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About Us
Services
Insurance Plans
Location
Patient’s form
- New Patient Form
- Existing Patient Form
Others
- Review
- Events
- Non-Insured
- Contact Us
- Resources

East Florida Premium Medical Care

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

Step 1 of 8 - Patient Registration

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PATIENT REGISTRATION INFORMATION
Patient First Name*
Patient Middle Name
Patient Last Name*
Patient DOB*
MM
DD
YYYY
Gender*
Phone*
Alternative Phone
Relation
Email
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Driver Licence
Emergency Contact*
Relation
Phone*
Are you Employed?*
Employment Type*
Are you Student?
Student Type
Marital Status
Preferred Language*
Other Language
Race
Other Race
Ethnicity
PHARMACY INFORMATION
Pharmacy Name
Address
Street Address City ZIP / Postal Code
Signature*
.

Assignment of Benefits / Release of Information / Notice of Privacy Practices / Appt of Authorized Representative
Date
Date Format: MM slash DD slash YYYY
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.
- I request that payment of authorized Medicare and other insurance benefits be made on my behalf to East Florida Premium Care, LLC for any services furnished to me by any healthcare providers associated with that group. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or insurance company any information needed to determine these benefits or the benefits payable for related services.
- I appoint East Florida Premium Care, LLC to act as my authorized representative in requesting an appeal from my insurance plan regarding its denial of services or denial of payment.
- Unless I request to the contrary, in writing, I will receive appointment reminders on my home telephone answering system and /or other information regarding my treatment or invoices by mail to my home address.
Patient Financial Responsibility Statement
In order to maintain our fees at the lowest possible level, it is important that we have a good understanding with our patients regarding financial responsibility. We hope that this summary will be helpful toward that end. We encourage you discuss it with us and to ask questions.
We understand that your health coverage is provided through _________________________.
- 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 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 Care, LLC

I have completed this form with accurate information. I have read and understood 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.
Signature*
Date
Date Format: MM slash DD slash YYYY
.

HEALTH HISTORY
First Name*
Middle Name
Last Name*
DOB*
MM
DD
YYYY
Welcome to our Practice. As a new patient, please fill out the information below to the best of your ability.

Mediation:

1	2	3

Allergies:*
- Yes
- No

Allergies:

Medications	Foods

Previous Surgery

Type	When(Date)	Hospital, City, State

Social History
Use of Alcohol*
Use of Tobacco*
How Many Pack
Use of Drug*

About Drug

Type of Drug	Frequency

Family Medical History
Father*
Medical Condition
Age Disease(If Any)
if Disease Cause of Death
Mother*
Medical Condition
Age Disease(If Any)
if Disease Cause of Death
Siblings

Age	Disease(If Any)

if Disease Cause of Death
Children

Age	Disease(If Any)

if Disease Cause of Death
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.
Signature of Patient, Parent or Guardian*
Date*
Date Format: MM slash DD slash YYYY
.

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
You may refuse to sign this authorization
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.
Name
First Name*
Middle Name
Last Name*
DOB*
MM
DD
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)):
- Entire Chart
- Dates
- Progress Notes
- Labs
- Operative Reports
- Radiology Reports
- Correspondence
- Hospital Records
- Test Results
- Other Provider Records
- PT notes
- Consultations
- Billing
- Radiology Films
- Other
Date*
Date Format: MM slash DD slash YYYY
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 **
.

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 a 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.
First Name*
Middle Name
Last Name*
being of sound mind and at least 18 years of age declare that:
1) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below: (Initial only one box)
Choice
- Choice NOT To Prolong Life. I do not want my life to be prolonged if within a relatively short time, I become unconscious and, to a reasonable degree of medical certainty, I will not regain my consciousness, the likely risks and burdens of treatment would outweigh the expected benefits.
- To Prolong Life. I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
(2) RELIEF FROM PAIN:
Except as I state in the following space, I direct that treatment for the alleviation of pain or discomfort should be provided at all times even if it hastens my death:
(3) OTHER WISHES:
(If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:
(4) PRIMARY PHYSICIAN: (OPTIONAL)

• I designate the following physician as my primary physician:

(Name of physician)	(Address)	(City)	(State)	(Zip Code)	(Phone)

OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the 2nd physician as my primary physician:

(5) DONATION OF ORGANS AT DEATH: (OPTIONAL)
Upon my death: (mark applicable box)
- I give any needed organs, tissues, or parts, OR
- I give the following organs, tissues, or parts only.
- My gift is for the this purposes: (1) Transplant (2) Therapy (3) Research (4) Education
Name of Part , tissue or Organ
Select Any One Purposes
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 ________ day of ________________, 20__, in the City of ___________________, Country of ___________________, State of ___________________.

Day	Date	Country	City	State

Signature*
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.
I further declare under the laws of penalty of perjury of the state of that I am neither related to the patient by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to ant portion of the patient’s estate upon the patient’s death under a will existing when the advance directive is executed or by operation of law.
Signed at ____________________ on this _____ day of _________________, 20___.
Signature*
Date
Date Format: MM slash DD slash YYYY

Witness Info

Name	Country	State

Click on + to add info of 2nd witness

On this the ________ day of _____________________, 20__, before me, the undersigned, a notary public in and for said County and State, personally appeared ________________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or entity upon behalf of which the person(s) acted, executed the instrument.
Date Name
Signature of Notary
WITNESS my hand and official seal.
.

First Name*
Middle Name
Last Name*
DOB*
MM
DD
YYYY
I freely give my permission for the health care providers at East Florida Premium Medical Care, LLC to discuss any and all issues pertaining to my health with the following individuals (please do not list doctor’s, RELATIVES ONLY)

Relatives

1	2

Click on the plus icon to add more.

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 select may or may not below.
The following issues specific to my health MAY/OR MAY NOT be discussed.
- Issues related to Sexually transmitted diseases
- Issues related to Pregnancy
- Issues related to psychiatric diagnoses
- Other issues

Issues

1	2

Click on the plus icon to add more.

Patient Signature
Date*
Date Format: MM slash DD slash YYYY
.

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.
Email
Phone
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*
MM
DD
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
First Name*
Middle Name
Last Name*
DOB*
MM
DD
YYYY
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.
Signature of Patient:*
Date*
Date Format: MM slash DD slash YYYY
or Person authorized to sign for patient:
Relationship

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FOR PATIENTS

We are committed to customer service of a high standard to meet your needs. Your medical information will always remain private and protected from unauthorized access. Every patient has a right to be heard and to be fully understood. Our facility has staffs that are fluent in Creole, French, Spanish and English.

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CONTACT INFO

Phone: (954) 724 3440

Fax: (954) 724 3440

care@efpmc.com

7421 N. University Dr. Suite 314
Tamarac, Florida 33321

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