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Child Information Form

  • 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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  • Present Problems

  • 6) Has your child experienced any of the following?
  • School Information

  • 1) What schools has your child attended?
  • 3) Estimate grade average for each year of school:
  • 4) Has your child experienced any of the following problems in school?
  • 7) What are your child’s usual conduct grades?
  • Medical History

  • If yes, please list below
  • If Yes, please explain
  • 4) Has your child experienced any of the following?
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  • 5) Which childhood illnesses or diseases has your child had and at what age?
  • Developmental Information:

  • 5) Average delays in:
  • Personal Information:

  • Nutritional Information:

  • Family History

  • If yes, please explain:
  • 9) Has anyone in the immediate family (mother, father, grandparents, aunts/uncles, siblings, etc.) ever had any of the following problems?
  • (I, We) understand that this information will be used in the evaluation of (my, our) child and will be included in the child’s record. Our commitment to your privacy:Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding your child and the treatment and services we provide to him/her. We are required by law to maintain the confidentiality of health information that identifies you and your child. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your child’s PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
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  • CLICK HERE TO PRINT THIS FORM BEFORE SUBMITTING