New Patient Form

Please complete to the best of your ability, completing these forms will help save time during the check-in process, all information is encrypted.

Name / Nombre:

Date of Birth / Fecha de nacimiento:

Marital Status / Estado civil:

Single / Soltero Married / Casado Divorced / Divorciado Widowed / Viudo Domestic Partnership / Asociación doméstica

SS#:

Address / Direccion:

City / Ciudad:

State / Estado:

Zip code / Codigo postal:

Phone / Telefono: (HM)

(WK):

(CEL):

Email:

Do you have a Living Will? / Usted tiene un testamento vital?

Yes / Si No / No

Employer / Empleador:

Occupation / Ocupacion:

Work Address / Direccion del Trabajo:

Referred By / Referido Por:

Emergency Contact / Contacto de emergencia

Name / Nombre:

Relationship / Relación:

Telephone number / Número de teléfono:

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

DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Usted acepta que su firma electrónica es el equivalente legal de su firma manual en esta solicitud.

Signature / Firma:

What medications are you taking now? / Que medicamentos esta tomando ahora?

Allergies / Alergias?

I authorize the release of any medical records or other information necessary to process my medical claims. I request payment of medical benefits to the physicians mentioned below, who accepts assignment. / Yo autorizo la entrega de mi historia clinica u otra informacion necesaria para procesar mis reclamaciones medicas. Yo pido se Ie pague directamente a los medicos abajo indicados por los servicios recibidos como su paciente.

SIGN ONLY IF YOU AGREE / FIRME SOLAMENTE SI ESTA DE ACUERDO

PRIME CARE OF CORAL GABLES, P.A. (OR) CLINICAL RESEARCH OF SOUTH FLORIDA

Patient / Guardian signature / Firma del Paciente o Guardian:

I hereby (agree) (do not agree) to have my blood drawn in this office with an administrative fee of $20.00 not covered by my insurance carrier. / Yo (estoy de acuerdo) (no estoy de acuerdo) en que me hagan analisis de sangre en esta oficina con el cargo administrativo de $20.00 que no cubre mi seguro medico.

agree / estoy de acuerdo do not agree / no estoy de acuerdo

Patient / Guardian signature / Firma del Paciente o Guardian:

Appointment cancellation / Cargo de cancelacion

I am aware that a $40.00 fee will be applied if an appointment is not cancelled at least 24 hours in advance. / Estoy consciente de que un cargo de $40.00 sera aplicado a mi cuenta si mi cita no es cancelada con 24 horas de anticipacion.

Patient / Guardian signature / Firma del Paciente o Guardian:

REF: Medical Malpractice Insurance

Under Florida Law, Physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice.

YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE

This is permitted under Florida Law subject to certain conditions. Florida imposes penalties against noninsurance physicians who fail to satisfy adverse judgement arising from claims of medical malpractice. This notice is provided pursuant to Florida Law.

This document must be signed before you initiate or continue treatment under our care.

Thank You,

I, (Name), have read this document and acknowledge and understand its contents.

Name:

Patient's Signature:

Date:

Print Name:

PATIENT CONSENT DISCLOSURE OF HEALTH INFORMATION

Patient's Name:

Patient Date of Birth:

Patient's SS #:

Notice to Patient

By signing this form, you grant consent to use and disclose your protected health care information for the purpose of treatment, various activities associated with payment, healthcare operations and to allow Clinical Research of South Florida to screen your chart for possible research studies under your physician supervision. Our notice of Privacy Practices provides more details on our treatment, payment activities and health care operations. If there is not a copy of the Notice accompanying this consent form, please ask for one. We encourage you to read it since it provides details on how information about you may be used and / or disclosed and describes certain rights you have health care information.

As stated in our Notice of Privacy Practices, we reserve the right to change our privacy practices. If we should do so, we will issue a revised notice. Since revisions may apply to your health care information, you have a right to receive a copy by contacting our Privacy Officer.

You have the right to revoke your Consent by giving written notice to our Privacy Officer. The revocation will not affect actions that were already taken in reliance upon Consent. You should also understand that if you revoke this Consent we may decline to treat you.

You are entitled to a copy of this Consent Form after you have signed it.

I hereby authorize Prime Care of Coral Gables to use / disclose protected health information concerning the above named patient to: Clinical Research of South Florida

I (Name(s) of person or facility to which disclosure is to be made) have read the contents of this Consent Form and the Notice of Privacy Practices. I understand that I am giving you my consent to use and disclose my health information to carry out treatment, payment activities and health care operations.

(Name(s) of person or facility to which disclosure is to be made)

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

Patient's signature or Signature of Patient's Representative:

Date:

Print Name of Patient's Representative:

Relationship to Patient:

Our Privacy Officer may be contacted as follows:
Name of Privacy Officer: Gemma M. Aguilar. HB. CHA. CHP / Maria Rodriguez, RMA-CRT-CCRC

Practice Address: Prime Care of Coral Gables I Clinical Research of South Florida.
370 MINORCA AVE Coral Gables, FL 33134
Phone: (305)443-3001 / (305)445-5537 Fax (786)235-8575

Your information will be encrypted.