Mobile Unit Intake Form

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Mobile Event Information

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PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

INSURANCE COMPANY – INCLUDING MEDICAID

Assignment and Release

I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to process this claim.

HEALTH HISTORY

FAMILY HISTORY

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform the doctors at the next appointment without fail. 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.

Notice of Privacy Practices/Patient Rights and Responsibilities

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this organization’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I also understand that the Patient Rights and Responsibilities are available for my review and that I have responsibilities regarding my care. I understand that:

  • I have the right to review this organization’s Notice of Privacy Practices prior to signing this acknowledgement;
  • I have the right to review the Patient Rights and Responsibilities prior to signing this acknowledgement;
  • This organization reserves the right to change these documents and that these documents are available to me upon request at my next visit, and on the organizations web site: www.pancarefl.org.

Consent for Treatment

I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated physicians, dentists, ARNPs, physician assistants and other medical personnel to administer examinations and treatments as deemed medically necessary.

Release of Medical/Dental Information

It is the provider's responsibility to ensure that the provider-patient relationship is confidential. Under the requirements of the Health Insurance Portability and Accountability Act (HIPAA), we are not allowed to release any patient information without the patient's consent. If you wish to have your medical/dental or billing information released to a family member, friend, or legal representative, you must sign this form. Signing this form will give consent to release this information to only the persons indicated below. This consent form will not allow PanCare Health to release any other information to these persons. You have the right to revoke this consent in writing.

I authorize/allow PanCare Health to release my medical/dental and/or billing information to the following individual(s):

Acknowledgement

I have initialed the Notice of Privacy Practices/Patient Rights and Responsibilities and Consent for Treatment. By doing so I acknowledge that I have read all of the aforementioned statements and will abide by the same and if I do not this may disqualify me from receiving care from PanCare Health/Dental Clinic. 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.

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