Medical Physicians Group PLLC
12443 San Jose Blvd Suite 403, Jacksonville FL 32223
531 South 6 St. Suite #1, Macclenny Florida 32063.
145 Hilden Road Suite 108, Ponte Vedra FL 32081 https://medicalphysiciansgroup.com
Phone # 863-874-0898
Fax # 833-728-7733
Health Insurance Portability and Accountability Act (HIPPA) Acknowledgement
I have received the HIPAA information. I understand that Medical Physicians Group PLLC and Dr. Leung will make all attempts to protect patient’s medical information.
Cancellation Policy and Payment Policy
I understand that there is a $25 for any cancellation less than 24 hours prior to the appointment. I understand if insurance does not pay for your benefits and/or if your benefits have expired, then it is the patient’s responsibility to pay for the office visit and/or the procedure, vaccination, and/or any medical services rendered.
Medical Physicians Group PLLC New Patient Information
Allergy and Drug Information- New Patient
By completing the above information, you acknowledge the following: All
prescribed and non-prescribed medications taken, including their current dosages and
strengths, have been truthfully stated on this form. Should our physician prescribe
medication which could cause a reaction with any unknown substances at the time of prescription, the patient agrees to hold harmless said physician.
If there is any change in medication taken from another provider, or another provider issues a new or change of prescription, it is up to the patient to notify us to update this change in his/her medical records and advise patient regarding any possible drug
Please Circle and Elaborate if You Have Seen a Physician or Have Been Diagnosed with Any of the Following:
I hereby attest to the best of my knowledge, all above statements regarding my previous known health conditions have been disclosed and answered truthfully.
I hereby attest that all insurance information is truthful and current. If insurance information is unable to be verified at time of appointment, or a company rejects any claim, it is up to the patient or patient’ representative to pay via cash and perform a self-claim filed with their own insurance company for self-reimbursement.