Sacowimedical.com



931 Wekiva Springs Road, Longwood, FL 32779 Office (407)960-6075 Fax (888) 622-0903PATIENT REGISTRATIONPatient Last Name______________________ First Name_______________________ Middle Initial_____________ Address__________________________________________________City______________________________ State _________ Zip_________ Home Phone______________________Work Phone______________________ Cell Phone_______________________ SS# _______________________ Date of Birth______________Sex______ Marital Status__________Email________________________________________________Emergency Contact_______________________________Phone______________________INUSRANCE INFORMATIONPrimary InsuranceName_______________________________ Policy #_______________________ Phone__________________ Name of Insured____________________________________________ Relationship_____________________________ SS# _______________________________ Date of Birth_______________________ Employers Name___________________________ Phone_________________________________ Employers Address_____________________________ City __________________ State__________ Zip____________ Secondary Insurance Name_______________________________ Policy #_______________________ Phone__________________ Name of Insured____________________________________________ Relationship_____________________________ SS# ___________________________Date of Birth_______________________Employers Name___________________________ Phone_____________________________Employers Address__________________________City __________________ State__________Zip____________Referring Physician Name ________________________Phone______________________________ PCP Name____________________________________________Phone_________________________________ I hereby authorize the providers of Sacowi Medical Clinic to treat the patient identified above. I acknowledge that I am responsible to pay all charges for all treatments administered by the physician to the patient. I understand that insurance may not pay for all charges and I understand that I am obligated to pay for all charges not paid by insurance. I also agree to pay reasonable attorney fees if my account is turned over to an attorney or collection agency. Signature of Patient I Authorized Person __________________________ Date _____________ Assignment and Release: I hereby authorize my insurance benefits to be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. Signature of Patient I Authorized Person __________________________ Date _____________931 Wekiva Springs Road, Longwood, FL 32779 Office (407)960-6075 Fax (888) 622-0903AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAAPatient Name _________________________________ DOB __________ SSN______________________ PatientAddress_________________________________________________________________________I, or my authorize representative, request that health information regarding my care and treatment be released as set forth on this form: 1. This authorization may include disclosure of information relating to ALCOHOL AND DRUGS ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if the I place my initial on the appropriate line in Item 5. In the event the health information describe below includes any of these types of information, and I initial the line on the box in Item 5. I specifically authorize release of such information to the person (a) indicated in item 4. 2. If I am authorizing the HIV- RELATED, ALCOHOL OR DRUG TREATMENT FOR MENTAL HEALTH treatment, the recipient is prohibited from re-disclosing such information without my authorization unless permitted to do so under federal or state law. 3. I understand that signing this authorization is voluntary 4. Name and address of health provider or entity to release this information: __________________________________________________________________________________________________________________________________________________________________________5. Specific information to be released: ____Medical Record from (insert date) _________________ to (insert date) ______________ ____Entire Medical Record, including patient histories, office notes (except psychotherapy notes) test result, radiology studies, films, referral, consult, billing records, insurance records, insurance records, and records sent to you by health care providers. ___ Alcohol/ drug Treatment ___Special Diagnostic test results ___Lab-Res ___Emergency Visit ___ Mental Health Info ___Admission History & Physical ___HIV-RELATED-INFORMATION ___ Psychiatric Treatment ___X-Ray6. Authority to sign on behalf of patient: _________________________________Signature of patient or representative by law: ____________________ Date: ___________931 Wekiva Springs Road, Longwood, FL 32779Office (407)960-6075 Fax (888) 622-0903PLEASE READ AND ANSWER EACH QUESTION PATIENT HISTORY QUESTIONNAIREDate____________________ Patient Name_________________________Date of Birth__________Why are you seeing our provider today? _______________________________________________________________ List of other medical problems, if any____________________________________________________________________ __________________________________________________________________________________What medications (prescription/nonprescription) are you currently taking? Medicine/Herbals Dose (Strength) FrequencyList of Allergies to medications? ________________________________________________________________________ Have you been hospitalized in the past years? Yes_____ No______ If Yes Where When Why__________________________________________________________________________________________________________________________________________________________________________ Do you/did you ever smoke cigarettes? Yes___ No_____ How many packs a day _____ Do you/did you ever drink alcohol? Yes___ No____ lf yes, how often? Do you consider yourself an alcoholic? _______ Do you/did you ever use street drugs? Yes___ No____ lf yes, which ones? _________________________________ What is/was your occupation? ___________________________________________ Retired?______ Unemployed_____ FAMILY HISTORY:Father Living? Yes ___No___If no, causes of death? _____________________________________________ Mother Living? Yes___ No___ If no, cause of death? __________________________________________________ Any Siblings? Yes ____ No___ any major health issues? ______________________ Do you have any family history of diabetic/heart disease/stroke/High Blood Pressure? If yes, whom __________________________________________________________________________________________________________________________________________________________________________ Mental Health Stress a major problem for you? Yes____ No____If yes, explain_______________________________________ _____________________________________________________________________________________Do you panic when stressed? Yes______ No______ If yes, explain______________________________________ _____________________________________________________________________________________Do you have problems with eating or appetite? Yes_____ No______ If yes explain______________________________________________________________________________________________________________Have you ever had any thoughts of hurting yourself? Yes ____ No_____. If yes explain___________________________________________________________________________________________________________Do you have trouble sleeping? Yes____ No_______ If yes explain__________________________________________________________________________________________________________________________Have you ever seen by Mental Health Counselor? Yes_____ No_____ If yes, Whom___________________________________________________________________________________________________________________ 931 Wekiva Springs Road, Longwood, FL 32779 Office (407)960-6075 Fax (888) 622-0903PATIENT HIPAA QUESTIONNAIREPlease list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations):Please list the family members or significant others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY: Name_____________________________________ Phone _____________________________Name_____________________________________ Phone_____________________________Please print the address of where you would like your billing statements and/or correspondence from our office to be sent if other than your home.__________________________________________________________________________________________________________________________________________________________________________Please indicate if you want all correspondence from our office sent in a sealed envelope marked "CONFIDENTIAL": YES_________ NO_________ V. Please print the telephone number where you want to receive calls about your appointments, lab and x-ray results, or other health care information if other than your home phone number:( )_____________________ * I am fully aware that a cell phone is not a secure and private line. ** I am fully aware my health information can be transmitted by facsimile (fax), mail or the internet.VI. Can confidential messages (i.e., appointment reminders) be left on your home answering machine or voicemail? YES____NO___PATIENT NAME______________________________ PATIENT/GUARDIAN SIGNATURE______________________________DATE_________________931 Wekiva Springs Road, Longwood, FL 32779 Office (407)960-6075 Fax (888) 622-0903Acknowledgement of Receipt of Notice of Privacy PracticesYour name and signature on this sheet indicates that you have been given the opportunity to review and request copy of Sacowi Medical Clinic Notice of Privacy Practices (Notice) on the date indicated. If you have any questions regarding the information in Sacowi Medical Clinic Notice of Privacy Practice, Please do not hesitate to contact a Sacowi Medical Clinic representative.Patient Name (Printed):If Patient Representative, Name (Printed):Signature:Date Notice Received:931 Wekiva Springs Road, Longwood, FL 32779 Office (407)960-6075 Fax (888) 622-0903BROKEN APPOINTMENT POLICYEvery effort is made to keep on schedule so we respectfully ask patient to be prompt and keep their appointments. Our standards office policy regarding appointments is as follows:A courtesy call is made to contact patients the day before your appointment to confirm. DO NOT DEPEND ON THIS. If we are unable to reach you, your appointment card will serve as your confirmation of appointment and implies your obligation to be present. We reserve the right to charge for office visits canceled or broken without 24 hours advanced notice.We ask that you notify us of any cancellation at least 24 hours prior to your office appointment so that we may give your allocated time to another patient in need of medical care.The broken policy appointment charge will depend on your co-pays and office visit charge. These charges are allowed by your insurance company and considered as your responsibility.If you should have any questions about this policy, do not hesitate to ask to speak with office manager. We believe that good communication is the key to excellence in healthcare.Signature: _________________________ Date: _______________________ 931 Wekiva Springs Road, Longwood, FL 32779 Office (407)960-6075 Fax (888) 622-0903 Pharmacy & Email Information Form If you would like your pharmacy information to be kept on file, please complete the required information below. Patient Name: _______________________________Pharmacy Name: ____________________________________Pharmacy Address: __________________________________________________ Pharmacy Tel. # __________________**IF YOU WOULD LIKE TO ACCESS OUR PATIENT PORTAL PLEASE WRITE YOUR EMAIL ADRRESS: ____________________________________Please inform the office if there are any changes to the above information. ................
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