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Adult Information Form

  • IDENTIFYING INFORMATION

  • If yes, please note that you are responsible for requesting Superbills from your visits to allow you to file your own claim with your insurance company.
  • CONSENT TO TREATMENT

  • I HEREBY CONSENT TO EXAMINATION AND TREATMENT AS DEEMED NECESSARY BY PATRICIA A. HESS, M.D. I hereby request that payment of authorized benefits be made on my behalf and hereby assign the benefits payable for physician services to the physician if she chooses to accept the assignment. I hereby authorize Patricia A. Hess, M.D. PA to furnish Patient Health Information concerning my relevant medical history to any insurance company who will be paying the claim.
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  • PRIVACY NOTICE

  • In accordance with the Health Insurance Portability and Accountability Act, patients of Patricia A. Hess M.D. PA are entitled to and afforded the rights to privacy regarding their health-related information as set forth under applicable law. Patricia A. Hess M.D. PA will strive to ensure that patient information is used only for purposes authorized by the patient and as otherwise required by law. Upon request, we can provide you with a complete copy of our Privacy Policies. Additionally, Patients have a right to review their medical records and furnish comments to their records during normal business hours, upon providing reasonable advance notice.
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  • PRESCRIPTION HISTORY CONSENT

  • Agree that Patricia A. Hess, M.D. PA may request and use my prescription medication history from other healthcare providers and E-Forse (Florida's Prescription Drug Monitoring Program) for treatment purposes.
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  • GOOD FAITH ESTIMATE

  • Dr. Patricia Hess, MD PA
    Mailing Address: 2725 NW 38th St Gainesville FL 32605
    Email: info@patriciahessmd.com
    Phone: 352-224-5220
    NPI: 1669669826
    TIN: 273120009

    PRIMARY SERVICE - Virtual Outpatient Visit
    $315 - First Evaluation (99205-95) - 1 visit
    $190 - First Follow Up or visits needing 40 minutes (99214-95) - 1-3 visits annually, depending on need
    $125 - 20 Minute Follow Ups (99213-95) - 4-10 visits annually, depending on need
  • Office Policies

    1. I certify that all of the information listed on this form is true and correct.
    2. I understand that this is a fee for service, to be paid on the day of services rendered, a credit card must be obtained and kept on file for all charges.
    3. If unable to keep your appointment, please give 24 hours’ notice of cancellation, otherwise a no show fee of $150 for new patients and $50 for established patients will be charged the day of missed appointment.
    4. If this account is assigned to an attorney, collection agency, or small claims court, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collection.
    5. Any patient 10 minutes late for a scheduled appointment will be considered late and likely rescheduled and will be charged a $50 late fee unless there is another available appointment later the same day.
    6. I understand that I am financially responsible for all charges, whether or not paid by said insurance. I hereby authorize said assignee to release all information to secure payment.
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  • PRESENTING PROBLEM

  • As an outpatient (clinic, private, etc.)

  • As an inpatient (in a hospital, residential treatment center, etc)

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  • Medical History

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  • If Yes, please list below
  • If Yes, please list below
  • If Yes, please list below
  • If Yes, please list below
  • If Yes, please list below
  • Have you experienced difficulty with any of the following? (Please check all that apply.)

  • Pregnancy Information (if applicable)

    If premature, please give the number of weeks early.
  • Family Information

  • Family History

  • Who in your family has had:

  • I understand that this information will be used in my evaluation and will be included in my records.
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