We are Happy to Announce

Transcription

1 Carlos R. Sarduy, MD Pablo E. Uribasterra, MD Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP We are Happy to Announce At Signature Women s Healthcare, we have been listening to your concerns and have been working hard to improve the care we provide you. As part of our commitment to you, we are proud to announce our new Patient Portal, a convenient way for you to interact and communicate with our office! As we continue in our efforts to provide you with the highest quality of care, we are constantly looking for methods of working together with you to ensure that you are not only aware of but also involved in the maintenance and improvement of your health. To that end, we are proud to announce that our practice now offers you the opportunity to use the power of the web to track all aspects of your health care through our office. The Patient Portal enables our patients to communicate with our practice easily, safely, and securely over the Internet. Patient Portal URL: Please take this opportunity to log in to our site and activate your account Only after activating your account will you be able to receive messages alerting you when your test results are available for viewing. Through the Patient Portal, you will be able to ask questions of doctors, nurses, and staff members request prescription refills and referrals set up appointments examine your current and past statements all from the comfort of your home, whenever it is convenient for you! By using the Patient Portal you no longer have to call the office, leave a message, and wait for a response to get the results of your lab work; those results will be available to you on the Portal. You no longer have to call with a question or concern; you can send a message to the office through the Portal and expect a prompt reply. Begin today to take an active role in managing your health care. 301 NW 179 th Avenue Suite 102 Pembroke Pines FL Phone: SignatureWHC.com Fax: swhptportal

2 By supplying my home phone number, mobile phone number, address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach & messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, balances due, lab results, or any other healthcare related function. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events and to leave a detailed message on my voice mail, answering system, or with another individual, if I am unavailable at the number provided by me. Signature: Date:

3 Al proporcionar mi número de teléfono, número de teléfono móvil, dirección de correo electrónico y cualquier otra información de contacto personal, autorizo a mi proveedor de atención médica a utilizar un sistema automatizado de mensajería y extensión para utilizar mi información personal, el nombre de mi proveedor de atención médica, la hora y el lugar de mi cita programada, y otra información limitada, con el propósito de notificarme de una cita pendiente, una cita perdida, un examen de bienestar vencida, saldos debidos, resultados de laboratorio o cualquier otra función relacionada con la atención médica. También autorizo a mi proveedor de atención médica a revelar a terceros, que pueden interceptar estos mensajes, información de salud protegida limitada con respecto a mis eventos de atención médica y dejar un mensaje detallado en mi correo de voz, contestador automático o con otra persona si no estoy disponible en el número proporcionado por mí. Firma: Fecha:

4 NEW PATIENT INFORMATION PRIMARY CARE DOCTOR: PCP # FAX # PATIENT NAME: BIRTHDATE: / / AGE: SOCIAL SECURITY # MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # CELLULAR # RELIGION: STREET ADDRESS: APT. # CITY: STATE: ZIP: PATIENT ADDRESS: DRIVER S LICENSE: DRIVER S LICENSE STATE: EMPLOYER/SCHOOL: TITLE: PHONE # STREET ADDRESS: CITY: STATE: ZIP: SPOUSE NAME: CONTACT TEL. # TRANSLATOR NEEDED ( ) YES ( ) NO PRIMARY LANGUAGE SPOKEN: REFERRED BY: ***************************************************************************************************************************************************************** EMERGENCY CONTACT NOT LIVING WITH YOU: NAME: PHONE # RELATIONSHIP: ADDRESS: CITY : STATE: ZIP: **************************************************************************************************************************************************************** IF PATIENT IS A MINOR, PLEASE COMPLETE THE FOLLOWING: MOTHER S NAME: EMPLOYED BY: PHONE # FATHER S NAME: EMPLOYED BY: PHONE # ****************************************************************************************************************************************************************************** PRIMARY INSURANCE INFORMATION: SECONDARY INSURANCE INRORMATION: INSURANCE CO. INSURANCE CO. ADDRESS: ADDRESS: CITY/STATE/ZIP: PHONE # I.D. # GRP # INSURED S NAME OR # CITY/STATE/ZIP: PHONE # I.D. # GRP # INSURED S NAME OR # IS THIS AN EMPLOYER PLAN ( ) YES ( ) NO IS THIS AN EMPLOYER S PLAN ( ) YES ( ) NO INSURED S SOCIAL SEC. # DOB: INSURED S SOCIAL SEC. # DOB: RELATIONSHIP TO INSURED: SELF HUSBAND WIFE CHILD OTHER RELATIONSHIP TO INSURED: SELF HUSBAND WIFE CHILD OTHER GUARANTEE OF PAYMENT AND RESPONSIBILTY I fully understand that I am directly responsible for payment to the physicians in this office for all medical services (consultations, evaluations, follow-up, procedures, treatment, etc.), and/or rendered supplies (IUD, Essure, Implanon, vaccines, etc.). I also understand that all bills are payable and become due at the time services are rendered, unless other arrangements have been made or covered by the insurance plan. Patients with no insurance coverage (Self-Pay) are responsible for all laboratory services (specimens, blood work, general testing, etc.). Patient will be billed directly by the laboratory, Genpath (BioReference), LabCorp, Quest Diagnostic, etc. I agree to pay all collection costs including reasonable attorney s fees and costs in the event it becomes necessary to file suit to effect payment. I authorize payments to be made directly to my doctor. AUTHORIZATION TO RELEASE INFORMATION I hereby authorize the Physicians in this office to release any information acquired in the course of my examination or treatment to my insurance, disability or FMLA company for the purpose of processing any insurance or disability claim. NOTICE OF PRIVACY PRACTICES I acknowledge that I have received the Notice of Privacy for Signature Women s Healthcare, LLC. The NPP is required to be provided to me under the Health Insurance Portability and Accountability Act of ASSIGNMENT OF INSURANCE BENEFITS If insurance claims are filed by this office on my behalf, I hereby authorize direct payment of any payment of any benefits to the physicians in this office for medic al or surgical treatment rendered to me. In these circumstances, I understand that I am financially responsible for any charges, services or supplies not covered by insurance. I permit a copy of the authorization to be used in place of the original. PERSONAL INFORMATION CONFIRMATION I confirm that all of the above Information is current and accurate, and I consent to all of the above specifications. SIGNATURE (Patient s parent if minor): DATE: / / Signature Women s Healthcare, LLC NW 179 th Avenue, Suite 102, Pembroke Pines, FL *** 6175 NW 153 Street, Suite 332, Miami Lakes, FL Tel. # Fax # SignatureWHC.com swh30a

5 PREFERRED PHARMACY NAME OF PHARMACY: ADDRESS: TELEPHONE # AUTHORIZATION TO DISCUSS PROTECTED HEALTH INFORMATION* I, (Patient name), authorize Signature Women s Healthcare, LLC to release or discuss information related to my medical condition (including information related to my treatment plan, medication information and/or billing information) to the following named person(s)* 1) Relationship: 2) Relationship: 3) Relationship: **************************************** * PLEASE BE ADVISED THAT ANY PERSON NOT REFERRED TO ON THIS LIST WILL NOT BE GIVEN ANY INFORMATION RELATED TO YOUR CARE, INCLUDING BILLING INFORMATION. YOU MAY CHANGE, RESTRICT OR EXPAND THIS LISTING AT ANY TIME. * YOU ARE NOT REQUIRED TO LIST ANY NAME IF YOU DO NOT CHOOSE. ****************************************** Please list any additional phone numbers where you would like us to contact you for: * Results Lab, X-ray, Ultrasounds, Mammograms, etc. * Reminder notices * Changes on scheduled appointments ADVANCE DIRECTIVE Do you have an Advance Directive / Living Will? ( ) YES ( ) NO If yes, please provide us with a copy for our records. If no, please let us know if you require information. Patient Signature: Date: / / I was referred to Signature Women s Healthcare, LLC by: Friend Relative Physician Insurance Reputation of LLC s Physician(s) Existing Patient Other Signature Women s Healthcare, LLC Carlos R. Sarduy, MD Pablo E. Uribasterra, MD Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP Swh30B

6 Carlos R. Sarduy, MD Pablo E. Uribasterra, MD Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP PATIENT FINANCIAL CONSENT Your care often requires the use of laboratory studies, imaging studies, or pathology evaluation. These studies are not performed at our practice. If your care does require the use of any of these modalities, you will receive a separate bill from the laboratory, physician, or center providing that specific service. Please understand that we do not control these costs. If you have any questions regarding these costs, please ask your physician prior to your procedure. If you have a health insurance plan, your insurance policy is a contract between you and the insurance company. It is an agreement that your insurance will pay for covered medical services. They may not pay for every bill or services. It is very important that you know which medical treatments they will pay for and which expense they will not cover. Please note, verification of benefits is NOT a guarantee of payment. We recommend you contacting your health insurance plan for questions regarding covered benefits under your plan. Please do not hesitate to contact any of our staffed employees to assist you with any questions. I acknowledge that I have read and fully understand that I am directly responsible for any and all services provided. Patient Name Patient Signature ID # Date: / / 03/04/ NW 179 th Avenue Suite 102 Pembroke Pines FL NW 153 Street Suite 332 Miami Lakes FL Phone # SignatureWHC.com Fax: swh15a

7 Carlos R. Sarduy, MD Pablo E. Uribasterra, MD Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura J. Paris, CNM, ARNP ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received the Notice of Privacy Practices for Signature Women s Healthcare, LLC. The Notice of Privacy Practices is required to be provided to me under the Health Insurance Portability and Accountability Act of Effective Date of Notice: April 14, 2003 Patient: Date: / / Or Patient s Representative: Date: / / Relationship to Patient: FOR USE BY SIGNATURE WHC STAFF ONLY: Patient refused to sign. Patient unable to sign. Signature Women s Healthcare Employee s Initials / / Today s Date 301 NW 179 th Avenue Suite 102 Pembroke Pines FL NW 153 Street Suite 332 Miami Lakes FL Phone: SignatureWHC.com Fax: swha1

8 Carlos R. Sarduy, MD Pablo E. Uribasterra, MD Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP NICA INFORMATION I have been furnished information by Signature Women s Healthcare, LLC prepared by the Florida Birth-Related Neurological Injury Compensation Association, and have been advised that Dr. Carlos R. Sarduy, Dr. Pablo E. Uribasterra, Monica Companioni, MD, Jenny Arango- Longo, MD, and Alvin Martinez, DO are participating physicians in the program, where in certain limited compensation is available in the event certain neuro-logical injury may occur during labor, delivery or resuscitation. For specifics on the program, I understand I can contact the Florida Birth-Related Neurological Injury Compensation Association (NICA), 1435 Piedmont Drive East, Suite 101, Tallahassee, FL I further acknowledge that I have received a copy of the brochure prepared by NICA. DATED this day of,20. Signature Name of Patient Social Security Attest: Witness / / Date SEE SECTION , FLORIDA STATUES 301 NW 179 th Avenue Suite 102 Pembroke Pines FL NW 153 Street Suite 332 Miami Lakes FL Phone: SignatureWHC.com Fax: swh02e