Firstclassmd.net

First Class MD, P.A.
2053 Fountain Professional Court, Suite B, Navarre, FL 32566 Phone: (850) 939-4150 Fax: (850) 936-5277 Patient Information: This section refers to the PATIENT ONLY
Marital Status: [ ]Married [ ]Single [ ]Divorced [ ]Widowed Race: [ ]Caucasian [ ]African American [ ]American Indian [ ]Asian [ ]Hispanic First Class MD, P.A.
2053 Fountain Professional Court, Suite B, Navarre, FL 32566 Phone: (850) 939-4150 Fax: (850) 936-5277 Responsible Party: Person/Party Responsible for Payment
Relationship to Patient: [ ]Self [ ]Spouse [ ]Parent [ ]Other If Self - Proceed to Section 2 on this page.
Marital Status: [ ]Married [ ]Single [ ]Divorced [ ]Widowed Race: [ ]Caucasian [ ]African American [ ]American Indian [ ]Asian [ ]Hispanic First Class MD, P.A.
2053 Fountain Professional Court, Suite B, Navarre, FL 32566 Phone: (850) 939-4150 Fax: (850) 936-5277 Insurance Information: PLEASE SHOW ALL NUMBERS ON YOUR CARD (S)
Primary Insurance Coverage: Self Pay: [ ]
Secondary Insurance Coverage:
Third Insurance Coverage:
First Class MD, P.A.
2053 Fountain Professional Court, Suite B, Navarre, FL 32566 Phone: (850) 939-4150 Fax: (850) 936-5277 AUTHORIZATION AND AGREEMENT FOR MEDICAL TREATMENT, SIGNATURE ON FILE
The undersigned hereby makes the following ACKNOWLEDGEMENTS AND AGREEMENTS regarding the treatment to be provided to the patient whose name appears below.
CONSENT OF TREATMENT: I hereby grant my authorization and consent for treatment formyself and/or minor children, and certify that no guarantee or assurance has been made asto the results which may be obtained.
AGREEMENT TO PAY FOR SERVICES: For, and in consideration of the care provided tome, I promise to pay First Class MD, P.A. all charges for service rendered to me or on my behalf. I understand that if insurance is filed on my behalf by First Class MD, P.A., I amnevertheless responsible for payment of all charges. I also understand that this responsibilityextends to the payment of services classified as "non covered" by my insurance company.
If my insurance company has failed to pay within 30 days of filing, I will render payment toFirst Class MD. I further understand that my failure to immedicately render such paymentmay result in my account being assessed as delinquent. I agree to pay any and all additionalcharges that may be incurred by First Class MD for the collection of my unpaid account, badcheck, or other payment instrument. LIFETIME AUTHORIZATION (MEDICARE PATIENTS): I certify that the information givenby me to be applied for payment under Title XVII of the Social Security Act is correct. I authorize release to any holder of medical or other information to the Social SecurityAdministration or its intermediaries who carry any information needed for this or a relatedMedicare claim. I assign the benefits payable for assigned services to the physician ororganization who will submit the claim for me and I request that payments for those claimsbe made on my behalf. I agree and understand this Medicare certification.
MEDICARE AUTHORIZATION: I request that payment of authorized benefits made on mybehalf to First Class MD for any services furnished to me by that physician or supplier. Iauthorize any holder of medical information about me to release to the Health CareFinancing Administration and its agents any information needed to determine these benefitsor the benefits payable for related services.
AUTHORIZATION TO PAY BENEFITS TO THE PHYSICIAN: I hereby authorize the officeof First Class MD to release any medical information required during the course ofexamination and treatment and permit payment directly to them any benefits due for theirservices rendered. I recognize and accept responsibility for services rendered regardless ofinsurance coverage. This includes but not limited to coinsurance, copayment, deductible and non covered services.
I FULLY UNDERSTAND AND AGREE TO COMPLY WITH THIS ABOVE STATEMENT.
PATIENT SIGNATURE: ______________________________ First Class MD, P.A.
2053 Fountain Professional Court, Suite B, Navarre, FL 32566 Phone: (850) 939-4150 Fax: (850) 936-5277 CONSENT TO RELEASE INFORMATION
(AUTHORIZATION TO SPEAK TO FAMILY MEMBERS) I, (Patient name) _____________________________ hereby authorize First Class MD, its agents and/orcontractors to release, upon request, private health information related to my injury/illness and/orsettlement to the individual(s) and/or firm(s) listed below: LIVING WILL/ADVANCED DIRECTIVES
Do you have a living will or durable power of attorney? If yes, please forward a copy to our office for our records.
HIPPA PRIVACY STANDARD
If you would like a copy of the Notice of Privacy Practices we would be happy to provide one to you.
I give permission for First Class MD, P.A. to obtain my medication history from my pharmacy.
Completion and Signing of this consent form:
Authorizes release of information to the person named above upon their request. This means that information disclosed to the above named person may be re-disclosed by them and may no longer be protected by law.
Is for release of information purposes only and does not affect benefits you are entitled to under the Medicare Program and all other insurance If your legal representative signs this form of you, a copy of their data must be attached. You have the right to revoke your authorization at any time in writing, except to the extent that Medicare/Insurance has already acted based on your permission. To revoke your authorization, please send a written request to this office.
First Class MD, P.A.
2053 Fountain Professional Court, Suite B, Navarre, FL 32566 Phone: (850) 939-4150 Fax: (850) 936-5277 ADULT MEDICAL HISTORY & FAMILY MEDICAL HISTORY
MEDICAL CONDITION
FAMILY EXPLAIN CONDITION OR RELATION
Please feel free to elaborate anywhere on this page.
FAMILY HISTORY
MOTHER: ALIVE-AGE DIED-AGE
FATHER: ALIVE-AGE DIED-AGE
SIBLINGS: AGES:
CHILDREN: NAMES, AGES AND MEDICAL
First Class MD, P.A.
2053 Fountain Professional Court, Suite B, Navarre, FL 32566 Phone: (850) 939-4150 Fax: (850) 936-5277 Name:
DO YOU HAVE ANY ALLERGIES? Describe reaction Hives, Rash, Swelling, Wheezing, Shock or other
PENICILLIN
SULFA
CODEINE
IODINE
LATEX
CEPHALOSPORIN
BEES
EGG
PEANUT
ERYTHROMYCIN
AZITHROMYCIN
OTHER
SURGERY OR PROCEDURES:
OTHER SURGERY: LIST DATES AND PROCEDURES
APPENDECTOMY:ADENOIDECTOMY:BRONCHOSCOPY:CAROTID REPAIR: R/L/BOTHBTL:CATARACTS: R/L/BOTHCOLECTOMYHEMORRHOIDECTOMYCORONARY BYPASS GRAFTGALLBLADDERGASTRIC BYPASSHYSTERECTOMY: TOTAL/PARTIALHERNIA REPAIRORTHOPEDICTONSILLECTOMYVASECTOMY MEDICATIONS: List ALL prescriptions (even birth control), over the counter, and herbalproducts and creams
NAME OF MEDICINE:
HOW IS THE MEDICINE TAKEN?
NEED REFILLS?

Source: http://www.firstclassmd.net/documents/concierge-enrollment-form.pdf