Orlando Gastroenterology, P.A.
Name ______Date ______Marital Status ______
SSN # ______Home Phone ______Birth Date______
Home Address ______
City______State ______Zip ______Sex: M or F
Employer ______Occupation ______
Email Address ______
Cell ______Work ______Emergency Contact ______
Pharmacy Info
Pharmacy Name: ______
Address: ______Phone: ______
Patient Acknowledgement: I understand I have the right to accept and refuse medical treatment and to exercise my right and implement an “Advanced Directive,” refers to any legal document that informs family members and medical personal how you wish to be treated if you are hospitalized and cannot communicate your wishes. Please check the following statements that apply:
I Have Not executed an Advanced Directive
I Have executed an Advance Directive
Living Will Location of Form______
Durable Power of Attorney
Do Not Resuscitate (DNR) Order
Designation of health care surrogate form Designee/Guardian______
Signature______Witness______Date______
Insurance Assignment & Release Form: I Hereby authorize my Insurance Benefits to be paid directly to Orlando Gastroenterology, P.A. I also authorize the physician to release any information required and/or requested by insurance carrier. Office policy: I understand that I am responsible for insurance deductibles, co-pays and percentages as per my insurance policy. I understand all fees are due at the time services are rendered. I understand that here is a $15 dollar charge on all returned checks and a $25 dollar charge for confirmed appointments cancelled without 24 hours prior notice or failure to show up for a scheduled and confirmed appointment. I also understand that Orlando Gastroenterology, P.A. files claims to the insurance company as a courtesy, and that I am responsible for any service the insurance company does not pay for.
Signature ______Date ______
Orlando Gastroenterology, P.A.
ACKNOWLEDGEMENT FORM
I have received the Notice of Privacy Practices and have been provided an opportunity to review it.
With my consent, Orlando Gastroenterology, P.A. may call home or designated location and leave a message on voice mail, answering machine or with family member______
(DOB) ______; in reference to any items that assist the practice in carrying out TPO (treatment, payment, and healthcare operations) such as appointment reminders, insurance items and calls pertaining to my medical care, including laboratory results, etc.
Name ______Birth date ______
Signature ______
Date ______
Sri Pothamsetty, MD.
Orlando Gastroenterology, P.A.
Date ______
Patient Name ______
DOB: ______S.S.N# ______-______-______Phone: ______
Patient Address ______
______
I herby authorize ______to release medical information to:
Name: Orlando Gastroenterology, P.A.
Address: 1507 S. Hiawassee Road, Suite 105
Orlando, FL32835
Phone: 407-445-9224 Fax: 407-445-6236
SPECIFIC DOCUMENTS TO BE RELEASED:
( ) ALL Records( ) Pathology Report(s)( ) Discharge Summary
( ) History/Physical( ) Procedure Report(s)( ) Consultation
( ) Labs( ) Radiology Reports( ) Progress Notes
( ) Physical Orders( ) Nurse Notes ( ) Medications
( ) Psychiatric ( ) HIV/AIDS ( ) Drug/Alcohol
( ) Specified Date(s)of service ______
( ) Hand Carry( ) Mail( ) Fax
PURPOSE FOR INFORMATION:
( ) Continued Medical Care( ) Insurance( ) Personal
This request is authorized to include any federal and/or state protection under Florida Statutes 394.459(9) Psychiatric Information, 397.053/396.112 Drug and Alcohol Abuse Information, 381.609 HIV and AIDS related conditions and/or 397.50(3) records of minor client.
NOTICE TO REQUESTING PARTY: Florida statue has established guidelines and cost rates for the copying of records. Your signature on this form indicates your knowledge of this statement.
I understand that any disclosure of information carries with the potential for an unauthorized redisclosure and the information may not be protected by federal confidentially rules.
I hereby release Orlando Gastroenterology, P.A. and their employees, agents, officer, and affiliates, from any and all liability, responsibility, claim and damages, which may result in the release of information authorized by the consent for release of information.
Sign:______Date:______
(If not patient, state relationship)
Form of ID verified______
Witness: ______Date: ______
1507 South Hiawassee Road Suite 105Orlando, FL32835
Phone: (407) 445-9224 Fax: (407) 445-6236
Sri Pothamsetty M.D.
Orlando Gastroenterology
1507 South Hiawassee Rd. Suite 105
Orlando, FL. 32835
PH: 407-445-9224F: 407-445-6236
Medication History Consent
Date ______
I ______hereby give Orlando Gastroenterologyconsent to
access my medication history through Rx Hub.
Patient Name ______DOB: ______
Witness: ______Date: ______