Financial/Office Policy Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida (813)

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Brandon Family Medical Care, P.A.

414 West Robertson Street

Brandon, Florida 33511

(813) 684-5255

B

Financial/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 attorneys office.

An Office visit is required for all forms that need addressed. Patient is responsible for

any financial fees, co pays and/or deductibles at the time of service. In addition, there

is a $30.00 minimum for all forms (FMLA, medical reports, physical forms,

disability forms or any special reports requested).

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.

There is a minimum of thirty business days to request medical record copies and sixty

business days for archived records.

A request for review of your medical record(s) requires an appointment with a

minimum of thirty-business days notice and sixty business days for archived records.

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. Saturday and Monday cancellations

must be done by close of business day on Friday.

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.

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Brandon

Family

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Brandon Family Medical Care, P.A.

414 West Robertson Street

Brandon, Florida 33511

(813) 684-5255

If the insurance requires a referral, it is the patients 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.

IF YOU HAVE HEALTH INSURANCE COVERAGE

* PHOTO ID REQUIRED

Claims will be submitted, however we must emphasize that as medical providers, the

relationship is with our patients, NOT the insurance companies. Although we attempt

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 and not a

guarantee of payment.

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

incurred are the patient’s responsibility.

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/Office Policy of

Brandon Family Medical Care and agree to meet all financial obligations.

I understand that this policy cannot be altered and if I do not agree with the office policy, I

understand that I will need to find another primary care physician.

_________________________ __________________________ _____

Print Name of Patient Patient/responsible party Date

Signature

_________________________

Responsible Party Print Name

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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY

PRACTICES & PERMISSION TO SHARE HEALTH INFORMATION

I have received a copy of the Brandon Family Medical Care Notice of Privacy Practices.

PRINT NAME__________________________________________________________

Signature______________________________________Date_____________________

NOTIFICATION OF FAMILY AND FRIENDS

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

following persons:

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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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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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: _________________________________ Date of Birth: _____________________________

Address:

_________________________________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

□ Consultation Reports

□ Radiology Reports

□ Discharge Summary

□ Progress Notes

□ Abstract/Pertinent Information

□ History & Physical Exam

□ Laboratory Tests

□ 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 Abuse²

□ 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 days 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 or 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)

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

²PROHIBITION ON REDISCLOSURE: This information ha 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.A.

414 West Robertson St.

Brandon, FL 33511

Phone: (813) 684-5255

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