New Patient Forms

Date

Last Name:

First Name:

Middle Name:

Permanent Address:

City:

State:

Zip:

Preferred Phone Number:

Home Cell Work

Add Additional Phone Number

Email address

Birthdate:

Social Security Number:

Responsible Party (if other than the patient)

Name:

Relation:

Phone Number:

Address:

City:

State:

Zip:

EMPLOYER INFORMATION

Name of Employer:

Phone Number:

Occupation:

PREFERRED PHARMACY:

(It's very important that you supply us with this information; we use ePrescribe)

Name:

Phone Number:

Who referred you to us?

MEDIATIONS:

No Medications

Add Medication

INSURANCE INFORMATION

Insurance:

Claims Address:

City:

State:

Zip:

Phone Number:

ID #:

Group #:

Policy Holder Name:

Policyholder Birthdate:

Social Security Number:

Does your insurance require referrals?

Yes No

This part of the medical record is strictly confidential. It will not be released to any other person or entity without your written authorization

PAST MEDICAL HISTORY

If other, specify:

SURGICAL HISTORY:

If other, specify:

ALLERGIES

No Allergies

Penicillin

Tape

Sulfa

Latex

Tetracycline

Iodine

Other:

FAMILY HISTORY

Unknown Family History

Please limit to parents, grandparents, and siblings.

Add new row

SOCIAL HISTORY:

None

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Colonoscopy

Date of Procedure

Endoscopy

Date of Procedure

Stress Test

Date of Procedure

Pap Smear

Date of Procedure

Mammogram

Date of Procedure

Bone Density

Date of Procedure

Physical

Date of Procedure

Flu Vaccine

Date of Procedure

Pneumonia Vaccine

Date of Procedure

Gardasil Vaccine (HPV)

Date of Procedure

Zostavax Vaccine (Shingles)

Date of Procedure

MENSTRUAL HISTORY:

In Menopause

Age of Menopause

Age of first period:

First day of last period:

Number of bleeding days:

Between periods:

Flow:

Light Medium Heavy

PREGNANCY HISTORY:

NONE

Please complete as throughly as possible

Miscarriages

Number

Year(s)

Abortions

Number

Year(s)

Type of Delivery:

Add new row

Reason for your Visit today:

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

Signature:

Date:

Name:

Summary of Privacy Practices

A copy of the complete "Notice of Privacy Practices" is available upon request or by calling 561.324.7224

OUR PRIVACY PRACTICES

In the course of providing healthcare services to you, we may use and disclose your protected health information to carry out treatment, to pursue payment, for health care operations at our facilities and for other purposes that are permitted or required by law. "Protected health Information" is Information about you, including demographic information, that may identify you and that relates to you past, present, or future physical or mental. health or condition and related health care service.

Some of the ways that we may use your information cold include the following:

Appointment Reminders
To Discuss Treatment Alternatives
Health-Related Benefits and Services
Fundraising Activities
Hospital Directory
Individuals Involved in a Patient's Care o Payment for a Patient's Care
Clinical trial sAs Required By Law
To Avert a Serious Threat to Health or Safety

In the following special situations, we may also be required to use or disclose your health information:

Organ and Tissue Donation
Military and Veterans Workers' Compensation
Public Health Risks
Health Oversight Activities
Lawsuits and DisputesLaw Enforcement
Coroners, Medical Examiners and Funeral Director
National Security and Intelligence Activities
Inmates

Castillo & Torres MD PA works closely with CNTD RESEARCH to provide comprehensive care to our patients. Demographic and medical information may be shared with CMD Research to make our patients aware of new treatments or services that may impact their health. Other uses and disclosures of medical information not covered by our Notice of Privacy Practices or the laws that apply to us will be made only with a patient's written permission.

Patient Rights

Patients have the following rights regarding medical information maintained by Castillo & Torres MD PA

Right of Request Restriction on who has access to information.
Right to Receive Confidential Communication
Right to inspect and Copy
Right to Amend
Right to an Accounting of Disclosures
Right to a Paper Copy of the Castillo & Torres MD PA Notice of Privacy Practices•
Right to File a Complaint

Patient will not be penalized for filing a complaint. Castillo & Torres MD PA is committed to protecting an Individual's rights under the Health Insurance Portability and Accountability Act (HIPAA) and at no point will require an individual to waive their right to file a complaint as a condition of the provision of treatment.

Important Contact Information

Castilo & Torres MD PA

Daylin Valdes, Privacy Officer

2328 S Congress Avenue, Suite 1E

Palm Springs, FL 33406

561.324.7224

U.S. Department of Health and Human Services (HHS),

Office for Civil Rights (OCR)

Volce Phone 404,562.7886

FAX 404.562.7881

http://www.hhs.gove/oc

By signing this form, I acknowledge that I have been made aware of the Castillo & Torres MD PA "Notice of Practices" and was offered a copy. I understand i am not required to sign this authorization.

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

Signature

Date:

Full Name

FINANCIAL POLICY

The following information is provided to make our financial policies clear and avid any possible misunderstandings concerning the payment of professionally services.

INSURANCE

Our practice participates in a variety of insurance plans. It is your responsibility to:

Bring in your Insurance Card to every visit
Be prepared to pay for any co-pays and deductibles that apply
Payment In full is due at the time of service for any medical care not covered by your insurance

SELF PAY PATIENTS

Payment for office bisits Is due at the time of service

REFERRALS

Please allow three (7) business days from date requested.

LAB FEES

Please be aware that lab fees for blood work and pathology (including PAP smears) are separate from our office charges and may be billed directly to you by the lab company.

Insurance coverage is complicated and each policy is different. If you have any questions about your insurance, we are happy to help you. However, details about your coverage must be directed to your insurance Company's member Service Department. Their number is usually found on the back of the insurance card.

ASSIGNMENT OF BENEFITS

I authorize payments of medical benefits to CASTILLO & TORRES MD PA practice for services rendered, I understand that I am responsible for all charges not covered by my medical insurance. In addition, I am responsible for any deductible, co-pay and co-insurance amounts.

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

Signature

Name

Date:

RELEASE OF INFORMATION:

MEDICAL RECORD RELBASEI authorize the release of any medical information necessary to process any insurance claim(s). 1 permit a copy of this authorization to be sued in place of the original.

The following person can have access to my medical information:

Name:

Relationship to Patient:

Do not leave me a message or release information to anyone. Speak directly with me before releasing medical information.

By signing this authorization, l understand that medical records results released may contain information related to HIV status, sexually transmitted diseases and other personal Information.

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

Signature

Date:

CONSENT FOR TREATMENT

I authorize request and consent for the performance of office procedures deemed necessary by the physician and their staff.

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

Signature

Date:

If the patient is less than 18 years of age

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

Signature of Parent ror Guardian

Relationship

Please be advised that some procedures require a specimen to go to the lab for analysis. These procedures include PAP smears and blood samples. Our office will not charge you for these services, The lab will bill on or your insurance directly.

AUTHORIZATION TO RELEASE MEDICAL RECORDS

PATIENT:

Name of Patient/Previous Names

Birth Date:

Social Security Number:

Street Address

City

State

Zip

AUTHORIZES MY CURRENT PHYSICIAN:

TO RELEASE PROTECTED HEALTH INFORMATION TO:

Physician Name

Physician Name/Self:

Dr. Luis Castillo/ Dr. Carmen Torress

Street Address

Street Address:

2328 S Congress Ave Ste 1E

City, State, Zip

City, State, Zip:

Palm Springs, FL 33406

TEL #: (561) 324-7224 | FAX #: (561) 225-1780

INFORMATION TO BE RELEASED:

I hereby authorize you to release all of my medical records for any treatment and laboratory/diagnostic tests performed except for information pertaining to:

Sexually transmitted disease

Treatment of alcohol or substance abuse

Records from other facilities/providers

Records from other facilities/providers Testing or treatment of HIV/AIDS

Communication between patient and psychotherapist for mental health treatment

For the Following Date(s): -

PURPOSES FOR NEED OF DISCLOSURE:

(select one)

Further Medical Care Insurance/Eligibility Ofter

If other, specify:

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:

I understand I must be provided with a signed copy of this authorization. I understand written notification is necessary to cancel this authorization and I may obtain information on how to withdraw my authorization by contacting the office of the above noted healthcare provider. I understand that Castillo & Torres MD PA will not be able to release my records to someone else without a signed authorization. IfI decide not to sign this form, Castilo & Tores MD PA will not refuse to continue treatment. By signing this authorization, I do expressly and voluntarily consent to the disclosure of the information checked above to the person/doctor/agency named above. I understand that if the person (3) and/or organization(s) listed above are not mandated by the federal privacy standards, the health information disclosed as a result of this authorization may be redisclosed without obtaining my authorization. I understand that I may be charged a fee for copying these medical records.

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

Signature Patient/Legal Rep:

(If signed by other than patient, state relationship and authority to do so)

Date:

EXPIRATION DATE: This authorization is good until the following date(s)or for six montes from the date signed.

Distribution of Copies: Original to provider;, copy to patient; copy to accompany released records.

Your information will be encrypted.