Patient Information Form

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Health Insurance Information


Emergency Contact Information



Medical History


Social History


Family History

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Financial Policy

We appreciate the confidence that you have expressed in selecting Barbara Rosa Martinez M.D. LLC for your healthcare needs and we look forward to working with you. If you have any questions about our services, fees or other aspects of your care please feel free to discuss your concerns with us.

A payment for your office visit is required at the time of service for:

1. Patients without insurance.
2. Patients with private insurance.
3. Patients who are not covered by one of our contracted insurance plans.
4. Patients who do not provide us with contracted insurance information.
(We must have a copy of your current insurance card on file.)


Any service that is rendered by this office that is not a covered benefit of our insurance policy is your responsibility to pay.

Our staff will assist you in dealing with your insurance company, but it is your responsibility to know and understand your own insurance policy. It is our sincere hope that this policy will be helpful and reduce any confusion or misunderstanding at a later date.


I understand the above policy and acknowledge that I am financially responsible for services rendered.


Releasing Information/Patient Rights and Acknowledgement of Receipt of Notice of Privacy Practices

The Department of Health and Human Services Has established a "Privacy Rule" to help Insure that personal health care Information is protected for privacy and Is only to be used or shared in the minimum necessary fashion. Healthcare providers are to obtain their patient's consent for uses and disclosure of health Information about the patient to carry out treatment, payment, or health care operations. By signing this consent, you understand that your physician may need to provide necessary medical information to other appropriate physicians, pharmacies, hospitals, insurance companies, laboratories, and billing agencies. Refusing to consent to the use or disclosure of your personal health Information prohibits the doctor from billing for their services; scheduling your care at a hospital, or calling in a prescription to a pharmacy, or medical need. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your personal health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke any actions that have already been taken which relied on this or a previo1.1sly signed consent.

If you have any objections to this form, please ask to speak with our Office Manager.

Patient Consent for use and disclosure of Protected Health Information as required and/or permitted by law.

And I also acknowledge that I have been provided with the "Notice of Privacy Practices"

And I also acknowledge that I have been provided with the "Notice Of Privacy Practices"


Compliance Assurance Notification for Our Patient's

The misuse of PHI has been identified as a national problem causing Inconvenience, aggravation, and money. We want you to know that all of our employees, managers, and doctors continually undergo training so that they may understand and comply with government regulations regarding HIPAA with particular emphasis on the "Privacy Rule". We strive to achieve the very highest standards of ethics and Integrity in performing service for our patients. It Is our policy to properly determine appropriate use of PHI In accordance with the government rules, laws, and regulations. We want to ensure that our practice never contributes in any way to the growing problem of Improper disclosure of PHI. As part of this plan, we have Implemented a Compliance Program that we believe will help us prevent any Inappropriate use of PHI. We also know that we are not perfect! Because of this fact, our policy Is to listen to our employees and our patients without any thought of penalization If they feel that an event In any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.


Patient Request for Confidential Communications of Protected Health Information

The Health Insurance Portability Act of 1996 ("HIPAA") provides you the right to request that PRIMEHEALTH PHYSICIANS., (PHP) communicate with you about your health Information at an alternative address or phone number, or by an alternative means (for example, by email) that is more confidential f9r you. PHP must accommodate your request If it is reasonable. PHP may require you to specify an alternative address or another method of contact before providing the requested accommodation. If your request is accepted, the Medical Center will make every attempt to communicate with you in the manner you have requested. Your election will remain in effect until you have instructed us in writing to change the manner of communication.

To request confidential communications, please complete the form below.

I am requesting that PRIMEHEALTH PHYSICIANS., communicate with me by an alternative means or at an alternative address or phone number that is more confidential for me. I understand that the Medical Center will not accommodate unreasonable requests.

REMINDER: If the alternative address selected by a patient is an e-mail, then E-Mail Consent Form MUST be completed.


E-Mail Consent Form

Purpose: This form Is used to obtain our consent to communicate with you by email regarding your Protected Health Information (PHI).

PRIMEHEALTH PHYSICIANS., (PHP) offers patients the opportunity to communicate by e-mail. Transmitting patient information by e­mail has a number of risks that patients should consider before granting consent to use e-mail for these purposes. PHP will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, PHP cannot guarantee the security and confidentiality of email communication and will not be liable for inadvertent disclosure of confidential information.

Patient's Acknowledgment and Agreement

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication of e-mail between PHP and me and consent to the conditions outlined herein. Any questions I may have had were answered.

I agree and consent that PHP may communicate with me regarding my protected health Information by e-mail.


Starting June 1st, 2016, there is a charge for not showing up for scheduled appointments. $25.00 per appointments canceled without a 24-hour notice. Repeated cancellations or missed appointment will result in loss of future appointment privileges.


$20.00 to have the blood drawn in the office.

$1.00 per page not exceeding $25.00 for Medical Records/Lab Results

$25.00 for Insurance Paperwork or Forms to be filled out.



ePresctibing is a way for doctors to send electronically an accurate, error-free, and understandable prescription from the doctor's office to the pharmacy. The ePrescribe Program also includes:

• Formulary and benefits transactions - Gives the healthcare provider information about which drugs are covered by your drug benefit plan.
• Fill status notification - Allows the health care provider to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled.
• Medication History Transaction - Provides the health care provider with information about your current and past prescriptions. This allows healthcare providers to be better informed about potential medication issues and to use that information to Improve safety and quality. Medication history data can indicate compliance with prescribed regimens, therapeutic Interventions, drug-drug and drug-allergy Interactions, adverse drug reactions, and duplicative therapy.

The medication history information would include medications prescribed by your health care provider at PrimeHealth Physicians, LLC as well as other healthcare providers involved in your care and may include sensitive information Including, but not limited to medications related to mental health conditions, venereal diseases/sexually transmitted diseases, abortion(s), rape/sexual assault, substance (drug and alcohol) abuse, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and, other sensitive health information.


By signing this consent form you are agreeing that your provider at PrimeHealth Physicians, LLC may request and use your prescription medication history from other healthcare providers and/or third-party pharmacy benefit payors for treatment purposes.

You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it.

This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but If you do, it will not have any effect on any action taken prior to receiving the revocation.

Understanding all of the above, I hereby provide Informed consent to PrimeHealth Physicians, LLC to enroll me in this ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.



I hereby acknowledge that I have received or have been given the opportunity to receive a copy of PrimeHealth Physicians, LLC Notice of Privacy Practices. By signing below I am ''only" giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices.

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