Highlands Advanced Rheumatology and Arthritis Center

Dear New Patient,

Please complete the enclosed questionnaire and bring it to your appointment on   Date   . In order for your doctor to assess your medical needs, please answer all questions pertinent to you. We may have to reschedule you if paperwork is not completed. Please bring insurance card(s), photo ID and copay with you.

We do realize that the wait to be seen in our office can be quite lengthy. We try to accommodate each person as best as we can. If for any reason you can not your appointment with us, please contact the office a minimum of 24 hours before your scheduled appointment as a courtesy to us and to others waiting to be seen. There is a fee for no shows or late cancellations. You will be rescheduled if you are 15 minutes late. Thank you.

It is very important that the doctor has copies of your previous medical records for evaluating your condition. Please bring a copy of your medical records with you to your appointment with us including the following: primary care & consultant physician's notes, lab results, X-ray films, CT scan, MRI, and other imaging reports. We have attached a medical records request form for your convenience, please fill it out and forward to your physician's office in time for you to receive your records prior to your appointment with our providers.

Please bring a copy of ALL medications you are taking.

We do expect you to be familiar with your own insurance coverage. If referrals are required by your insurance company, it is your responsibility to arrange for a current referral to be in place for your office visit. If pre-certification is required by your insurance company for bone-density test in our office, please arrange for this with your ordering physician's office. In order to avoid any complications or misunderstandings, we ask that you arrange for a hard copy of the referral or a phone call from your referring doctor's office to be forwarded to our office prior t your visit.

If you have any questions, please feel free to give our office a call. We look forward to meeting you.

Sincerely,

Staff

Appointments

Each time you arrive for your appointment, we will review the insurance information that we have in our files.

You must notify us of any changes in your coverage prior to us beginning your appointment. If there are any changes in your insurance coverage, we need to process and verify the changes before your treatments begins.

Your signature ensures us a payment and makes the accuracy of your insurance information that is filed in our System.

Examples of changes we need to be aware of:
-Changes of insurance companies
-Changes in type of policy (HMO, PPO, POS, INDEMNITY....)
-Change in prefix
-Change in ID#
-Change in copay amount
-Change in insurance order (MVP first - MEDICARE second...)
-Change in subscriber

Remember, these are examples of some of the changes we review and verify, the more YOU know about YOUR insurance coverage, the easier your medical journey will be.

596 US Hwy 27 North
Avon Park, Florida 33825
Phone: (863) 314-8555 Fax: (863) 453-3400
Dr. Alexander Torres, MD

PATIENT DEMOGRAPHICS FORM

Patient Authorization to the use and disclosure of Protected Health Information for Treatment, Payment or Healthcare Operations

I have the following restrictions for the use and disclosure of my personal information:
initials   (initial here if NONE)

I,   First Name   Last Name   , understand that as part of my decision to be a patient at Highlands Advanced Rheumatology and Arthritis Center, P.L. (HARAC), Alexander Torres, MD and staff will posses and maintain paper and/or electronic medical records which may include any medical history, treatment and examinations, lab and radiology results, diagnosis, records released from other physicians and other plans for my care and treatment.

I understand that as part of HARAC's treatment, payments or healthcare operations, it may be necessary to provide my protected health information to another entity e.g. insurance provider or healthcare provider. I completely understand that my personal health information may be released to those whom I specify and those named above.

I understand that HARAC is not required to agree to the restrictions I request. I understand that I may revoke this consent in writing, except to the extent that HARAC has already acted in reliance. I also understand that by refusing to sign this consent or revoking consent, HARACA may refuse to treat me as permitted by Section 164.506 of the code of Federal Regulations.

I understand that HARAC, reserves the right to change their notice and practices prior to implementation, in accordance with Section 164.520 of the code of Federal Regulations. Should HARAC change their notice they will send a copy of the revised notice to the address I have provided (US Mail or if I agree via email).

I acknowledge that I have been provided with a Notice of Health Information Practices.

Office communication, Message & Refill Policies
Each and every phone call that comes into our facility is answered by a live operator. We currently serve over 10,000 patients so at times you may be placed on a brief hold before your call will be handled. Please note that we have a 72-hour response time if you choose to leave a message, send an email or send a message through the patient portal.      

Prescription Refill Policy
It is our office policy that ALL PRESCRIPTION REFILL REQUESTS require a 72-hour advance notice. Prescriptions will not be refilled on the SAME DAY as your request. Please do not wait until you are out of medication before requesting a refill.   initial   

Patient Waiver/ Consent an Agreement to Pay
Insurance Authorization: I request that the payment of authorized benefits be made to HARAC on my behalf, for any services provided to me. I authorize any holder of medical and other information pertaining to me be released to any insurance company responsible for paying such payments; including all information needed to determine the benefits for related services I also authorize all benefit information pertaining to my insurance claim to be released to assist with the reimbursement process. My consent is valid until further written notice.   initial   

Release of Medical Records: To ensure proper follow up and continuity of care, I agree that a copt of my medical records be released to my primary and/or referring physician.

I understand that by signing this agreement, I am authorizing the practitioners of HARAC to evaluate, perform and bill for the medical treatment(s) provided to me. I have also read, understand and have a copy of the above policy.

Directives:
Initial here for NONE      

If yes for morning stiffness, lasting how long?
Minutes   Hours   

I,   First Name   Last Name   , understand that in order to receive care for the treatment of pain or the use of controlled medications, I agree to and will comply with the following:

A. MENTLA HEALTH AND/OR PAIN MANAGEMENT CONSULTANT: A mental health assessment and/or continuing psychological therapy may be required. If I am currently involved in mental health therapy, or if I enter such therapy, I will authorize my mental health practitioner to exchange unrestricted information regarding my condition and treatment with the undersigned physician.

B. USE OF MEDICATIONS: I will take all medications as prescribed. I will speak with the undersigned physician before making any change in wither the dose or frequency of my medications. There will be no early refills of controlled medications without prior authorization from this office. Narcotic pain medications must all be obtained from the same pharmacy each time (any exception must be approved by the undersigned physician). I will abstain from alcohol use.

C. SEEKING PRESCRIPTIONS: I will neither seek nor fill prescriptions for any controlled medication from any other health care provider unless authorized by the undersigned physician. I will not harass or repeatedly speak with the pharmacist about refills which may be early. I will not call the physician after hours about my controlled substance prescription refills.

D. MEDICAL RECORDS RELEASES: I will inform all of my health care providers that I recieve pain management and will maintain an unrestricted and current medical records release on file.

E. DRUG SCREENING: I will participate in drug screening as a part of my treatment plan. I understand that drug screening may be conducted at least every 12 months and may be required more frequently at the discretion of the undersigned physician. Screening may include urinalysis, blood testing or pill counts. I agree to pay all costs associated with drug testing not covered by my insurance. Refusal to submit to screening at the time specified may result in termination of services.

F. ILLEGAL AND NON-PRESCRIBED DRUG USE: I understand that the use of any controlled medication not prescribed by the undersigned physician may result in termination of care. I authorize the practice to cooperate fully with any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of controlled medicines. I authorize the practice to provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I also understand that the use of any illegal substance, including marijuana, may result in termination of care.

G. LOST OR STOLEN MEDICATIONS: I agree to safeguard all medications prescribed by the undersigned physician and understand that lost or damaged medications will not be replaced.

H. PRESCRIPTIONS WHILE TRAVELING: The practice may provide prescriptions fro up to 90 days when patients are traveling out of state. Patients will have to arrange for shipment of controlled substances by their pharmacy at their own expense. Patients who will be out of state longer than 90 days need to arrange for health care at their travel destinations.

I. DRIVING & OPERATING EQUIPMENT: Many medications can cause drowsiness and/or a very relaxed state of mind cauSing operation of equipment or vehicles to be dangerous. I agree to refrain from driving or operating dangerous equipment for 72 hours after any change in medication dosage and whenever I feel drowsy.

J. OTHER RESTRICTIONS AND/OR CONSIDERATIONS:

K. TERMINATION: I will no longer be eligible for care if I am in possession of illicit drugs or substances, trafficking in controlled or illegal substances, intoxicated or if arrested for DUI. If I alter my prescription in any way, sell or share my medications, I will no longer be eligible for care.

I UNDERSTAND AND AGREE TO THE CONDITIONS OF CARE DESCRIBED ABOVE AND WILL COMPLY WITH THEM. ALL OF MY QUESTIONS ABOUT THE TERMS OF THIS AGREEMENT HAVE BEEN ANSWERED TO MY SATISFACTION. FAILURE TO COMPLY WITH ANY OF THE TERMS OF THIS AGREEMENT MAY RESULT IN IMMEDIATE TERMINATION OF SERVICE.

No Call/ No Show

In an effort to provide successful and orderly treatment to all of our patients, it is the policy of this office that new patient appointment cancellations are made at least 24 hours prior to your scheduled appointment time.

If a new patient appointment is not cancelled or patient fails to show up for appointment, Highlands Advanced Rheumatology & Arthritis Center conserves the right to postpose the appointment to the following available appointment. Related to the fact that this is a Speciality Practice, take into account our establishment acquires a great extent of new patient referrals regularly. This may result in a prolonged waiting period before obtaining an appointment.

If you have any questions concerning this form, please contact us before signing.

Please Print:

Patient Name: First Name   Last Name  
Patient's/Guardian's Signature:   First Name   Last Name   
Date:    Date