OFFICE POLICY. I, have read and understand the Financial Policy of Brandon Family Medical Care and agree to meet all financial obligations.

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Brandon Family Medical Care, P.A. 414 West Robertson Street

Brandon, Florida 33511 (813) 684-5255

OFFICE POLICY

The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make your visits as convenient as possible.

By signing below you confirm that you have read this policy and understand that:

 It is the patient’s responsibility to inform the office of any address or telephone changes.

 The patient’s account must be kept current. All self-pay or insurance co-payments, co-insurances and deductibles will be collected at the time of service. Payable by cash, check (with driver’s license) or credit card.

If the patient does not have their payment(s), the appointment will be rescheduled.

 Due to time allowed for each appointment patients may be asked to schedule another appointment for issues other than the reason of the original appointment.

 A returned check will result in a minimum service charge of $25.00 and checks will not be accepted for future payment(s). Unpaid returned checks will be turned over to the state attorney’s office.

 There is a $50.00 minimum for all FMLA and Short Term Disability, and any medical report form. All other forms have a minimum charge of $30.00. Payment due at time of service.

 Medical records copy fee $1.00 per page for copies up to 25 pages and $0.25 per page for copies of 26 pages and greater. Copy Service will handle all medical records request.

 A request for review of your medical record(s) requires an appointment with a minimum of seven-business days notice.

 Twenty-four hour notice must be given to reschedule or cancel appointment to avoid cancel/no show charge. If the proper notice is not given there is a charge of $20.00 for a (15) minute appointment, a $40.00 charge for a (30) minute

appointment, and $30.00 for an urgent appointment. Saturday appointments are all urgent and any no show or cancellation will have a $30.00 charge.

 There is no phone service on Saturdays, answering service only.

 Prescription refills require a seven (7)-business day notice.

 No narcotics called in after hours by any on call physician.

 If you’re insurance requires a referral it is your responsibility to get all information to the primary care doctor for processing within seven (7) business days. If the correct time is not allowed the patient may need to reschedule.

 Appointment is required to request a referral with a specialist.

HEALTH INSURANCE COVERAGE

Claims will be submitted, however we must emphasize that as medical providers, the relationship is with patients,

NOT insurance companies. Although we attempts to verify benefits with insurance policies, please be advised this is only

an estimate of the coverage based on the information given at the time of inquiry.

 It is the patient’s responsibility to inform us of any changes in their insurance.

 Not all services are covered benefits with all insurance plans.

 It is the patient’s responsibility to be aware of the service(s) provided, and their covered benefit(s) under the insurance policy.

 The patient is responsible for any non-covered charges not payable by the insurance policy.

 Although filing insurance claim(s) is a courtesy extended to the patient, all charges are always the patient’s responsibility from the date services are rendered.

 Any unpaid balances older than 30 days may be subject to a 1.5% interest per month.

 If a patient’s account is turned over to a collection agency, the patient will be responsible for any costs incurred in collection of the balance, which will include collection agency fees, court cost, and attorney fees.

 In the event that a patient does not meet their financial obligation, the patient will be discharged from the practice.

I, ______________________ have read and understand the Financial Policy of Brandon Family Medical Care and agree to meet all financial obligations.

_________________________ __________________________ _____ Print Name of Patient Patient/responsible party Date Signature

_________________________ Responsible Party Print Name

Brandon Family Medical 1218 Millennium Parkway Brandon, FL 33511 (813) 684-5255

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PATIENT HISTORY FORM

LAST NAME ________________________ FIRST NAME: _________________________ DOB: _______________ DATE_________________

Review of Systems

(2 pages)

Circle Yes or No.

General Symptoms NOW PAST (Comments) Genitourinary NOW PAST (Comments) Weight change Chills Sleep Disorder Y Y Y N Y N N Y N N Y N Change in stream

Nocturia (getting up at night) Urinary frequency > 8 times/day

Y Y Y N Y N N Y N N Y N Other Other Eyes Musculoskeletal Double vision Glaucoma Cataracts Y Y Y N Y N N Y N N Y N Bone pain Muscle pain Joint pain Y Y Y N Y N N Y N N Y N Other Other Ear/Nose/Throat/Mouth Skin Hearing changes Sore throat Sinus problem Y Y Y N Y N N Y N N Y N Rash Lumps or bumps Moles, skin tags

Y Y Y N Y N N Y N N Y N Other Other

Cardiovascular

Neurological Chest pain Irregular heartbeat Swelling in ankles Y Y Y N Y N N Y N N Y N Tremors Dizzy spells Numbness/tingling Y Y Y N Y N N Y N N Y N Other Other Psychologic Respiratory

Are you generally happy? Do you feel depressed? Do you feel anxious?

Y Y Y N Y N N Y N N Y N Wheezing Frequent cough Shortness of breath Y Y Y N Y N N Y N N Y N Do you feel safe

in your home? Y N Y N Other

Endocrine Gastrointestinal Excessive thirst Too hot/cold Tired/sluggish Y Y Y N Y N N Y N N Y N Abdominal pain Nausea/vomiting Indigestion/heartburn Y Y Y N Y N N Y N N Y N Other Other

Hematologic/Lymphatic

Sexual History

Swollen glands Blood clotting problem Bruising Y Y Y N Y N N Y N N Y N

Change in sex drive?

Sexual performance satisfactory? Y Y N N

Other Other (i.e. sexual trauma)

Allergic/Immune

Last Exams or Lab tests: Please enter date (mo/yr)

Hay Fever Drug allergies Food Y Y Y N Y N N Y N N Y N

Dental: __________________ Eye : _________________

Pelvic: ___________________ PAP smear: ____________

Mammogram: _____________ Cholesterol: _____________

Colonoscopy:______________ Stool Tested: ____________

Prostate ______________ PSA test: ______________

Other

Living Will? Yes No Advanced Directive? Yes No Doctor’s signature: _______________________

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Medical History

Medical None (High Blood Pressure, Diabetes, Cancer, Heart Disease, etc.)

____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ Pregnancy History

Year Sex Complications

_____ ____ _____________________ _____ ____ _____________________ _____ ____ _____________________ _____ ____ _____________________ _____ ____ _____________________ Surgical None (Tonsillectomy, Appendectomy, Hysterectomy, Hernia, etc - Please enter year surgery was done if known)

__________________________ _________________________ ___________________________ __________________________ __________________________ _________________________ ___________________________ __________________________ __________________________ _________________________ ___________________________ __________________________ __________________________ _________________________ ___________________________ __________________________ Allergies to medications? None (If Yes, please explain type of reaction, i.e. hives, wheezing, upset stomach, swelling, etc.) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Last Immunizations: FLU ____/____/___ PNEU___/_____/___ Tetanus ___/____/___ Other __________ ____/_____/___ Current prescription medicines: None

Name of drug mg dose # tablets # times per day _________________ _______ ________ _____________ _________________ _______ ________ _____________ ________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________

Additional current prescription medicines:

Name of drug mg dose # tablets # times per day _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ _________________ _______ ________ _____________ Current Non-Prescription Medicine (Aspirin, Tylenol, Ibuprofen, Aleve, vitamins, anti-acids, herbals.)

_________________________ __________________________ ____________________________ _________________________ _________________________ __________________________ ____________________________ _________________________

Family History

Father: Living - Age: _____ Deceased, Age at Death_____ (Cause) __________________________________________ Mother: Living - Age: _____ Deceased, Age at Death_____ (Cause) __________________________________________ Siblings: Number Living _____ Number deceased ________ (Cause) ___________________________________________

List other illnesses in your family (Example - Diabetes, heart disease, colon, breast, or prostate cancer, arthritis, depression etc) ( Family Member) (Illness ) ( Family Member) (Illness) (Family Member) ( Illness) ________________= _________________ __________________ = __________________ ______________= ______________

Social History

Caffeine Yes No If yes, how much? _____

Smoke? Yes No If yes, how much? _____ # of packs/day ______ # of years When did you stop smoking? _________ Alcohol? Yes No If yes, how much? ________________

OCCUPATION. ____________________ Retired Significant prior industrial or agricultural exposures? Yes No

MARITAL STATUS MARRIED SINGLE DIVORCED WIDOWED NUMBER OF CHILDREN _________ None

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BRANDON FAMILY MEDICAL CARE

PATIENT INFORMATION

PATIENT NAME______________________MI____LAST NAME_______________________

ADDRESS____________________________________________________________________

(REQUIRED)

CITY__________________________STATE_______________ZIP_______________________

HOME PHONE ____________CELL PHONE ____________WORK PHONE______________

DATE OF BIRTH _______________SEX________ SS# ________________RACE__________

(REQUIRED)

DRIVERS LICENSE________________________ MARITAL STATUS___________________

(PHOTO ID REQUIRED)

Email address______________________________________________________

Can we leave a message at home Yes No Can we leave a message at work Yes No

(circle one) (circle one)

GUARANTOR/SPOUSE/PARENT INFORMATION REQUIRED

GUARANTOR/SPOUSE/PARENT

NAME_______________________________________________________________________

ADDRESS____________________________________________________________________

TELEPHONE NUMBER_______________________CELL PHONE____________________

POLICY HOLDER’S INFORMATION REQUIRED

POLICY HOLDERS NAME______________________________________________________

ADDRESS____________________________________________________________________

TELEPHONE NUMBER _______________________CELL PHONE ____________________

SOCIAL SECURITY NUMBER______________________DATE OF BIRTH______________

EMPLOYER NAME____________________EMPLOYER PHONE NUMBER_____________

EMPLOYER ADDRESS ________________________________________________________

PATIENT’S RELATIONSHIP TO POLICY HOLDER

(CIRCLE):

SELF SPOUSE CHILD

OTHER:______________________________________________________________________

INSURANCE COMPANY_______________________________________________________

(INSURANCE CARD REQUIRED, PRESENT TO FRONT DESK)

DO YOU CURRENTLY HAVE AN ADVANCE DIRECTIVE ____YES ____NO

HOW DID YOU HEAR OF US _____________________________________________

I AUTHORIZE BRANDON FAMILY MEDICAL CARE TO RELEASE ANY MEDICAL

INFORMATION NECESSARY TO PROCESS CLAIMS, COORDINATE CARE,

REFERRALS, AND FOR QUALITY MANAGEMENT AND/OR UTILIZATION

ACTIVITIES. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO BRANDON

FAMILY MEDICAL CARE FOR SERVICE’S RENDERED.

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Office Policy for FMLA and Short Term Disability Forms

Completion of forms requires an office visit.

A minimum charge of $50.00 per form is due at time of service.

It is the patient’s responsibility to bring in the correct forms at the time of visit.

Appointment may be rescheduled if the correct paperwork in not available.

Patient is required to provide a copy of his/her job description at time of service.

All forms require a two week period before the dead line date. No exceptions.

FMLA/Disability paperwork is not considered an emergency or urgent

appointment.

I, ____________________________________ have read and understand the FMLA /Short Term form

Policy of Brandon Family Medical Care. I understand that this policy cannot be altered and if I do not

agree with the policy, I understand that I may find another physician to follow my care.

_________________________

__________________________

______________

Print name of patient Patient

Signature

Date

Brandon Family Medical Care

1218 Millennium Parkway

Brandon, FL 33511

(813) 684-5255

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

I hereby authorize________________________________Phone#_____________________ Fax#_____________________

and its entities, its officers or agents to permit inspection, copying and/or release of health information compiled in the

ordinary course of business in connection with the following:

Patient Name: __________________________________

Address: __________________________________

__________________________________

Date of Birth: ________________________________

Telephone: ________________________________

Social Security #: ________________________________

I further understand and acknowledge that in complying with my request for release, such disclosure will require Brandon

Family Medical Care to disclose, as provided under applicable federal law, Protected Health Information, as defined in 42

C.F.R. 160 et seq.

Information to be disclosed:

□ Complete Health Record

□ Discharge Summary

□ History & Physical Exam

□ Consultation Reports

□ Progress notes

□ Laboratory Tests

□ Radiology Reports

□ Abstract/Pertinent Information

□ Emergency Department Record

□ Other (Please Specify)_______________________________________________

I UNDERSTAND THIS MAY INCLUDE INFORMATION RELATING TO THE FOLLOWING UNLESS EXPRESSLY

EXCLUDED BY CHECKING THE BOX(ES) BELOW:

□ Acquired Immunodeficiency Syndrome (AIDS) or infection with Human Immunodeficiency Virus (HIV)

□ Psychiatric Care (behavioral Health)

1

□ Treatment for Alcohol and/ or Drug Abuse

2

□ Genetic Testing

□ Sexually Transmitted Diseases (STDs)

This information is to be disclosed to: ____________________________________________________________________

__________________________________________________________________________________________________

I understand there may be a charge for copying my records as provided under federal and state law.

I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in

reliance on this authorization. Unless otherwise revoked in writing, this authorization will expire 60 dates from the date of

execution. A photocopy or FAX of this document is valid as the original.

The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for

disclosures of the above information to the extent indicated and authorized herein:

Signature of Patient or Legal Representative_________________________________________Date_________________

Witness:_____________________________________________________________________ Date _________________

The patient information requested above may not be further disclosed to any party under any circumstances except with the

patient's express written consent or as otherwise permitted by law. The information may not be used except for the need

specified above. (form updated 2/11/10)

1 Except psychotherapy notes as provided under federal and state laws.

2 PROHIBITION ON REDISCLOSURE: This information has been disclosed from records whose confidentiality is protected by federal and state law.

Federal Regulation (42 CFR Part2) prohibit the receiver of these records from making any further disclosure of this information except with the specific written consent of the person who it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose.

Brandon Family Medical Care

P.O. Box 2637

Brandon, FL 33509-2637

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What can be charged for medical records pursuant to

Florida Administrative Code?

64B8-10.003 Costs of Reproducing Medical Records

• (1) Any person licensed pursuant to Chapter 458, F.S., required to release copies of patient

medical records may condition such release upon payment by the requesting party of the

reasonable costs of reproducing the records.

• (2) For patients and government entities, the reasonable costs of reproducing copies of

written or typed documents of reports shall not be more than the following:

• (a) For the first 25 pages, the cost shall be $1.00 per page.

• (b) For each page in excess of 25 pages, the cost shall be 25 cents.

• (3) For other entities, the reasonable costs of reproducing copies of written or typed

documents or reports shall not be more than $1.00 per page.

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY

PRACTICES & PERMISSION TO SHARE HEALTH INFORMATION

I have read Brandon Family Medical Care Notice of Privacy Practices Act. I understand that I

may have a copy upon request.

Patient Name: _______________________________________

DOB: ___________________

Signature: __________________________________________

Date: ___________________

NOTIFICATION OF FAMILY AND FRIENDS

I hereby authorize Brandon Family Medical Care to disclose my health information to the

following person(s):

1) ________________________________________________________________________

2) ________________________________________________________________________

3) ________________________________________________________________________

4) ________________________________________________________________________

Signature: _____________________________________________________________________

RESTRICTIONS ON THE USE & DISCLOSURE OF YOUR HEALTH

INFORMATION

As further described in the Brandon Family Medical Care Notice of Privacy Practice, I

understand that I may request certain restrictions on the use and disclosure of my health

information. I request the following restrictions. Brandon Family Medical Care is not required

to agree to my requests.

1) ________________________________________________________________________

2) ________________________________________________________________________

3) ________________________________________________________________________

Signature ______________________________________________________________________

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Referral Process Agreement

It is the responsibility of the patient to verify with his or her insurance company if the doctor or

radiology center is “In-Network” with their insurance plan before scheduling an appointment. Once

this information is confirmed by your insurance company, we will need the following information to

move forward with obtaining your Authorization.

Specialist Doctors Office's:

Doctor Name

Phone #

Date & Time of Appointment

Diagnosis & Procedure Codes (if this is a follow up appointment only)

Radiology Centers:

Facility Name & Location

Phone #

Date and time of Appointment

Diagnosis (if ordered by another doctor's office only)

Brandon Family Medical Care requires (7) Business Days to process your referral requests. If the

above Required information and the allotted time of (7) days are not allowed, you may be required to

reschedule your appointment with the specialist/radiology center.

_________________________________________________________________________________

I have read and understand my responsibility to provide the required information needed to process my

referral request. Any appointments scheduled will comply with the 7 day time frame needed to process

the referral request.

___________________________ _______________________ _______________ ___________

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