New Patient Form

Patient Registration Information

Pharmacy Information

Previous Primary Care Physician Information

Health History

Welcome to our Practice. As a new patient, please fill out the information below to the best of your ability

Past Medical History. Have you ever had the following:

Social History

Family Medical History

To the best of my knowledge, the question on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

Advance Health Care Directive

INSTRUCTIONS: This form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is provided for you to add to the choices you have made or for you to write out any additional wishes. This form also lets you express an intention to donate your bodily organs and tissues following your death. Lastly, this form lets you designate a physician to have primary responsibility for your health care.

After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before notary public. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any health-care agents you have named.

(4) PRIMARY PHYSICIAN: (OPTIONAL)

I designate the following physician as my primary physician:

OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician:

(5) DONATION OF ORGANS AT DEATH: (OPTIONAL)

• Transplant
• Therapy
• Research
• Education

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment , and I accept the consequences from such refusal.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

I execute this declaration, as my free and voluntary act, on this

INSTRUCTIONS

This advance health care directive will not be valid for making health care decisions unless it is either: (1) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature; or (2) acknowledged before a notary public.

I declare under penalty or perjury under the laws of the state of (1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual’s identity was proven to me by convincing evidence, (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and (5) that I am not the individual’s health care provider, an employee of the individual’s health care provider, the operator of a community health care facility, the operator of a community health care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly.

WITNESS my hand and official seal.

Notice Of Privacy Practices-short Form

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 act 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 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 will be 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:

• Treatment
• Appointment Reminders
• Release of Information to Family/Friends
• Payment
• Treatment Options
• Disclosure Required by Law
• Health Care Operations
• Health-Related Benefits and Services

The following categories describe the different ways in which we may use and disclose your Identifiable Health Information:

• TPublic Health Risks
• Health Oversite Activities
• Lawsuits and Similar Proceedings
• Law Enforcement
• Deceased Patients
• Organ and Tissue Donation
• Serious Threats to Health or Safety
• Research
• Military
• National Security Inmates
• Workers’ Compensation

What are your rights concerning your individually Identifiable Health Information (IIHI)?

What rights have 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.

Authorization For Release Of Information

Section A: Must be completed for all authorizations

I hereby authorize the use or disclosure of my individual 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.

This form must be filled out

Persons/organizations receiving the information:
East Florida Premium Medical Care
7421 N. University Drive, Suite 301 Tamarac FL 33321- 2977
PHONE: (954) 724-3440 FAX (954) 724-3494

Section B:

Must be completed if only if a health plan or health care provider has requested the authorization.

• I understand that my health care and the payment for my health care will not 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 get a copy of this form after I sign it. Further, I understand there may be a fee for a copy of this information

Section C

Must be completed for all authorizations

• 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 effect 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.

** YOU MAY REFUSED TO SIGN THIS AUTHORIZATION **

EFPMC – Financial Responsability

Assignment of Benefits / Release of Information / Notice of Privacy Practices / Appt of Authorized Representative

** PLEASE READ AND INITIAL EACH PRARAGRAPH **

East Florida Premium Medical Care, LLC and associated physicians are committed to securing the privacy of your health information. We are supplying you with a copy of our Notice of Privacy Practices. You are not required to read this notice. By initialing, you are acknowledging receipt of this notice.

Patient Financial Responsibility Statement

• If you have out-of-network benefits, we will happily file claims on your behalf.
• You must pay any co-payment and applicable deductible amounts at the time of services unless other arrangements have been made with our office.
• The remainder of your bill will be sent to your health plan for direct payment to our office.
• If, your insurance carrier has not paid our claim within 45 days, we will expect payment from you.
• If, by mistake your health plan remits payment to you, you will send it to us along with all paperwork which accompanied it.
• Your health plan may refuse payment of a claim for some of the following reasons:
  1. If it is a pre-existing illness that is not covered by your plan.
  2. You have not met your deductible for the full calendar year.
  3. The type of medical service required is not covered by your plan.
  4. The health plan was not in effect at the time of service.
  5. You have other insurance which must be filled out first.

Please understand that financial responsibility for medical services rests between you and your health plan. While we are pleased to be of service by filing your medical insurance for you, we are not responsible for any limitations in coverage that may be included in your plan. If your health plan denies this claim for any of these other reasons, our office cannot be responsible for this bill. It is your responsibility as the patient to pay the denied amounts in full.

Our primary mission is to provide you with quality, cost effective, medical care. Together we are trying to adapt to the changing way health care is financed and delivered. Again, we value you as a patient and our priority is to provide you with the best possible care. With this housekeeping chore complete, we are pleased to serve you.

Sincerely,
East Florida Premium Medical Care, LLC

I have completed this form with accurate information. I have read and understand my obligations and responsibilities. I acknowledge that I am fully responsible for supplying correct insurance information, billing information, and payment call any services not covered or approved by my insurance carrier.

Permission to Share Medical Information

This consent is given with full understanding that any information will be given verbally only. Physical copies of medical records must be requested and collected by me. Consent is also given with full understanding that I may change, remove, or add names to the list, or withdraw consent altogether, at any time.

Exception: Please circle may or may not below.

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.

• 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.