WHO IS FINANCIALLY RESPONSIBLE FOR THIS PATIENT
POLICY HOLDER INFORMATION (if different from Patient).
Emergency Contact (Parent/Guardian if patient is a minor)
PLEASE HAVE YOUR INSURANCE CARD AND DRIVER'S LICENSE READY FOR THE RECEPTIONIST. PAYMENT FOR PROFESSIONAL SERVICES IS DUE AND PAYABLE WHEN SERVICE IS RENDERED.
The undersigned hereby consents to evaluation or treatment the assigned healthcare provider may deem necessary to the patient name above
I hereby authorize my insurance benefits to be paid directly to Divaker Pediatrics. I understand and agree that, regardless of my insurance status, I am ultimately responsible for my account balance for any professional services rendered.
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.
I understand that the terms of any Advance Directive that I have executed will be followed by the health care facility and my care givers to the extent permitted by law. Please check one of the following statements:
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.
The doctor will keep this record in your medical file or your child's medical file. They will record what vaccine was given, when the vaccine was given, the name of the company that made the vaccine, the vaccine's special lot number and the signature and title of the person who gave the vaccine.
"I have been provided a copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Material(s) and have read, or have had explained to me, information about the diseases and the vaccines listed below. I have had a chance to ask questions and they were answered to my satisfaction. I understand the benefits and risks of the vaccines cited, and ask that the vaccine(s) listed below be given to me or the person named below (for whom I am authorized to make this request)."
Information about Person to Receive Vaccine
Signature of Person to Receive Vaccine or Authorized to Make the Request (Parent or Guardian)
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.
Please complete the following information for all requests
I hereby request the following regarding the use of my PERSONAL HEALTH 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.
By signing this Written Acknowledgement, I hereby expressly acknowledge my receipt of Divaker Pediatrics Notice of Patient Privacy Practices.
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.
Acknowledgement NOT obtained because:
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.
By signing this Authorization, I hereby authorize and permit the use and/or disclosure of my protected health information (medical record) for the limited purposes, and in the limited manner, described in this form. In addition, I understand that this Authorization is completely voluntary and I am signing it under my own free will and I have the right to revoke this authorization.
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.
Persons/organizations receiving this information: (Complete w/Address)
Divaker Pediatrics
6551 N Orange Blossom Trail, Ste 229, Mount Dora, FL 32757
352-383-8384 (Phone) 678-553-0329 (Fax)
Dr. Rezia Divaker
The following items must be initialed to be included in the use or disclosure of other health information
1. Divaker Pediatrics must complete the following:
2. The patient or the patient's representative must read and initial the following statements:
The patient or the patient's representative must read and initial the following statements:
I understand that this authorization will expire (Please choose 1 of the 3 options below):
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.
YOU MAY REFUSE TO SIGN THIS AUTHORIZATION
Your information will be encrypted.