Professional Health Care Of Pinellas, LLC

Patient Information

Thank you for choosing PHC as your medical care provider. Enclosed in this packet you will find: our patient information, medical history forms, financial policy, and patient‘s rights and responsibilities information. Please complete these forms and bring them completed with you to your appointment, along with your medication list. As a courtesy, we will file for reimbursement from your insurance company. Please keep us updated with any changes to your insurance and personal information. ALL FEES INCLUDING CO-PAYMENTS, CO-INSURANCES, AND DEDUCTIBLES ARE DUE AT TIME OF SERVICE.
Please remember to bring the following to your appointment:
⦁ Photo ID
⦁ Insurance card(s)
⦁ Bring Medication(s)
Please refrain from wearing any cologne, perfume, or scented body lotion. These are chemical irritants that can cause problems for other patients and staff with breathing difficulties. We strive to ensure your comfort and safety by encouraging a fragrance-free environment.
We look forward to seeing you soon.
PHC Physicians and Staff

Demographic Information :

Pharmacy Information:
I am hereby authorizing the medical staff of Professional Health Care of Pinellas, LLC. to render medical services as deemed necessary. I also certify that no guarantee or assurance has been made as to the results that may be obtained. If our office prescribes any pain medications to you, you will be subject to random drug testing. I have the right to refuse any procedure or treatment. I have the right to discuss all medical treatment with any physician. I understand that I am ultimately responsible for the full payment of my treatment and care. My insurance policy is a contract between Professional Health Care of Pinellas and my insurance company(s). Professional Health Care of Pinellas will file my claim. I am required to provide the most correct and updated information about my insurance and will be responsible for any charges incurred if the information provided is not correct or updated. Patients are responsible for the pavement of all co-pays, coinsurances, deductibles, procedures, treatments, and explanations of any services not covered. Payment is due at the time services are rendered. Insurance companies will only nav for services that it determines to be “reasonable and medically necessary” under the Insurance Companies standards. Insurance companies may deny pavement for services that they deem are screenings or not meeting medical necessity guidelines per the local coverage determinations. I permit this office to endorse co-issued remittances for the conveyance of credit to my account.

Professional Health Care of Pinellas, LLC cannot waive co-payments or bills on your behalf. For your convenience, ye accept cash, check, and most major credit cards.


Medication Allergies:

Past Medical History:
Previous Surgery:
Social History:
This authorization is prepared pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), 42 U.S.C. Section 1320d, et.seq., and regulations promulgated there under, as amended from time to time (collectively) referred to as "HIPAA".
This authorization of 'ects your yights in the privacy of your personal healthcare informofion. Please read it carefully before signing.

Professional Health Care of Pinellas, LLC will not condition treatment, payment, enrollment in a health plan or eligibility for benefits, as applicable, on your providing authorization for the requested use of disclosure. YOU MAY REFUSE TO SIGN THIS AUTHORIZATION.
By signing this authorization you acknowledge and agree that Professional Health Care o/ Pinellas, LLC may use or disclose your personal health care information to other medical professionals relating to your treatment, payment, or health care options.
Further by signing this authorization you acknowledge that you have been provided a copy of, have read and understand Professional Health Care of Pinellas, LLC's HIPAA Notice of Patient Privacy Practices containing a complete description of your rights, and the permitted uses and disclosures, under HIPAA. While, Professional Health Care o/ Pinellas, 11C has reserved the right to change the terms of its Privacy Notice, copies of the Privacy Notice as amended are available from Professional Health Core o/ Pinellas, LLC. at any of its offices or by sending a written request with return address to 1839 Central Avenue, St. Petersburg, FL 33713, or 5500 MLK St. N. St. Petersburg, FL 33703 or 8133 54’h Avenue N. St. Petersburg, FL 33709, depending on your primary care office. In accordance with your rights under, and subject to certain restrictions imposed by HIPAA, you may inspect or ask for a copy of your Personal Health Information (PHI) in the designated record set maintained by Professional Health Care of Pinellas, LLC. for as long as the Personal Health Information (PHI) is maintained in the designated record set.
You have the right to revoke this authorization, in writing; at any time, except to the extent that Professional Health Care of Pinellas, LLC has taken action in reliance on it. A revocation is effective upon receipt by Pro 'essionaI Health Care of Pinellas, LLC of (a) written request to revoke and a copy of the executed authorization, (b) a finding by the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights that this authorization is not in compliance with requirements of HIPAA, (c) complete satisfaction of the purpose for which this authorization was originally obtained, to be determined in the reasonable discretion of Professional Heofch Care of Pinellas, LLC or (d) six years from the date this authorization was executed.
By signing this authorization you acknowledge and agree that any information used or disclosed pursuant to this authorization could be at risk for re-disclosure by the recipient and no longer protected under HIPAA. Professional Health Care of Pinellas, LLC will provide you with a copy of this signed authorization, if requested.

You have the right to request a copy of our “Notice o/Patient Privacy Practices” prior to signing this authorization for a more complete description of health information uses and disclosures.
I fully understand and agree to this authorization and acknowledge the above rights and disclosures.
Acknowledged and agreed to by:
Name of Guardian or Representative:

*If other than patient is signing, are you the parent, legal guardian, and legal custodian, or have a Healthcare Power of Attorney for this patient?
Acknowledges and agreed to by:

Professional Health Care of Pinellas, LLC originates, maintains paper and electronic records describing your health history, symptoms, examinations, test results, diagnoses, treatments, any plans for future care or treatment and payment for the services or treatments we've provided. We use this information to:
⦁ Plan your care and treatment
⦁ Communicate with other healthcare professionals or entities who contribute to your healthcare
⦁ Submit your diagnosis and treatment information for payment for the services or treatment provided to you
To disclose, as may be necessary, your health information (including HIV-P/AIDS status, drug/alcohol abuse notes and qualified mental health notes) to other healthcare providers and healthcare entities (such as referrals to or consultation with, other healthcare providers and healthcare entities (such as referrals to or consultation with, other healthcare professionals, laboratories, hospitals, etc.) or to others as may be required by law or court order concerning your treatment, payment or healthcare. To request from other healthcare entities or healthcare providers (i.e. doctors, dentists, hospitals, labs, imaging centers, etc) specific healthcare information we may need for planning your care and treatment. To submit the necessary information to your insurance company(s) for coverage verification as well as the diagnosis and treatment information to your insurance company(s), other agencies or individual(s) for payment of our services or treatments provided to you.

To leave appointment reminders or other minimum necessary information related to your healthcare or healthcare payments on your answering machine, mobile voice mail, email or with a household family member.
Please understand that email is an unsecured medium of transmission and is potentially accessible by others. In addition to checking the box, we reserve the right to require you to send as an email authorizing transmission of your healthcare information to you by unsecured email.
To discuss yout healthcare or payment information (only the minimum necessary in our judgment) with family members or others persons who are or may be irivolved with your healthcare treatment or payments. Please list by name and relationship the persons with whom we may share this information:
Your Rights:
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Get an electronic or paper copy of your medical record ⦁ You can ask to see or get an electronic or papef copy of your medical record and other health information we have about you. Ask us how to do this.
⦁ We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your • You can ask us to correct health information about you that you think is medical record incorrect or incomplete. Ask us how to do this.
⦁ We may say ”no" to your request, but we'll tell you why in writing within 60 days.
Request confidential
• You can ask us to contact you in a specific way (for example, home or office communications phone) or to send mail to a different address.
⦁ We will say ”yes" to all reasonable requests. Ask us to limit what we use or share Get a list of those with whom we've shared information
⦁ Get a copy of this privacy notice
⦁ Choose someone to act for you
File a complaint if you feel your rights are violated
⦁ You can ask us not to use or share certain health information for treatment, payment, or our operations.
⦁ We are not required to agree to your request, and we may say "no" if it would affect your care.
⦁ If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
⦁ We will say "yes" unless a law requires us to share that information.
⦁ You can ask for a list (accounting) of the times we‘ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
⦁ We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within J2 months.
⦁ You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
⦁ If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
⦁ We wil| make sure the person has this authority and can act for you before we take any action.
⦁ You can complain if you feel we have violated your rights by contacting us using the information on page 1.
⦁ You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W„ Washington, D.C. 20201, calling 1-877-696-6775, or visiting
⦁ We will not retaliate against you for filing a complaint.

Your Choices:
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have
• Share information with your family, close friends, or others involved in both the right and choice
Your care to tell us to,
• Share information in a disaster relief situation
⦁ Include your information in a hospital directory
⦁ Contact you for fundraising efforts
If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases, we never
• Marketing purposes
share your information unless you give us written permission:
⦁ Sale of your information
⦁ Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.

© 2021 Professional Health Care Of Pinellas, LLC . All Rights Reserved.