this Notice 7.Right to file a complaint 8.Right to provide and Authorization for other uses and disclosures If you have any questions about this notice, please ask the receptionist to speak to our Privacy Officer.
I have read the short notice provided by East Florida Premium Medical Care and have been informed of how to obtain more information regarding our Notice of Privacy.
Patient’s signature*
Date
Date Format: MM slash DD slash YYYY
.
AUTHORIZATION FOR RELEASE OF INFORMATION
Section A: Must be completed for all authorizations I hereby authorize the use or disclosure of my individually identification health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
Patient Name*
First Middle Last
DOB*
Date Format: MM slash DD slash YYYY
Last 4 digits of SSN #: XXX- XX-
Please enter a number from 1000 to 9999.
Phone
Medical Provider to Release medical records
Name of Office Address City State Phone No. Fax
Persons/organizations receiving the information:
East Florida Premium Medical Care
7421 N. University Drive, Suite 314 Tamarac FL 33321- 2977
PHONE: (954) 724-3440 FAX (954) 724-3494
Specific description of information (including date(s)):
- Dates
- Progress Notes
- Labs
- Operative Reports
- Radiology Reports
- Correspondence
- Hospital Records
- Test Results
- Other Provider Records
- PT notes
- Consultations
- Entire Chart
- Billing
- Radiology Films
- Other
Section B
Must be completed if only if a health plan or health care provider has requested the authorization.
Will the health plan or care provider requesting the authorization received the authorization receive financial or in-kind compensation in exchange for using or disclosing the health information described above?
- Yes
- No
- I understand that my health care and the payment for may health care will no be affected if I do not sign this form.
- I understand that I may see and copy the information described on this form if I ask for it, and that I et a copy of this form after I sigh it.
- Further, I understand there may be a fee for a copy of this information
Section C
Must be completed for all authorizations.
What is the purpose of the use or disclosure?
I understand that authorization will expire on
Date Format: MM slash DD slash YYYY
Or at the term of __________ event. If not specified, this release will expire 180 days from the date signed.
- I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do it won’t have any affect on any actions they took before they received the revocation.
- I understand that my records are protected under state and federal law. I understand that specific information to be disclosed may include history of drug or alcohol abuse, mental health treatment, AIDS or any other medical information.
Signature of Patient or Patient’s Representative (Form must be completed before signing)
Printed name patient’s representative:
Relationship to patient:
** YOU MAY REFUSED TO SIGN THIS AUTHORIZATION **

CONSENT TO RECEIVE TEXT MESSAGES AND EMAILS
By signing below, I authorize EAST FLORIDA PREMIUM MEDICAL CARE to contact me by SMS text message and /or emails to serve me better.
Phone*
Email
EAST FLORIDA PREMIUM MEDICAL CARE will send me text messages and /or emails through its member outreach program to help me stay healthy, including:
- Timely reminders about needed doctor visits
- How to get help scheduling my visits and transportation at no cost
- Tips for keeping me safe
- Information to help me manage my illnesses
I understand that message/data rates may apply to messages sent through East Florida Premium Medical Care to my cell phone and that I may receive up to 20 texts a per month. I know that I am under no obligation to authorize East Florida Premium Care to send me text messages as part of this program.
I may opt-out of receiving these communications for East Florida Premium Medical Care at any time by calling East Florida Premium Medical Care at 954-724-3440.
First Name*
Middle Name
Last Name*
DOB*
Date Format: MM slash DD slash YYYY
Witness / Guardian Name:
Relationship
Signature*
Date*
Date Format: MM slash DD slash YYYY

TELEMEDICINE CONSENT
Telemedicine involves the use of electronic communications to enable health care providers at East Florida Premium Medical Care to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
- Patient medical records
- Medical images
- Live two-way audio and video
- Output data from medical devices and sound and video files
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Expected Benefits:
1. Improved access to medical care by enabling a patient to remain in his/her provider’s office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
2. More efficient medical evaluation and management.
3. Obtaining expertise of a distant specialist.
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
1. In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s).
2. Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
3. In exceedingly rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
4. In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.
By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my care at any time, without affecting my right to future care or treatment.
3. I understand that I have the right to inspect all information obtained and recorded during a telemedicine interaction and may receive copies of this information for a reasonable fee.
4. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
5. I understand that it is my duty to inform my provider of electronic interactions regarding my care that I may have with other healthcare providers.
Patient Consent To The Use of Telemedicine I, _____________________, have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
First Name*
Middle Name
Last Name*
DOB*
Date Format: MM slash DD slash YYYY
Signature of Patient:*
or Person authorized to sign for patient:
Relationship
Date*
Date Format: MM slash DD slash YYYY

CONSENT FOR PELVIC AND/OR RECTAL EXAMINATION
A Pelvic Examination is an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum or external pelvic tissue or organs (including scrotum, testicles, penis, prostate). This procedure is used to diagnose and/or treat conditions that involve the pelvis. It may be perform using any combination of modalities, which may include the health care providers gloved hands and instrumentation. For purposes of this consent, vaginal sonography performed by ultrasound technician is included.
By signing this consent, I*
Patient's Name Middle Last
DOB*
Date Format: MM slash DD slash YYYY
authorize and direct*
Doctor's Name Middle Last
to perform a pelvic examination, including vaginal sonography, as described above. By my signature below, and I acknowledged that I have read and understand the content of this form.
Patient Signature*
Witness Signature*
Witness Name
DOB*
Date Format: MM slash DD slash YYYY

East Florida Premium Medical Care

Step 1 of 4

NOTICE OF PRIVACY PRACTICES-SHORT FORM

East Florida Premium Medical Care

AUTHORIZATION FOR RELEASE OF INFORMATION

Section B

Section C

CONSENT TO RECEIVE TEXT MESSAGES AND EMAILS

TELEMEDICINE CONSENT

CONSENT FOR PELVIC AND/OR RECTAL EXAMINATION

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