New Patient Form

Patient Demographics

Patient Name(Required)

Prefix First Middle Last

Date of Birth(Required)

Height/Weight(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone(Required)

Home Phone

Work Phone

Email(Required)

Appointment Confirmations Via(Required)

Home

Cell

Text

Do you give permission to our physicians/staff to leave messages on your answering machine/voicemail/text regarding your Personal Health Information (i.e. Test results, Etc.)?(Required)

yes

If so, what phone number?

Photo of Driver’s License or State ID(Required)

Max. file size: 100 MB.

Emergency Contact Name & Relationship to Patient(Required)

Emergency Contact Phone Number(Required)

Alternate Emergency Phone Number

Pharmacy Name(Required)

Pharmacy Phone Number(Required)

Pharmacy Address(Required)

Insurance Information

Insurance Plan Name:(Required)

Group number:(Required)

Member ID number:(Required)

Insurance Address/PO Box to submit medical claims:

Photo of Insurance Card (Front)(Required)

Max. file size: 100 MB.

Photo of Insurance Card (Back)(Required)

Max. file size: 100 MB.

Do you have a secondary insurance plan?(Required)

Yes

Secondary Insurance Plan Name:

Group number:

Member ID number:

Insurance Address/PO Box to submit medical claims:

Photo of Insurance Card (Front)

Max. file size: 100 MB.

Photo of Insurance Card (Back)

Max. file size: 100 MB.

Medical History

Primary Care Provider

Primary Care Provider Phone

Primary Care Provider Fax Number

Reason for the Visit(Required)

Past Medical History: Please check all that apply(Required)

Type of Cancer

Other (Medical Problem not listed)

Any Known Drug Allergies(Required)

Yes

Please list all Allergies(Required)

Please write "none" if applicable.

Current Medications(Required)

Please list all current medications (supplements) with your dosage. Please write "none" if applicable.

Surgical History(Required)

Please list all previous surgeries. Please write "none" if applicable.

Family Medical History(Required)

Please list the condition and relationship to the patient. Please write "none" if applicable.

Pregnancy History

No Prior Pregnancy

Total Pregnancies:

Miscarriages/Abortions

Vaginal Deliveries:

C-Sections:

Living Children:

Social History:

Currently using Tobacco Products?(Required)

Yes

If yes, quantity per day:

Do you exercise regularly?(Required)

Yes

If yes, how often?

Do you consume Coffee,Tea and/or Sodas?(Required)

Yes

If so, how much of each?

Do you consume Alcohol?(Required)

Yes

If so, amount:

Are you Sexually Active?(Required)

Yes

Marital Status

Healthcare Maintenance

Date (first day) of Last Menstrual Period:

Date of Last Mammogram:

Result (normal/abnormal):

Date of Last Pap smear:

Result (normal/abnormal):

Date of Last Bone Density:

Result (normal/abnormal):

Review of Symptoms

Please choose all that apply.

General:

Weight Gain

Weight loss

Fever

Chills

Problems Sleeping

Daytime sleepiness

Snoring

Psychiatric:

Depression

Anxiety

Memory problems

Psychosis/hallucinations

Neurological:

Mini Strokes

Strokes

Seizures

Fainting spells

Headaches

Dizziness

Cardiovascular:

Chest Pain

Shortness of breath

Heart Murmur

Palpitations

Swelling of the feet

Pulmonary:

Cough

Shortness of breath

Sodium production

Emphysema/COPD

Gastrointestinal:

Heartburn

Change of Appetite

Vomiting

Diarrhea

Constipation

Change in bowel habits

Black tarry stool

Rectal bleeding

Head/Neck:

Vision change

Ear infections

Sinus Infections

Trouble Swallowing

Impaired Hearing

Genitourinary:

Pain/Burning while urinating

Blood in urine

Hesitancy

Frequency/Urgency

Incontinence

Nighttime urinating

Musculoskeletal:

Arthritis

Muscle weakness

Frequent fractures

Osteoporosis

Joint stiffness

Skin:

Rashes

Jaundice

Cancer

Financial and Administrative Policies and Agreement Form

Thank you for choosing Florida Center for Urogynecology for your medical care. We value all our patients and strive to provide compassionate and expert care. Below, please see our financial and appointment policies. All policies listed are simply to assure quality care and accessibility to all our patients.

Insurance Information and Patient Financial Responsibility
Your health insurance is a contract between you and your insurer. Any charges not paid by your insurer for any reason, are your responsibility. It is your responsibility to understand your insurance benefits, including plan limitations, the difference between screening or preventive care benefits, diagnostic procedure benefits, and the need for referrals or pre-authorizations. We will bill your insurance for all services we provide; However, we require you pay any portion of your financial liability for care including but not limited to co-pays, deductibles, or co-insurance prior to any service. Certain services performed by our office for your benefit, may not be covered by your insurance plan(s); these will be your financial responsibility..

At the time of check-in, all co-payments and any outstanding balances must be paid unless previous arrangements have been made with our office. This includes both in-person and telemedicine visits. For your convenience, we accept cash, check or credit/debit cards. We run payments through a secure, HIPPA and PCI-compliant merchant services application. If you decide to use a credit/debit card, there will be a 3% service charge for any transaction. You may Zelle your payment to 954-256-4999, without additional fees, and please text us to notify us of your choice of Zelle or use cash to complete your transaction. If you have any questions, please call the office..

Patients without insurance coverage or coverage by an insurance in which the office does not participate with your account will be set up as “Self-Pay.” You may be given an estimate of “Self-Pay” cost prior to your visit, but this cost may change depending on the level of care and any procedures required during your visit..

Outstanding balance Policy
All past due accounts are contacted via statements, letter, and/or phone calls within accordance with our internal policy by our billing office. If resolution is not made after these attempts, the account will be sent to our collection’s agency..

Administrative Fees and Missed Appointment Fees
There is a $35.00 charge for returned checks for any reason. Failure to remedy the returned check may result in legal action. Missed appointments without 72 hours cancellation notice to the office, same day cancellations, or “no-shows”, will result in a fee. The charged fee will be $75.00 for pelvic floor rehabilitation appointments and for urodynamic testing appointments. For any other type of office appointment, the fee charged will be $50.00. Surgeries without one week’s cancellation notice, will result in a $250 fee. These fees will be charged to the credit card on file with our office. Our fee for the completion of medical forms is $25.00. There is a charge for copying medical records in accordance with state laws. Missed appointment fees are due prior to rescheduling your appointment..

For purposes of this agreement, the terms “I” and “my” refer to the patient or responsible party for such patient executing this agreement..

Insurance Information and Patient Financial Responsibility
I have read and understand the Florida Center for Urogynecology’s financial and administrative policies, and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.

I authorize payment of medical and/or surgical insurance benefits to proceed directly to Florida Center for Urogynecology. I understand I am responsible for any copayments, non-covered services, and any balances my insurance plan does not cover. In the event I do not meet my obligations, I will be responsible for collections costs, if any, including legal fees and allowed interest. I authorize Florida Center for Urogynecology to release any information acquired during my treatment necessary to process insurance claims. I authorize the physician/practitioner to initiate a complaint to the insurance company for any reason on my behalf.

If my insurance has changed, it is my responsibility to notify the Florida Center for Urogynecology. If I do not notify the Florida Center for Urogynecology of changes in my insurance, then I am responsible for any costs that occur for medical care or procedures that are not covered, or that were not authorized by my new insurance plan, with the Florida Center for Urogynecology under my new insurance plan or lapsed insurance. This includes any fees for visits, procedures, labs, imaging, or physical therapy.

I authorize Florida Center for Urogynecology, to use the payment information (debit/credit card) on file to charge for the applicable missed appointment fees and “patient-responsibility” balances under $300 as per the EOB from my insurance company. If there is no payment information on file, I understand that I will be billed for the applicable fee. Payments will not exceed my indebtedness to the practice. A photocopy of this assignment shall be considered as effective and valid as the original. I acknowledge that I have read, understand, and agree to the above policy statement regarding the fees for missed appointments.

Patient Name(Required)

First Last

Signature(Required)

Date(Required)

PATIENT AUTHORIZATION FOR USE AND DISCLOSURES OF PROTECTED HEALTH INFORMATION TO THIRD PARTIES

The Health Insurance Portability and Accountability Act (HIPAA) signed into law in 1996, protects the sensitive patient health information from being disclosed without the patient’s consent or knowledge. The Privacy Rule was created to protect your rights as a patient. Under the Privacy Rule you have access to your medical records, allowed control over how your protected health information is used and disclosed and allowed to act if your privacy is compromised by the practice’s policy. Our practice is dedicated to maintaining the privacy of your personal information. By completing this form, you are authorizing The Florida Center for Urogynecology to release any protected health information requested to the named person(s). This authorization is voluntary, and you may choose to revoke at any time by signing and dating the revocation of your copy of this form and returning it to this office.

Patient Name(Required)

First Last

Date of Birth(Required)

I authorize the Florida Center for Urogynecology to release any protected health information requested to any/or all the following:

Name of Person & Relationship to Patient

I authorize the Florida Center for Urogynecology to access any protected health information from the hospital electronic medical records available to my provider (Epic, etc) and to contact me about my health information using the indicated following:

Privacy Practices(Required)

I acknowledge that I was provided and have reviewed a copy of Florida Center for Urogynecology’s Notice of Privacy Practices.

To review a copy of the Florida Center for Urogynecology’s Notice of Privacy Practices please click here.

Patient Signature(Required)

CONSENT FOR PELVIC EXAMINATION AND TREATMENT

A Pelvic Examination is an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs. This procedure is used to diagnose and/or treat conditions that involve the pelvis. It may be performed using any combination of modalities, which may include the health care provider’s gloved hand or instrumentation. For purposes of this consent, vaginal sonography and pelvic floor rehabilitation therapy is included.

The Florida Center for Urogynecology and my treating health care provider, to treat my medical conditions and to perform pelvic examination and procedures. I understand that a pelvic examination may be needed while receiving medical care from The Florida Center for Urogynecology in the future, and I hereby agree and acknowledge that this written consent applies to any and all pelvic examinations conducted today, or in the future, by a health care provider with The Florida Center for Urogynecology unless I revoke this consent in writing by hand delivering a copy of the revocation to the practice. By my signature below I acknowledge, that I have read or have had read to me and understand the contents of this form.

Name(Required)

Date(Required)

Patient/Legal Representative Signature(Required)