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AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

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5831 Bee Ridge Road | Sarasota | FL | 34233 Phone: 941.379.8481 | Fax: 941.379.8142

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient Name:__________________________________ Date of Birth:_________________________ Previous Name:_________________________________ Social Security:_______________________ I request and authorize to release healthcare information of the patient named above to:



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6DUDVRWD, FL 342

Fax: (941) 379-8142

This request and authorization applies to :

□ Healthcare information relating to the following treatment, condition or dates:_________________ ____________________________________________________________________________________ □ All Healthcare Information

□ Other

Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simples, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, AIDS (Acquired Immunodeficiency Syndrom), and gonorrhea.

□ Yes □ No I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

Yes □ No I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Patient Signature:__________________________________ Date:________________________

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Registration Form

Patient Name:__________________________________________ Date of Birth:________________________ Social Security Number:_________________________________ Sex: □ Male □ Female

Home Phone Number:__________________________ Mobile Phone Number:___________________________ Email Address:______________________________________________________________________________ Local Address:______________________________________________________________________________ City:__________________________________ State:___________ Zip:________________________________ Out of State Address:________________________________________________________________________ City:__________________________________ State:___________ Zip:________________________________ Emergency Contact:____________________________________ Phone:________________________________ Marital Status:_____________________ Occupation:_______________________________________________ Where you referred by another Physician? If so, Name:_____________________________________________ Race:___________________________ Preferred Language (if other than English):_______________________ Ethnicity: □ Non-Hispanic □ Hispanic/Latino □ Other:________________________________ How did you hear about our practice? □ Google □ Newspaper □ Friend □ Other:_______________ How would you like to receive appointment reminders? □ Phone □ Text □ Email

Would you like to be added to our mailing list to receive information regarding news and events? __________

Primary Insurance Information

Guarantor Name (if different from above):______________________________________________________________ Insurance Company:________________________________________________________________________________ Policy #___________________________________________________ Effective Date:___________________________ Secondary Insurance Information (if applicable)

Guarantor Name (if different from above):______________________________________________________________ Insurance Company:________________________________________________________________________________ Policy #___________________________________________________ Effective Date:___________________________ Authorization and Agreement – I hereby authorize my insurance benefits to be paid directly to Bradenton Physicians Medical Center

a division of MAXhealth. I acknowledge that I am responsible to pay non-covered services, benefits paid directly to me, and services which are not paid by my insurance in a timely manner. I hereby authorize the release of my medical records to my insurance carrier, other treating physicians, and my attorney in response to subpoena duces tecum, or to my representative.

Patient Signature:______________________________________________ Date:___________________ Legal Guardian/ POA: _________________________________________ Relationship:_________________

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Medical History

Today’s Date: _______________________________ Name: _________________________________ Birth Date: _______________________________ Allergies to medications, x-ray dyes, or other substances:

Yes

No

If yes, please list and explain: ______________________________________________________________ ________________________________________________________________________________________ Past medical history and review of symptoms:

Please list and date all operations/surgery: ____________________________________________________ _______________________________________________________________________________________ Hospitalizations other than surgery: ___________________________________________________________ _______________________________________________________________________________________ Please check circle next to any problems you have had, or currently have:

O High blood pressure O Diarrhea O Transfusion – Date:________ O Diabetes O Change in bowel habits O Headache

O High cholesterol O Blood in stool O Hay Fever/Sinus

O Cancer O Hemorrhoids O Head/Neck Radiation

O Heart disease O Colitis O Swallowing Problems O Chest pain/tightness O Gallbladder disease O Skin Disease/Itching O Palpitation O Hepatitis or jaundice O TIA/Stroke

O Shortness of breath O Frequent urination O Visual Disturbance O Lightheadedness O Leakage of urine O Gait/Balance Problem O Ankle swelling O Kidney disease O Severe Memory Problem O Asthma/weezing O Kidney stone O Arthritis/Gout

O Persistent cough O STD’s (VD) O Back Problems O Bronchitis/pneumonia/TB O Unusual fatigue O Alcohol or Drug Use O Abdominal pain O Fever/Chills/Sweats O Anxiety/Depression O Indigestion/heartburn O Abnormal Weight Loss O Inability to Sleep O Nausea/vomiting O Anemia

O Constipation O Blood Disorder(s)

Do you require assistance in bathing/dressing? O YES O NO Do you require assistance to walk about? O YES O NO Do you use a walker, cane, wheelchair, hospital bed or oxygen? O YES O NO Do you exercise regularly? O YES O NO Do you always wear a seatbelt O YES O NO Have you worked with asbestos or other hazardous material? O YES O NO Do you use tobacco? O YES O NO Do you drink alcohol? O YES – Drinks per day______________ O NO How much caffeine (coffee, tea, colas)?____________________________

When was your last physical exam?_______________________________

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Last Stool check for blood? ______________________________________________________________ Last Colonoscopy?______________________________________________________________________ Eye Exam?____________________________________________________________________________ Do you believe you have been at risk for acquiring AIDS? O YES O NO

Are you sexually active? O YES O NO Do you practice birth control? O YES O NO Number of sexual partner in last year?_______________ 2 years?_______________

Have you ever been hurt by your intimate partner? O YES O NO

How do you resolve conflict with your intimate partner?_________________________________________ Female Questionnaire

Gynecologic & Obstetric History

Age at onset of periods__________ Frequency_______________ Length of period__________________ #Pregnancies____________ #Birth_____________ #Miscarriages_____________ #Abortion_________ Last Period______________ (Normal)______________ Prolonged or Abnormal Bleeding_____________ History of abnormal pap?

Pelvic pain/pain with intercourse? Abnormal discharge?

When was your last PAP Smear?____________Breast Exam?______________ Mammogram Do you examine your breasts for lumps monthly?

Male Questionnaire

Do you have erection difficulties?

Do you check your testicles for lumps monthly?

When was your last scrotal/testicular exam?________________ Rectal/prostate exam?_________ Immunization History

Tetanus O YES – Date:___________ O NO Hepatitis B O YES – Date:___________ O NO Hepatitis A O YES – Date:___________ O NO

Pneumovax O YES – Date:___________ O NO Flu O YES – Date:___________ O NO Other: O YES – Date:___________ O NO Please list: _______________________________ Family History

Father O Living O Died at (age)________ Mother O Living O Died at (age)________ Siblings Number_________ Number Living___________

Have you or any family member (including parents, grandparents and siblings) ever had the following? O TB/TB Exposure O Stroke/TIA O Thyroid Disease

O Diabetes O Mental Disease/Suicide O Epilepsy O High cholesterol O Drug/Alcohol Addiction O Kidney Stones O Hypertension O Glaucoma/Blindness O Gallbladder O Heart Disease O Bleeding Diseases O Ulcers

O Cancer (type)____________ O Gout O Other:__________________ Medications/Prescriptions including Vitamins or Herbal Supplements

Drug Dose How Often

Please list any other concerns you would like to discuss with your doctor:____________________________ _____________________________________________________________________________________ Do you have an Advance Directive? O YES O NO

Health Surrogate? O YES O NO Living Will? O YES O NO Power of Attorney? O YES O NO

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Authorization for Use or

Disclosure of Protected Health Information (PHI)

I hereby authorize the use and disclosure of individually identifiable health information related to me, which is called PHI, Protected Health Information, under a federal health privacy law, as described below.

I, _________________________________authorize 0$;KHDOWK, to release and obtain my private health information to/from (check all that applies):

My Spouse/partner Name of spouse/partner: ___________________________

My Primary Care Physician/staff Name of Physician: _______________________________

My Pharmacy Name of Pharmacy: _______________________________

My parent/child(ren) Name(s): _______________________________________

My Personal Representative Name of Representative: ___________________________

Other Name: _________________________________________

None of the above

May our office leave a message on your machine?

Yes

No Are there any restrictions on PHI to be disclosed?

Yes

No If yes, please describe:

________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ The PHI will be disclosed to confirm appointments, to render to caregivers counseling on my treatment, for prescription pick ups, and any other reason to ensure I obtain optimum treatment and care while I am a patient with 0$;KHDOWK. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to attention Privacy Officer at, PO Box25487, Sarasota, FL 34277. I understand that my revocation will not affect any actions taken by 0$;KHDOWK prior to receiving my revocation. I understand that information disclosed pursuant too this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I understand that I may refuse to sign this authorization and that my refusal in no way affects my treatment. My physician will not condition my treatment or payment on whether I provide authorization for the requested use of disclosure except if health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party. This authorization shall be effective for 1 year from the date signed, at which time this authorization to obtain and release this protected health information expires.

_____________________________________________ _________________________ Patient Signature or Authorized Representative Date

_____________________________________________ Patient Name Printed

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Assignment of Benefits & Financial Policy

ASSIGNMENT OF BENEFITS If you have no insurance:

I agree to pay my medical expenses, in full, when I am seen by the doctor. If for any reason there is a balance owed on my account, I agree to pay promptly upon receipt of the monthly statement.

If you have Medicare:

I request that payment of authorized Medicare benefits be made on my behalf to the rendering physician for any services furnished to me. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any

information (including HIV, alcohol, and mental health) needed to determine these benefits or the benefits payable for related services. I agree to pay any portion of my charges that my Medicare carrier determines to be my responsibility.

If you have HMO, PPO, or commercial insurance:

I authorize any holder of medical information about me to release to my insurance company or its agents any information (including HIV, alcohol, and mental health) needed to determine benefits payable for related services. I agree to comply with the terms of my insurance coverage, including payment of my co-payment at the time of service rendered and payment of any portion of charges that my insurance carrier determines to be my responsibility, upon receipt of my monthly statement.

If you have Medigap insurance (Medicare Supplement):

I request that payment of authorized Medigap benefits be made either to me or on my behalf to the rendering physician for any services furnished me by that provider. I authorize any holder of medical information about me to release to my Medigap carrier any information (including HIV, alcohol, and mental health) needed to determine these benefits or the benefits payable for related services.

STATEMENT OF FINANCIAL RESPONSIBILITY

All insurance forms processed by this office, prior to payment in full, are assigned to this practice. Your cooperation in complying with the terms of this assignment will be appreciated. If your visit is related to an auto accident or work-related injury, this information must be provided prior to seeing the physician and all claim and billing information must be furnished prior to the appointment.

Patients who cancel an appointment without a 24 hour notice may be subject to an administrative fee depending upon the length of the scheduled appointments (this fee also applies to diagnostic testing.)

I, the UNDERSIGNED, have read the above and realize that all medical charges incurred by me, or my dependents are my financial responsibility. All court fees, attorney fees, or other fees necessary to collect this account, should it become delinquent, are payable by me.

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5831 Bee Ridge Road | Sarasota | FL | 34233 Phone: 941.379.8481| Fax: 941.379.8142

Patient General Consent to Treatment

I, the undersigned hereby consent to the following:

• Administration and performance of general treatments • Use of prescribed medication

• Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgment of my physician or their assigned designees. I fully understand that this consent is given in advance of any specific diagnosis or treatment. I intend that this consent is continuing in nature even after the specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.

A photocopy of this consent shall be considered as valid as the original.

Medicare Patients: I authorize MAXhealth to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services at MAXhealth.

I acknowledge that I have been notified of 0$;KHDOWK Privacy Practices and understand that if I have a question or complain that I should contact the Privacy Official. (Patient Initials_____________).

I, the undersigned, authorize 0$;KHDOWK to use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

_________________________________________ __________________

References

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