NEW PT PACKET (English)

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Patient Registration Form

EMERGENCY CONTACTS

INSURANCE INFORMATION

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Health Questionnaire: Health History

Please indicate the symptoms you currently have/had in the past year:

Please tell us your family's health history:

Relation: Father
Relation: Mother
Relation: Brother/Sister

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Please tell us of any previous hospitalizations:

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Please tell us of any previous surgical histories:

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I understand that it is my responsibility to inform the physician if I have any changes in my health. By signing below, I agree that I have completed this new patient registration to the best of knowledge and as accurately as possible.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PATIENT CONSENT

Request for Care and Consent for Treatment

The undersigned consents to the medical care and treatment, as may be deemed necessary or advisable in the judgment of my physician or other provider, which may include but are not limited to laboratory procedures, X-ray examination, medical or surgical treatment or procedures or other services rendered to the patient under the general and special instructions of the the patient's physician. Gastro Florida has the right to refuse to treat you if you refuse to sign this consent or it, at any time, you choose to revoke this consent.

Permission for Treatment

Permission is hereby granted for physicians and employees or agents of Gastro Florida to render such medical and surgical treatment as is deemed necessary to the patient named below.

Assignment of Insurance Benefits

I authorize payment directly to Gastro Florida of any insurance benefits otherwise payable to me for services, at a rate not to exceed Gastro Florida regular charges for such services.

Authorization to Release Information

I authorize the release of medical records and related information from Gastro Florida to authorized representative of my third party payor or provider related to my care. I authorize review of records for any necessary agency audit and the release of the physician plan of care and discharge summary from my medical record upon my transfer to or from another health care facility.

Communication

By providing my email and phone number(s), I authorize Gastro Florida to provide me information regarding my appointment (e.g. visit reminder), billing status, and/or educational material that may be related to my condition(s), in addition, to periodically inform me of Gastro Florida services/community events and requesting feedback regarding my experience with Gastro Florida. I can opt out at any time by emailing service@gastrofl.com to make this request. I understand that emailing confidential information may not be a HIPAA compliant secure form of communication and that Gastro Florida does not monitor emails for specific patient care.

I authorize Gastro Florida to enroll me in its secured patient portal that may also include the above information along with my clinical test results and medications. I understand that I should not rely on the portal to communicate important or emergency information regarding my specific care.

I authorize Gastro Florida to include my patient survey or online review comments on its website or promotional material (note: your last name will not be used.)

The undersigned certifies that he/she has read the foregoing, received a copy thereof and is the patient or is duly authorized by the patient as patient's general agent to execute the above and accepts its terms.

HIPAA Consent

I understand that as part of my healthcare, Gastro Florida originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future treatment. I understand that this information serves as:

  • A basis for planning my care and treatment
  • A means for communication among health professionals who contribute to my care, such as referrals
  • A source of information for applying my diagnosis and treatment information to my bill
  • A means by which a third-party payer can verify that services billed were actually rendered
  • A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff.

Restrictions

Messages or Appointment Reminders

Notice of Privacy Practices

I acknowledge that I have been informed of Gastro Florida's Notice of Privacy Practices that provides a description of Protected Health Information use and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this statement. I understand that the Gastro Florida reserves the right to change its Notice of Privacy Practices that will be effective for health information Gastro Florida already has about me, as well as any they receive in the future. Gastro Florida will post a current copy of the Notice. I understand that I may obtain a copy of the current Notice in effect upon request. I have read all of the above and understand/agree to all the provisions therein regarding responsibility for payment, permission for treatment and Notice of Privacy Practices.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

OUR FINANCIAL POLICY

Thank you for choosing us as your health care provider. We are committed to the success of your treatment. Please understand that payment of your bill is considered to be part of your treatment arrangement. The following is our Financial Policy, which we require you to read prior to any treatment.

All patients must complete our Registration and History forms before seeing the doctor. You must supply us with both your insurance card and driver's license prior to your visit.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, AND ALL MAJOR CREDIT CARDS.

Statement of Financial Responsibility

I understand that I am responsible for the payment of this account, and hereby assume and guarantee prompt payment of all the expenses incurred.

Notice of "Non-Covered" Services

I am aware that some services performed by Gastro Florida may be considered "non-covered" by my insurance carrier or Medicare, therefore I will become fully responsible for payment of these services.

For patients with "Out-of-Network" coverage there is a Waiver of "Usual, Customary and Reasonable" Clause. I acknowledge that the fee charged by Gastro Florida for services rendered to me, or the person for whom I assume financial responsibility, may exceed the fee considered "usual, customary and reasonable", due to specialized services and staff. However, I agree to pay Gastro Florida fees in full, even if the amount is greater than what I am reimbursed from my insurance company.

Missed Appointments

Unless canceled at least 48 hours in advance, our policy is to charge for missed appointments. The current rate is $50.00.

Procedures

We will ask that you pay 100% of any outstanding deductible/co-insurance prior to your procedure. This is due no later than 3 days prior to your procedure. Any refunds due to you will be sent 7-10 days after you have incurred the refund.

Bill To/Payment Instructions

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I hereby authorize Gastro Florida to bill my insurance company and/or Medicare (indicated or initialed above) for services provided to me and request that payment for such services be made to Gastro Florida on my behalf.

List Names of Those Whom You Want Us to Share Your Financial Responsibility Information:

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Financial Agreement

The undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the service to be rendered to the patient, he/she obligates himself/herself to pay the account with Gastro Florida in accordance with the regular rates and terms of Gastro Florida. Should the account be referred to an outside agency or an attorney for collections, the undersigned agrees to pay reasonable collection and attorney fees for collection expenses.

Billing Questions

Please address all billing questions to our Central Business Office (727) 347-0005

Payment Plans

You can call our Central Business Office to determine if you qualify for this arrangement.

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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