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Patient Information Intake Form

  • PRIMARY INSURANCE

  • 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.
  • Date Format: MM slash DD slash YYYY
  • 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.
  • Date Format: MM slash DD slash YYYY
  • 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.
  • Date Format: MM slash DD slash YYYY
  • Office Policies of Patricia A. Hess, M.D. PA

    1. I certify that all of the information listed on this form is true and correct.
    2. I understand that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment.
    3. In order to control the cost of billing and accordingly, the cost of medical service, it is asked that payments be made at the time of service. All balances over sixty (60) days old, with no payment activity, will incur a $15 per month service charge. I understand this policy and agree to abide by the same.
    4. 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.
    5. 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.
    6. A credit card must be obtained and kept on file for all patients prior to first appointment and to be used for late or missed appointment fees. All fees will be charged to the card the day of missed or late appointment.
    7. 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.
    8. I hereby assign all medical benefits to which I am entitled, including private insurance and other health plans to Patricia A. Hess M.D. PA. This assignment will remain in effect until revoked by the patient in writing. A photocopy of this assignment is to be considered as valid as the original.
    9. 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.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
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