• Medical Physicians Group PLLC

     

    7855 Arygle Forest Blvd #504, Jacksonville FL 32244 

    12443 San Jose Blvd Suite 403, Jacksonville FL 32223        

    531 South 6 St. Suite #1, Macclenny FL 32063

    https://medicalphysiciansgroup.com

    admin@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.

  • Clear
  •  / /
    Pick a Date
  • Medical Physicians Group PLLC

    Cancellation Policy and Payment Policy

    I understand that there is a $25 for any cancellation, rescheduleing, and/or "No Show" 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.

  • Clear
  •  / /
    Pick a Date
  • Medical Physicians Group PLLC New Patient Information

  •  / /
    Pick a Date
  •  / /
    Pick a Date
  •  / /
    Pick a Date
  • Clear
  •  - -
    Pick a Date
  • Allergy and Drug Information- New Patient

  • Clear
  •  - -
    Pick a Date
  •  

    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

  • Clear
  • Clear
  • Please Circle and Elaborate if You Have Seen a Physician or Have Been Diagnosed with Any of the Following:

  • Clear
  •  - -
    Pick a Date
  • I hereby attest to the best of my knowledge, all above statements regarding my previous known health conditions have been disclosed and answered truthfully.

  • Clear
  •  / /
    Pick a Date
  • Surgical History

  • Social History

  • Family History

  • Clear
  •  - -
    Pick a Date
  • Insurance Information

  • 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.

  • Clear
  •  / /
    Pick a Date
  •  
  • Should be Empty: