Patient Name
Email
Appointment Date
Appointment time
Primary Care Physician
Phone
Primary Care Address
City, State, Zip
Dear, ALL FEES INCLUDING CO-PAYMENTS, CO-INSURANCES, AND DEDUCTIBLES ARE DUE AT TIME OF SERVICE. PHC Physicians and Staff
Demographic Information :
First Name
Last Name
Date of Birth
Social Security
Race
Primary language
Street Address
City
State
Zip Code
Home Phone
Cell Phone
Email
Employer
Occupation
Employer Phone
Employer Phone
Marital Status
Select Single Married Divorced Widowed
Spouse Name
Emergency Contact
Relationship
Phone
Pharmacy Information:
Pharmacy Phone
Address
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.
Patient Name
Date
PATIENT CASH HISTORY:
Patient Name
Date
Height
Weight
Chief Complaint / Reason for visit
Duration of present Condition
Medication Allergies:
If yes, What medication (s)
What is your reaction to this medication?
Past Medical History:
Previous Surgery:
Type
Date
Social History:
If so how many packet (s) per day?
Family History ( Please list )
Please list the medications that your are taking?
HIPAA PRIVACY AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION YOU MAY REFUSE TO SIGN THIS AUTHORIZATION.
HIPAA PRIVACY AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION : Acknowledged and agreed to by:
Patient Signature
Printed Name
Date
Name of Guardian or Representative:
Signature
Printed Name
Date
Relationship
FOR OFFICE USE ONLY:
Patient refused to sign the form
Acknowledges and agreed to by:
Patient Signature
Printed Name
HIPAA PRIVACY AUTHORIZATION FOR USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION
⦁ Plan your care and treatment
“ONLY AS PERMITTED OR REQUIRED BY FEDERAL OR STATE LAW”, 45 CFR Parts 160 &164 WE MAY USE YOUR PROTECTED HEALTHCARE INFORMATION TO DO THE FOLLOWING:
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:
Relationship
Signature
Relationship
Signature
Relationship
Signature
Patient Signature
Date
Your Rights:
Your Choices:
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