Patient Health Questionnaire - dukethrush.comdukethrush.com/mgsfl/images/Primary Care New Patient...

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Patient Health QuestionnaireName: ________________________________ Age: _________________ Date of Birth: ____________________________

Address: ______________________________ City/State: _____________ Zip: ___________________________________

Second Address: ______________________________ City/State: _____________ Zip: ____________________________

SS#: _______________________________

Work Phone:___________________ Email: ________________________________ Marital Status:

Emergency Contact’s Name: ___________________________ Emergency Contac

Your Occupation: ___________________ Employer: ___________________

Insurance Company: _________________________ Policy # ______________ Group

Insured Name: __________________ SS# ________________ Date of Birth: ___________ Employer: _________________

Insured Address: ____________________________________ City/State: _____________ Zip: ______________________

Do you have a co-pay? � Yes � No Do you have a deductible?

Secondary Insurance Company: ______________________ Policy # _______________ Group # _____________________

Insured Name: __________________ SS# ________________ Date of Birth: ___________ Employer: __________


Do you have a co-pay? � Yes � No Do you have a deductible?

Workman’s Compensation/PIP Insurance Information

Insurance Company: _______________________________ Policy # ______________ Claim # _______________

Adjuster’s Name: _________________________________

Do you have a deductible? � Yes � No Is this insuranc

Insured Name: __________________ SS# ________________ Date of Birth: ___________ Employer: ____________

Insured Address: ____________________________________ City/State: _____________

All Patients must complete this section

Chief Complaint: ______________________________________________________________________________________

_________________________________________________________________________

_____________________________________________________________________________________________________

Have you seen another physician for this condition?

Are you taking Nutritional supplements? � Yes

If yes, what vitamin supplements? _______________________________________________________________Date of Your Last Full Physical: ____/____/_____ Physician Name: _____________________Testing/Immunization Record: (Please circle all that apply)

EKG Chest X ray Breathing Test Lab Work Urine Rectal Sigmoidoscopy Colonoscopy

Tetanus shot: Date ____/____/_____

Pneumonia Vaccine: Date ____/____/____ Flu Shot: Date_____/_____/______

Are you interested in early prevention of med

living children: ________

Luis Ulloa, M. an Poncy, M.D. / Amir Lubarsky601 University niversity Blvd, Suite #201Jupiter, Florid er, Florida 33458Phone: (561) 6 e: (561) 627

www.mgsfl.com

Patient Health Questionnaire Name: ________________________________ Age: _________________ Date of Birth: ____________________________



SS#: _________________________________ Home Phone: ______________ Cell Phone: __________________________

Work Phone:___________________ Email: ________________________________ Marital Status:

Emergency Contact’s Name: ___________________________ Emergency Contact’s Number:________________________

Your Occupation: ___________________ Employer: ___________________

Insurance Information

Insurance Company: _________________________ Policy # ______________ Group # _____________________________

_________________ SS# ________________ Date of Birth: ___________ Employer: _________________


No Do you have a deductible? � Yes � No


Insured Name: __________________ SS# ________________ Date of Birth: ___________ Employer: __________


No Do you have a deductible? � Yes � No

Workman’s Compensation/PIP Insurance Information


Adjuster’s Name: _________________________________ Adjuster’s Phone # ___________________________

No Is this insurance in your name: � Yes � No If no, please fill out the next section


Insured Address: ____________________________________ City/State: _____________ Zip: __________________

All Patients must complete this section

Chief Complaint: ______________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Have you seen another physician for this condition? � Yes � No If yes, Physician Name: ____________________________

Health History

Yes � No

If yes, what vitamin supplements? _______________________________________________________________Date of Your Last Full Physical: ____/____/_____ Physician Name: _____________________Testing/Immunization Record: (Please circle all that apply)

ray Breathing Test Lab Work Urine Rectal Sigmoidoscopy Colonoscopy

Tetanus shot: Date ____/____/_____

Pneumonia Vaccine: Date ____/____/____ Flu Shot: Date_____/_____/______

Are you interested in early prevention of medical illness: � Yes � No Number of

Mo60JupPh

Patient Health Questionnaire Name: ________________________________ Age: _________________ Date of Birth: ____________________________



__ Home Phone: ______________ Cell Phone: __________________________

Work Phone:___________________ Email: ________________________________ Marital Status: � M � S � D � W

t’s Number:________________________

____________________________

_________________ SS# ________________ Date of Birth: ___________ Employer: _________________



Insured Name: __________________ SS# ________________ Date of Birth: ___________ Employer: ________________



___________________________

No If no, please fill out the next section


Zip: __________________

Chief Complaint: ______________________________________________________________________________________

____________________________

_____________________________________________________________________________________________________

No If yes, Physician Name: ____________________________

If yes, what vitamin supplements? _______________________________________________________________ Date of Your Last Full Physical: ____/____/_____ Physician Name: _____________________

ray Breathing Test Lab Work Urine Rectal Sigmoidoscopy Colonoscopy

Jupiter, Floridaa 3Phone: (561)

Avishai Mendelson, M.D. 4700 North Congress Ave., Suite #301 West Palm Beach, Florida 33437 Phone: (561) 721-6898 Fax: (855) 215-0151 Fax: (855) 346-7590

Luis Ulloa, M.DD. / Michelle Carrillo, M.D. Ronald Surowitz, D.O. 601 University B Blvd, Suite #202

33458 62277-7766

411 West Indiantown Road Jupiter, Florida 33458 Phone: (561) 746-7826 Fax: (855) 495-0998 Fa

Morrggan Poncy, M.D. / Amir Lubarsky6011 UUniversity Blvd, Suite #201 Jupiitter, Florida 33458 Phoonne: (561) 627-2727

x:(855) 777-0163

www.mgsfl.com

If you are male: Do you examine your testicles monthly? Yes No

If you are female: Last PAP Date: ___/___/___

Last Mammogram Date: ____/____/____

Physician/Facility Performed By: _______________________________________

Number of pregnancies: _______ Number of Live Births:_______ Weight of largest baby at birth: ___ lbs ____ounces

Is it possible you are pregnant? � Yes � No

Please select all choices that apply to you

� Abdominal Pain � Bulimia � Fainting � Irritable Colon � PMS � Sickle Cell Anemia

� Allergies � Cancer � Kidney Disease � Polio � Sinus Trouble � Angina � Headaches

� Kidney Stones � Spinal Disc Disorder � Anorexia � Convulsions � Heart Disease

� Liver Disease � Prostate Disease � Stroke � Arthritis � High BP � Lung Disease

� Asthma � Dizziness � HIV/AIDS � MS � Scoliosis � Ulcer � Blood Disorder

� Osteoporosis � Breast Disorder � Sex Transmitted Diseases

� List any other Medical Condition: _________________________________________________

� List any medical conditions that run in your family____________________________________

� Do you live with someone other than yourself: _______________________________________

Patient Exercises: � Rarely � Moderately � Regularly � Never

Patient Smokes: � Current, How Many per day__ � Never � Former � If Former, How Long __Mths___Yrs

Patient uses alcohol: � Rarely � Moderately � Regularly � Never

Allergies: � Dust � Penicillin � Pollen � Sulfa Drugs � Dander � Dairy Products

� Latex � Perfumes � 2ndary Smoke � Eggs � Contrast Dye � Soaps � Meds

� Other ____________________________________________

Past Surgical/Hospitalization History

Type of Surgery/Cause of Hospitalization: ___________________________________________________

Date: ___________________________

Where:______________________Surgeon:__________________Complications:_____________________

Type of Surgery/Cause of Hospitalization: ___________________________________________________

Date: ____________________________

Where:______________________Surgeon:__________________Complications:_____________________

List all medications you are taking

Name/Dose: ___________________________________________________________________________

Name/Dose: ___________________________________________________________________________

Name/Dose: ___________________________________________________________________________

Name/Dose: ___________________________________________________________________________

Name/Dose: ___________________________________________________________________________

Name/Dose: ___________________________________________________________________________

Name/Dose: ___________________________________________________________________________

Pharmacy: ____________________________ Location: _____________________ Phone # _______________




33458 62277-7766



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Avishai Mendelson, M.D. Luis Ulloa, M.D. / Michelle Carrillo, M.D. Ronald Surowitz, D.O. Morgan Poncy, M.D. / Amir Lubarsky 4700 North Congress Ave., Suite #301 601 University Blvd, Suite #202 411 West Indiantown Road 601 University Blvd, Suite #201 West Palm Beach, Florida 33437 Jupiter, Florida 33458 Jupiter, Florida 33458 Jupiter, Florida 33458 Phone: (561) 721-6898 Phone: (561) 627-7766 Phone: (561) 746-7826 Phone: (561) 627-2727 Fax: (561) 354-6460 Fax: (561) 691-4865 Fax: (561) 744-1970 Fax: (561) 627-4327

www.mgsfl.com

I understand and agree that insurance policies are an arrangement between my insurance carrier and myself.

This office will prepare and file all claims on my behalf to my insurance company. I authorize payment to be

paid directly to this office, which will be credited to my account upon receipt for any services furnished me by

the physician. I understand that my signature also authorizes release of medical information necessary to pay

the claim. This assignment of benefits will remain in effect until revoked by me in writing. A photocopy of this

assignment is to be considered as valid as an original. I understand that all services rendered to me are

charged directly to me and I am personally responsible for payment if my insurance company refuses to pay

the claims in a timely manner (45 days from initial filing shall be considered a timely manner).

All bills that you receive will say The Medical Group of South Florida, Inc. If you have any questions

regarding this, please call our billing department 561-622-1975.

Patient’s Name __________________________________________________

Patient’s Signature _______________________________________________ Date ____/____/_____

Guardian’s Name ________________________________________________

Guardian’s Signature _____________________________________________Date ____/____/_____

www.mgsfl.com

CONSENT FOR RX HUB INQUIRY

I hereby provide my consent for The Medical Group of South Florida to obtain my Rx history

using the SureScripts-RxHub network. I understand that this inquiry will provide my physician

with an accounting of my medication history reported by Pharmacy Benefit Managers and

retail pharmacies. I also understand that Sure Scripts-Rx Hub has certified that Rx History

Capture follows strict security protocols to align with HIPAA requirements and respect patient

privacy. All queries and responses are made automatically through secure system-to-system

communications.

Signature:______________________________________ Date:______ /______ /_____

Print Name:____________________________________ Date of Birth:_____/____ /______

AUTHORIZATION FOR OTHER DISCLOSURES OF HEALTH INFORMATION

By signing below, you are authorizing additional use and disclosure of your health information. We may not deny you treatment if you refuse to grant this requested Authorization.

I authorize The Medical Group of South Florida to use or disclose my health information to

Health Awareness, Inc. (“HAI”) for the purpose of determining my eligibility, availability, and

qualification to participate in one or more clinical trial and research studies conducted or

sponsored by HAI. My health information will not be used for any purpose other than an initial

determination of qualification to participate in the HAI study or studies unless and until I have

been contacted by HAI and expressly agreed to participate in one or more of the HAI

programs.

Print Name: _______________________________ Birthdate: _________________________

Signature: __________________________ SS#:_____________________ Date: __________




33458 62277-7766



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NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I

have certain rights to privacy regarding my protected health information. I understand that this

information can and will be used to:

1. Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who

may involve in that treatment directly and indirectly.

2. Obtain payment from third-party payers. 3. Conduct normal healthcare operations such as quality assessments and physician certifications.

Upon request, I can receive and read your Notice of Privacy Practices containing a more complete

description of the uses and disclosures of my health information. I understand that this

organization has the right to change its Notice of Privacy Practices from time to time and that I

may contact The Medical Group of South Florida at any time to obtain a current copy of the

Notice of Privacy Practices. If you request copies of your clinical records, we will charge you

$1.00 for each page up to 25 pages and $.25 for each page after 25 and any postage.

I understand that I may request in writing that you restrict how my private information is used or

disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but you do agree then you are bound to abide by

such restrictions.

Patient Name____________________________________________________________

Relationship to Patient____________________________________________________

Signature _______________________________________________________________

Date____________________________________________________________________

OFFICE USE ONLY I attempted to obtain the patient’s signature in acknowledgement of this Notice of Privacy Practices

Acknowledgement, but was unable to do so as documented below.

Date_______________________________Initials_______________________________

Reason _________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________




33458 62277-7766



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Medical Records Release Authorization

Patient Name: ________________________ Patient’s Date of Birth: ___/___/____ Doctor/Hospital: ____________________________________________________________ Address: _____________________________________________________________________ ____________________________________________________________________________

Authorization: I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV),behavioral or mental health services, or treatment for alcohol and drug abuse.

I understand authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or obtain copies of the information to be used or disclosed, as provided in 45 CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information I can contact the appropriate office below.

Patient’s Name: _________________________________ Date: ________________________

Patient’s Signature: __________________________________

Signature of Guardian Relationship to Patient (if minor):______________________________

Witness to above Signature. Please print name: ______________________________________

Note: Under HIPPA guidelines you can be charged a reasonable fee for coping records. $1.00 per page up to 25

pages and .25 cents after 25 pages. HIPPA allows up to 30 days for a provider to respond to your request for

records, with one 30-day extension for good reason.

___ 601 University Blvd, Suite #201 Jupiter, Florida 33458

(561) 627-2727

(561) 627-7766

(561) 746-7826

___ 601 University Blvd, Suite #202 Jupiter, Florida 33458

___ 411 West Indiantown Rd Jupiter, Florida 33458

___ 4700 N. Congress Suite # 301, West Palm Beach, Florida 33407

Thank you in advance for your prompt consideration.

(561) 721-6898

___ 601 University Blvd, Suite #104, Jupiter, FL 33458 (561) 694-1771




33458 62277-7766



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.lvd,3458

We, at The Medical Group of South Florida, INC.

help you understand our policies, please read this agreement. If there is anything you do not understand,

please clarify with our staff prior to signing.

I understand and agree that:

• I am financially responsible for all professional services rendered to me.

• These services are payable at the time of service

As a courtesy, our office will file your insurance if proper information is received. Please be aware that

you are responsible for:

• Payment of your co-pay, coinsurance, and / or deductible at the time of the visit.

• Follow up with your insurance carrier on unpaid claims over 60 days.

• Unpaid claims over 60 days will be your responsibility to pay the balance in full

IT IS YOUR RESPONSIBILITY TO NOTIFY US OF ANY NEW INSURANCE OR ADDRESS

CHANGES.

A Service fee will be applied to your account for the reasons listed below:

• There is a $5.00 fee each time we bill you for unpaid balances, after the first statement.

• There is a $25.00 fee for each

to cancel.

• There is a $32.00fee for checks returned from the bank.

• There is a $25.00 fee if your account is sent to a collection agency, in addition to, but not

limited to, postage, court fee

Your cooperation with our office policies is appreciated.

I authorize The Medical Group of South Florida, INC.

• Submit Medicare or other insurance claims using my signature on file below.

• Be paid directly for medical services described on the claim form by the practitioner

indicated.

• Release medical records when necessary to authorized physicians and hospitals.

• Consent to Medically Treat

_______________________________

Patient’s or guarantors signature

Your signature acknowledges that you understand this agreement.

Luis Ulloa, M. an Poncy, M.D. / Amir Lubarsky601 University niversity Blvd, Suite #201Jupiter, Florid er, Florida 33458Phone: (561) 6 e: (561) 627

www.mgsfl.com

Financial Agreement

The Medical Group of South Florida, INC., appreciate the opportunity to be of service to you. To


please clarify with our staff prior to signing.

lly responsible for all professional services rendered to me.

These services are payable at the time of service.

, our office will file your insurance if proper information is received. Please be aware that

pay, coinsurance, and / or deductible at the time of the visit.

Follow up with your insurance carrier on unpaid claims over 60 days.

Unpaid claims over 60 days will be your responsibility to pay the balance in full

Y TO NOTIFY US OF ANY NEW INSURANCE OR ADDRESS

A Service fee will be applied to your account for the reasons listed below:

There is a $5.00 fee each time we bill you for unpaid balances, after the first statement.

There is a $25.00 fee for each missed appointment. Please give us 24 hour notice if you need

There is a $32.00fee for checks returned from the bank.

There is a $25.00 fee if your account is sent to a collection agency, in addition to, but not

limited to, postage, court fees, attorney fees, interest, and collection agency fees

Your cooperation with our office policies is appreciated.

PATIENT AUTHORIZATION

The Medical Group of South Florida, INC. to:

Submit Medicare or other insurance claims using my signature on file below.

Be paid directly for medical services described on the claim form by the practitioner

Release medical records when necessary to authorized physicians and hospitals.

onsent to Medically Treat

_______________________________ __________________________ ____________

Patient’s or guarantors signature Parent/guardian if minor


Mo60JupPh

, appreciate the opportunity to be of service to you. To


, our office will file your insurance if proper information is received. Please be aware that

pay, coinsurance, and / or deductible at the time of the visit.

Unpaid claims over 60 days will be your responsibility to pay the balance in full.

Y TO NOTIFY US OF ANY NEW INSURANCE OR ADDRESS

There is a $5.00 fee each time we bill you for unpaid balances, after the first statement.

missed appointment. Please give us 24 hour notice if you need

There is a $25.00 fee if your account is sent to a collection agency, in addition to, but not

s, attorney fees, interest, and collection agency fees.

Submit Medicare or other insurance claims using my signature on file below.

Be paid directly for medical services described on the claim form by the practitioner

Release medical records when necessary to authorized physicians and hospitals.

____________

Date





33458 62277-7766



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www.mgsfl.com

FORBEARANCE AGREEMENT

In exchange for medical treatment and the agreement to not require immediate payment for medical services provided to me, I hereby authorize and direct my attorney to pay directly to The Medical Group of South Florida (hereinafter referred to as “Healthcare Provider”) all sums due and owing for any and all services rendered by Healthcare Provider, or any balance thereof, including, but not limited to, medical services rendered, reports made or duplicated, depositions given, or time spent as an expert witness in this case. Payment shall be made at Healthcare Provider’s address above. I authorize my attorney to withhold such sums from any insurance settlement, judgment, verdict or other source as may be necessary to adequately protect Healthcare Provider. I hereby further give a lien to Healthcare Provider for all funds owing to me from my case by way of insurance payments, judgment, verdict or other source which may be paid to my attorney or myself.

I fully understand that I am personally and directly responsible to Healthcare Provider for all medical bills submitted for services rendered to me. I further understand that this agreement is made solely for the additional protection of Healthcare Provider and in consideration of Healthcare Provider awaiting payment. I understand that nothing herein releases me of the primary responsibility and obligation of paying Healthcare Provider in full for services rendered. I further understand that my obligation of payment is not contingent on any settlement, judgment or verdict. I also understand that the agreement applies to Healthcare Provider when that entity is used in conjunction with any medical and/or diagnostic procedure.

I agree to keep Healthcare Provider apprised of the name and address of all attorneys who represent me. Notification of any such changes must be made to Healthcare Provider within ten (10) days of the date I retain said attorney. I also understand that if my attorney does not wish to cooperate in protecting Healthcare Provider’s balance, then Healthcare Provider will not await payment but will require me to pay my account on a current basis.

In the event any dispute arises as to the charge for any services rendered by Healthcare Provider, I hereby authorize and direct my attorney to withhold the full sum claimed by Healthcare Provider, until said time as the matter is settled by compromise, settlement or judgment. I also agree that I shall be responsible to Healthcare Provider for all attorneys’ fees and costs related to the resolution or litigation of any dispute arising hereunder, and I agree the proper venue for such action shall be Palm Beach County, Florida. By my signature below I have read and understand the terms of this agreement and have been notified of the fees associated with my procedure or I will request such information as treatment is needed. I fully understand that even if I change attorneys, my contract with The Medical Group of South Florida is legally binding and I instruct my new attorney to honor this agreement.

Patient Signature: _________________________ Date: ______/______/______

The undersigned, being the attorney of record for the above patient, does hereby agree to observe all the terms of the above and agrees to withhold such sums from any insurance payment, settlement, judgment or verdict as may be necessary to adequately protect Healthcare Provider. If I receive money paid on this case, then I agree to hold all sums due and owing to Healthcare Provider. If a dispute arises, payout will be made only upon agreement of all parties or a court order. I agree that all sums will be due and payable within thirty (30) days from the resolution of the subject litigation relating to my client.

In addition, I further agree that any and all charges for medical reports, review of records, independent medical evaluations, deposition, expert testimony and photocopying are not charges payable on a contingent basis and that I am fully responsible for these charges. These charges shall be paid to Healthcare Provider regardless of the outcome of the litigation and even if there is no recovery or funds obtained from a third party to pay for these services.

I agree to notify Healthcare Provider in writing within ten (10) days if the above named patient changes his/her status as my client and I am no longer attorney of record. I also agree that I shall be responsible to Healthcare Provider for all attorneys’ fees and costs of collection in the event I fail to protect the Healthcare Provider’s balance out of any settlement proceeds received on the Patient’s case. I agree that any action brought on account of any matter set forth above may be brought in the Circuit Court in Palm Beach County, Florida and I agree that the service of process at any location shall confer jurisdiction on such court.

Attorney Signature: _______________________ Date: ____/_____/______




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Notice of Emergency Medical Condition

The undersigned licensed medical provider, hereby affirms:

The below injured patient, has in the opinion of this medical provider, suffered an Emergency Medical

Condition, as a result of the patients injuries sustained in an automobile accident that occurred on

___/___/_____, as defined in F.S. 395.002.

A. “Emergency Medical Condition” means (i) a medical condition manifesting itself by acute

symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a

prudent layperson who possesses an average knowledge of health and medicine, could reasonably

expect that the absence of immediate medical attention could reasonably be expected to result in any of

the following: (A) serious jeopardy to the health of a patient, including a pregnant women or fetus; (B)

serious impairment to bodily functions; (C) serious dysfunction of any bodily organ or part; (ii) with

respect to a pregnant women: (A) that there is inadequate time to effect safe transfer to another hospital

prior to delivery; (B) that a transfer may pose a threat to the health and safety of the patient or fetus; (C)

that there is evidence of the onset and persistence of uterine contractions or rupture of membranes. (see s. 395.002, F.S.).

B. “Emergency Services” or “Emergency Services and Care” means medical screening,

examination and evaluation by a physician or, to the extent permitted by applicable laws, by other

appropriate personnel under the supervision of a physician, to determine whether an emergency medical

condition exists. If an emergency medical condition exists, emergency services and care includes the

care or treatment that is necessary to relieve or eliminate the emergency medical condition within the service capability of the facility.

I hereby attest that I am a physician licensed under chapter 458 or chapter 459, a dentist licensed under

chapter 456, a physician assistant licensed under 458 or chapter 459, or an advanced registered nurse

practitioner licensed under chapter 464, and the above facts are true and correct.

Physician Name: _______________________ Signature: _________________________

Date: _____/_____/_____

The undersigned injured person or legal guardian of such person affirms:

1. The symptoms I reported to the medical provider are true and accurate.

2. I understand the medical provider has determined I sustained an Emergency Medical Condition as aresult of the injuries I suffered in the car accident, as defined in F.S. 395.002.

Patient Name: _______________________ Signature: _________________________

Date: _____/_____/_____




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PATIENT CONSENT TO FILE CLAIMS TO MEDICAL INSURANCE

WHEN PIP INSURANCE EXHAUSTED

My medical insurance carrier is: _______________________________________

By signing this consent I give The Medical Group of South Florida authorization to file any unpaid

claims after my Personal Injury Protection (PIP) has been exhausted to my medical insurance carrier.

I understand that in filing claims to my medical insurance I will be responsible for the following:

(1) Any co-payments as set by my insurance carrier

(2) Any unsatisfied deductibles

(3) Any amount my insurance carrier deems my responsibility

(4) Any amount considered non-covered by my insurance carrier

(5) Termination of coverage

TMGSF cannot guarantee that any particular service will be a covered benefit nor can TMGSF guarantee that your insurance carrier will pay for all services. All payments are regulated by our contract with each insurance carrier and any patient responsibility is determined by the patient’s insurance carrier.

□ I HAVE READ THE ABOVE INFORMATION AND AGREE TO BE FINANCIALLY

RESPONSIBILITY FOR ANY AND ALL SERVICES RENDERED BY TMGSF.

□ I DECLINE THE OFFER TO HAVE MY BALANCES FILED TO MY MEDICAL

INSURANCE CARRIER.

Patient Name Patient Signature

Date: ____/_____/______




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APPLICATION FOR FLORIDA “NO FAULT” BENEFITS

NAME OF INSURANCE COMPANY

DATE OUR POLICY HOLDER DATE OF ACCIDENT FILE NUMBER

TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE FLORIDA PERSONAL INJURY PROTECTION LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE

COMPANY MAKES A STATEMENT OF CLAIM CONTAINING ANY FALSE INCOMPLETE OR MISLEADING

INFORMATION, IS GUILTY OF A FELONY OF THE THIRD DEGREE.

YOUR NAME PHONE NO.

HOME BUSINESS

YOUR ADDRESS (NO, STREET, CITY OR TOWN, STATE AND ZIP CODE) DATE OF BIRTH SOCIAL SECURITY NO.

PERMANENT ADDRESS, IF DIFFERENT HOW LONG HAVE YOU LIVED IN FLORIDA?

DATE AND TIME OF ACCIDENT PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE)

BRIEF DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED:

DESCRIBE MOTOR VEHICLE YOU OWN - DESCRIBE MOTOR VEHICLE OWNED BY ANY MEMBER OF YOUR FAMILY-

AS A RESULT OF THIS ACCIDENT, WERE YOU INJURED? IF YOUR ANSWER IS YES, COMPLETE THE REST OF THIS FORM. IF NO, SIGN HERE AND

RETURN THIS FORM TO US.

SIGNATURE: DATE: DESCRIBE YOUR INJURY

WERE YOU TREATED BY A DOCTOR?

DOCTOR'S NAME AND ADDRESS

IF YOU WERE TREATED IN A HOSPITAL, WERE YOU AN IN PATIENT ____ OUT PATIENT _____

HOSPITAL'S NAME AND ADDRESS

AMOUNT OF MEDICAL BILLS TO DATE WILL YOU HAVE MORE MEDICAL EXPENSE?

AT THE TIME OF YOUR ACCIDENT, WERE YOU IN THE COURSE OF YOUR EMPLOYMENT?

DID YOU LOSE WAGES OR SALARY AS A RESULT OF YOUR INJURY? IF YES, AMOUNT OF LOSS TO DATE WHAT IS YOUR AVERAGE WEEKLY WAGE OR SALARY?

IF YOU LOST WAGES: DATE DISABILITY FROM WORK BEGAN DATE YOU RETURNED TO WORK

HAVE YOU RECEIVED, OR ARE YOU ELIGIBLE FOR, PAYMENTS UNDER ANY WORKMEN'S COMPENSATION OR EMPLOYMENT LAW?

IF YES, AMOUNT PER WEEK PER MONTH

LIST NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYER(S) AND GIVE YOUR OCCUPATION AND DATES OF EMPLOYMENT FOR EACH

EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO



AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? SIGNATURE: DATE:

IF YES, EXPLAIN ON REVERSE SIDE

IMPORTANT: 1. TO BE ELIGIBLE FOR BENEFITS COMPLETE AND SIGN THIS APPLICATION 2. SIGN AND ATTACH AUTHORIZATION(S) 3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE

OFFICE OF

Bureau of Property & Casualty Forms and Rates

Standard Disclosure and Acknowledgement Form

Personal Injury Protection

The undersigned insured person (or guardian of such person) affirms:

1. The services or treatment set forth below were actually rendered.

2. I have the right and the duty to confirm that the services have already been provided.

3. I was not solicited by any person to seek any services from

4. The medical provider has explained the services to me for which payment is being claimed.

5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in t

insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

Name (PRINT or TYPE)

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and

A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal

Injury Protection benefits.

B. The treatment or services rendered were explained to the insured person, or his or her guardian,

informed consent.

C. The accompanying statement or bill is properly completed

This means that each request for information has been responded to

D. The coding of procedures on the accompanying statement or bill is proper. This means that

constitutes an invalid or not medically necessary diagnostic test

627.736(5)(b)6, Florida Statutes.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable

Name (PRINT or TYPE)

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or anapplication containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section817.234(1)(b), Florida Statutes.

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and maynot be electronically furnished. Failure to furnish this form may result in nonOIR-B1-1571

Pub. 1/2004

FFICE OF INSURANCE REGULATION

Bureau of Property & Casualty Forms and Rates

Standard Disclosure and Acknowledgement Form

Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

actually rendered. This means that those services have already been provided.

that the services have already been provided.

by any person to seek any services from the medical provider of the services described above.

the services to me for which payment is being claimed.

If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle

insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

Signature

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and

or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal

The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with

properly completed in all material provisions and all relevant information has been provided therein.

n has been responded to truthfully, accurately, and in a substantially complete

The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled

medically necessary diagnostic test as defined by Section 627.732(14) and (15), Florida Statutes or Section

Services or Medical Director, if applicable (Signature by his/ her

Signature

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or anapplication containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and maynot be electronically furnished. Failure to furnish this form may result in non-payment of the claim.

already been provided.

the medical provider of the services described above.

he amounts paid by my motor vehicle

Date

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal

for that person to sign this form with

in all material provisions and all relevant information has been provided therein.

substantially complete manner.

no service has been upcoded, unbundled, or

as defined by Section 627.732(14) and (15), Florida Statutes or Section

her own hand):

Date

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may payment of the claim.

HIPAA COMPLAINT AUTHORIZATION FOR THE RELEASE OF

PATIENT INFORMATION

(PURSUANT TO 45 CFR 164.508)

Patient Name ______________________________ Date of Birth ____/_____/_______

I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with legal claim. I expressly request the designated record custodian of information including under HIPAA indentified above disclose full and complete protected medical information including the following:

o All medical records, meaning full disclosure, but not limited to: office notes, face sheets, history andphysical, consults, treatments, and test results.

o All outside consults, physical, occupational and rehab request and record receive by other medicalproviders.

o All pharmacy/prescription records. All billing records.

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.

I hereby authorize The Medical Group of South Florida, INC. to disclose my medicine records as stated above to:

Name: __________________________________ Relationship: ____________________

Name: __________________________________ Relationship: ____________________

I understand the following: See CFR § 164.508(c)(2)(i-iii)

a. I have a right to revoke this authorization in writing at any time, except to the extent information hasbeen released in reliance upon this authorization.

b. The information released in response to this authorization may be re-disclosed to other parties.c. My treatment or payment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.

_______________________________________________ ________________ Signature of Patient or Legally Authorized Representative Date

__________________________________________________________ __________ Name and Relationship of Legally Authorized Representative to Patient Date

Witness: _______________________ Date: ______________

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