Medical History Form

1. Patient Information / Informacion del Paciente

2. Insurance Information / Informacion de Seguro

3. Pharmacy Information / Informacion de Farmacia

4. Past Medical History / Historia Medica Previa

5. Family History / Historia Medica de Familia

6. Social History / Historia Medica Social

7. Allergies / Alergias

8. Medications (Current) / Medicamentos (Actuales)

Authorization and Request for Release of Medical Records

Office Policies

Office Hours: Monday - Friday | 7:00AM to 3:00PM

- I acknowledge that I have been candid in revealing any condition which may have an effect on my treatment, such as: medications, surgery, allergies, hormones, pregnancy or breastfeeding.

- I acknowledge that I will notify the office immediately with any changes in my medical condition such as pregnancy, medication, recent surgeries, or hospitalizations.

- I understand that any test results will be discussed with me at the time of my next visit, and not over the phone.

- I understand that is my responsibility to schedule a follow up appointment 1 week after any procedure, test or surgery.

- I understand that payments for services are due when the treatment is rendered. The office visit and any outstanding balance on the account are due and payable in full at the time of the visit.

- I understand that is my responsibility to bring the referral (if applicable) with me at the time of the visit. If we do not have a referral you may be asked to reschedule your appointment, or you may be ask to sign a waiver accepting full financial responsibility for the services you receive.

- I understand that I am responsible for all charges regardless of what the insurance company pays or designates as “usual and customary”.

- I understand that any balance that is older than 60 (sixty) days is subject to a 1.5 %( 18%/year) finance charge; regardless if the insurance company has paid. If for any reason you are unable to make payments, please contact our office manager to discuss your account. If it becomes necessary to seek legal means to collect on an overdue account, you will be billed for any legal services at the standard fee plus any court cost, plus any additional collection agency costs.

- I understand that returned checks are subject to a fee. Checks returned by the bank for any reason will be assessed a $30.00 processing fee per check. Payments for continued care will only be accepted in cash, money order or a valid credit card.

- I understand that broken appointments are subject to a fee of $30.00. If you are unable to keep an appointment, we ask you to kindly provide us with at least a 24hrs notice. This courtesy, on your part will make it possible to give your appointment to another patient.

- As a courtesy to others we reserve the right to reschedule your appointment if you are more than 15 minutes late, unless the physician schedule can still accommodate you.

- I understand that after 3 “no show” or 3 “rescheduled” appointments we will no longer be able to provide you with an appointment and you would need to seek care from another physician.

- I acknowledge that I have read, and that I fully understand the office policies.

Notice of Office Policy Change

- Due to the large number of same day appointment cancellations, and patients not showing on appointment date; we are forced to make the following change in our office Policy. Effective immediately, a $35.00 fee will be charged to you, if you miss or cancel with less than 24 hours notice your appointment more than once. Other appointments will not be issue unless this fee is paid.

- After 3 Consecutive No shows or cancelations you will automatically dismiss from the practice for non compliance with appointments.

In signing this form, I understand that I am responsible for the above mentioned charge for any missed or cancel within 24 hours more than once.

Aviso de cambio de política de la oficina

- Debido a la gran cantidad de cancelaciones de citas el mismo dia,y de pacientes que no atienden a sus citas; nos vemos obligados a hacer el siguiente cambio en nuestras regulaciones. Efectivo inmediatamente, un costo de $35.00 se le cobrara a Ud si omite o cancela con menos de 24 horas de antelacion su cita , más de una vez. Otra cita no se ofrecera a menos que este cargo sea pagado.

- Después de 3 pérdidas consecutivas o cancelaciones de citas usted será automáticamente expulsado de la practica debido al incumplimieto de sus citas medicas.

Al firmar este formulario, entiendo que soy responsable de los cargos ocasionados por citas canceladas o perdidas sin previo aviso y con menos de 24 Hrs. de notification a nuestra oficina.

I certify that the information provided above is complete and accurate to the best of my knowledge

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment . Payment or health care operations (TPO) and for other purposes that are permitted by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information , that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. 

1- Uses and Disclosures of Protected Health Information 

Your protected health information may be used and disclosed by your physician , our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law. 

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services . This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. 

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services, for example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. 

Healthcare Operations: We may use or disclose as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. 

We may use your protected health information in the following situations without your authorization. These situations include: as required by law; Public Health issues i.e. communicable Diseases, health oversight, abuse or neglect; Food and Drug Administration requirements; Legal proceedings; Law Enforcement, criminal activity, inmates; coroners, funeral Directors and organ donation; research; military cctivity; national Security; Workers' Compensation. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. 

Other Permitted and Required Uses and Disclosures will be made only with your consent, Authorization or Opportunity to object unless required by law. 

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization. 

2- Your Rights 

Following is a statement of your rights with respect to your protected health information. 

You have the right to inspect and copy your protected health information, under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. 

You have the right to request a restriction of your protected health information, this means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restrictions requested and to whom you want the restriction to apply to. 

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional. 

You have the right to request to receive confidential communications from us by alternative means or at an alternative location, you have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. 

You may have the right to have your physician amend your protected health information, if we deny your request for amendment, you have the right to file a statement of disagreement with us and we might prepare a rebuttal to your statement and will provide you with a copy of such rebuttal. 

You have the right to receive an accounting of certain disclosures we have made of your protected health information. 

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. 

3- Complaints 

You may voice/file a complain with our office or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by our office. You may voice/file a complain with our office by calling and speaking to the designated person at the time of your complain as the privacy contact. We will not retaliate against you for filing a complaint. 

This notice was published and becomes effective on/or before April 14, 2016. 

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any questions after reading this notice, please ask to speak with our HIPAA Compliance officer in person or by phone at our Main phone Number. 

I confirm that by signing below, I ackowledge receipt of the HIPAA Notice of Privacy Practices

Physician-Patient Arbitration Agreement

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by Florida law, and not by a lawsuit or resort to court process except as Florida law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All claims Must be Arbitrated:It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership and the employees, agents and estates of any of them, must be arbitrated, including without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect the assertion of any claim, against the physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law:A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such party's pro-rate share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in the arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court against such additional person or entity shall be stayed pending arbitration.

The parties agree that provision of Florida law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable Florida statue of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitration shall be governed by the Florida Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation This agreement may be revoked by written notice delivered to the physician within 30 days of signature and if not revoked will govern all medical services to the physician within 30 days of signature and if not revoked will govern all medical services received by the patient.

Article 6: Retroactive Effect: If the patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below.

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.