New Patient Form

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Emergency Contact

Insurance Information

Please provide your Insurance Card to the Receptionist

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.

CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTH CARE OPTIONS

I consent to the use or disclosure of my protected health information by Digestive Disease Associates of Central FL for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to the conduct health care operations of Digestive Disease Associates of Central FL. I understand that diagnoses or treatment of me by Digestive Disease Associates of Central FL may be conditioned upon my consent as evidenced by my signature on this document.

My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearing house. This protected health information relates to my past, present or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review the Digestive Disease Associates of Central; FL Notice of Privacy Practices prior to signing this document. The Digestive Disease Associates of Central FL Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Digestive Disease Associates of Central FL The Notice of Privacy Practices for Digestive Disease Associates of Central FL is also provided at 2050 ASHLEY OAKS CIR STE 102, Wesley Chapel, FL 33544. This Notice of Privacy Practices also describes my rights and duties of Digestive Disease Associates of Central FL with respect to my protected health information. Digestive Disease Associates of Central FL reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

Lifetime Authorization: By signing below I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carries, or to the billing agent or this physician or supplier, any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to myself or to the party who accepts assignment. The original authorization will be kept on file by the Digestive Disease Associates of Central FL.

I may obtain a revised Notice of Privacy Practices by requesting in writing from the Digestive Disease Associates of Central FL or asking for one at the time of my next appointment.

Financial Responsibility

I understand that the insurance billing is a services provided as a courtesy and that I am all times financially responsible of the Digestive Disease Associates of Central FL (DDACF) and or its affiliated entities for any charges not covered by healthcare benefits. It is my responsibility to notify DDACF of any changes in my healthcare coverage. In some cases exact insurance benefits cannot be determined by DDACF and/or my healthcare insurer if the submitted claims or any part of them are denied of payment. I understand that by signing this form that I am accepting financial responsibility as explained above for all payment for medical services and/or supplies received.

Assignment of Benefits

I authorized direct remittance of payment of all insurance benefit Medicare, if I am a beneficiary, to Digestive Disease Associates of Central FL (DDACF) for all covered medical services and supplies provided to me during all courses of treatment and care provided by DDACF and/or its affiliated entities or otherwise at its direction. I understand and agree this Assignment of benefits will constitute a continuing authorization, maintained on file with DDACF, which will authorized and allow for direct payment to DDACF of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies, and/or care provided to me by DDACF.

Ownership Disclosure

I understand that the Digestive Disease Associates of Central FL is a physician-owned medical practice comprised of specialty care gastroenterology and ambulatory surgery center services. During the course of my care, I may be not obligated to receive these departments. I have the right to choose where to receive these services. I understand I am not obligated to receive these services at Digestive Disease Associates of Central Florida department.

ACKNOWLEDGEMENT RECEIPT

Notice of Privacy Practices

I acknowledge that I have received a copy of Digestive Disease Associates of Central FL's Notice of Privacy, which describes how DDACF will use and protect my health information. This Notice describes my right under the Health Insurance Portability and Accountability ACT (HIPAA) and DDACF's policies on use and disclosure of my protected health information.

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.

DDACF Consent for Treatment, Payment and Health Care Operations

PATIENT QUESTIONNAIRE

Personal History

System Review (Please check those that apply to you)

Family History

Please mark the applicable items for each family member(s)

Social History

CANCELLATION/MISSED APPOINTMENT POLICY FOR OFFICE APPOINTMENTS

Due to the increased number of missed and/or canceled office appointments, the office has found it necessary to charge a $25.00 fee if 24 hours' notice is not given. This will be due prior to rescheduling your appointment.

CANCELLATION/MISSED APPOINTMENT POLICY FOR PROCEDURES

Due to the increased number of missed and/or canceled procedure appointments, the office has found it necessary to charge a $50.00 fee if 48 hours is not given. This will be due prior to rescheduling your appointment.

It is of the utmost importance that you cancel and/or reschedule with the procedure scheduler.

ACKNOWLEDGE OF RECEIPT

I acknowledge that I have read and understand Digestive Disease Associates of Central Florida's cancellation and/or missed procedure policy.

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 Communication/Learner Assessment

1. Can we leave messages regarding your health?

Below, please list the individuals that you would like to have access to your health information and which information you would like them to have access to:

AT ANY TIME, you may revoke the right you have given the individuals listed below.

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In accordance with the health information privacy Act passed on April 14, 2003, you must sign below to have the practices listed above take place.

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.

*Note: If these records contain any information from previous or information about HIV/AIDS status. Cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.

I release Digestive Disease Associates of Central Florida from any laws related to the disclosure of confidential or privileged information. I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment; receive payment; or eligibility for benefits unless allowed by law. By signing below, I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

Thank you for your consideration and prompt attention regarding my medical records.

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.

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