New Patient Form

Patient Information

Date

Patient's Last Name

First Name

Middle Name

Suffix

Gender

M F Other

DOB

Race

Preferred Language

Mailing Address

City

State

Zip

Home Address

(Disregard if same address)

City

State

Zip

Home Ph #

Cell Ph #

Work Ph #

Email address

Emergency Ph #

WHO IS FINANCIALLY RESPONSIBLE FOR THIS PATIENT

Self Spouse Parent Other

Last Name

First Name

Middle Initial

SSN

DOB

Home Ph #

Cell Ph #

Work Ph #

Street Address

City

State

Zip

Employment Status (check one)

Full-Time Part-Time Retired

Retired Date

POLICY HOLDER INFORMATION (if different from Patient).

If same as responsible, please check here

Self Spouse Parent Other

Last Name

First Name

Middle Initial

SSN

DOB

Home Ph #

Cell Ph #

Work Ph #

Street Address

City

State

Zip

Employment Status (check one)

Full-Time Part-Time Retired

Retired Date

Emergency Contact (Parent/Guardian if patient is a minor)

Name

Relationship

Home Ph #

Cell Ph #

Work Ph #

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.

Consent for Evaluation or Treatment

The undersigned hereby consents to evaluation or treatment the assigned healthcare provider may deem necessary to the patient name above

Patient, Parent, Legal Guardian or Authorized Representative

Date

Insurance Assignment

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.

Patient's Signature

Date

Advanced Directive

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:

I have executed an Advance Directive (Living Will, Durable Power of Attorney, Designation of a Health Care Surrogate)

I HAVE NOT executed an Advance Directive

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's Signature

Date

Vaccine Administration Consent

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

Name

Signature of Person to Receive Vaccine or Authorized to Make the Request (Parent or Guardian)

Signature

Date

Name

Relationship

Communication Use and Disclosure Authorization

Please complete the following information for all requests

1. Today's date

2. Patient name

3. Date of Birth

4. Address

I hereby request the following regarding the use of my PERSONAL HEALTH INFORMATION:

You may leave the following messages on voicemail:

Referral Information Prescription refill information Test Results Other

If other, please specify.

You may discuss and/or give access to information regarding my treatment and care with the following family members and /or friends (name and phone number please)

You may contact me regarding my treatment and care at the following numbers

Signature of Patient or Guardian

Date

Signature of Staff Person

Name of Employee

Written Acknowledgement of Receipt of Divaker Pediatrics Notice of Patient Privacy Practices

By signing this Written Acknowledgement, I hereby expressly acknowledge my receipt of Divaker Pediatrics Notice of Patient Privacy Practices.

Patient or Legal Representative Signature

Printed Patient or Legal Representative Name

Relationship to Patient

Date

Acknowledgement NOT obtained because:

Patient, or legal representative, declined to accept Notice of Patient Privacy Practices

Patient received Notice of Patient Privacy Practices, but refused to sign Acknowledgement

Other

If other, please specify.

Employee Signature

Name of Employee

Date

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (MEDICAL RECORD)

Part A: Must be completed for ALL Authorizations

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.

Patient Name

Home Address

DOB

Previous physician providing the information: (Complete w/Address)

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

HIV/AIDS related health information and/or records.

Mental health information and/or records

Genetic testing information and/or records

Domestic violence information and/or records

Drug/alcohol diagnosis, treatment and /or referral information (Federal regulations require a description of how much and what kind of information is to be disclosed. Federal law prohibits the disclosure of such information.

Part B: Must be completed only if Divaker Pediatrics has requested the Authorization

1. Divaker Pediatrics must complete the following:

a. What is the purpose of the use or disclosure? (Check one.)

At the patient's (or the patient's representative's) request or direction. For marketing For fundraising Other

If other, please specify.

b. Will Divaker Pediatrics requesting the Authorization, receive financial compensation of any kind, directly or indirectly in exchange for using or disclosing the health information?

Yes No

2. The patient or the patient's representative must read and initial the following statements:

a. I understand that my health care and the payment for my health care will NOT be affected if I DO NOT sign this form.

b. I understand that I may see and copy the information described on this form if I ask for it and that I get a copy of this form after I sign it.

Part C: Must be completed for ALL Authorizations

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):

a. No expiration (permitted only for Authorizations used to create or maintain research databases or repositories.)

b. On

Initial

c. When the following event occurs

Initial

Signature

Of Patient or Patient's Representative (Form MUST be completed before signing)

Date

Name of Patient's Representative

Relationship to Patient

*Reason Authorization is signed by the Patient's Representative: (check one)

Minor Incompetent Other

If other, please explain.

YOU MAY REFUSE TO SIGN THIS AUTHORIZATION

Your information will be encrypted.