NEW PATIENT PACKET
All Payments are due at time of services rendered. This practice has a legal obligation to the insurance companies that we are contracted with to collect copayments, coinsurance and deductibles at time of service. Once a balance reached 90 days old without payment, the balance may be transferred to a third party for further collections or other actions. Our office will obtain your insurance benefits; however, it is your insurance information prior to your appointment to avoid unnecessary wait times.
If you are unable to keep your appointment, please notify our office at least 24 hours in advance to cancel or reschedule your appointment. Your courtesy will allow to other patients seeking medical treatment the option to use your scheduled appointment time. Patients will be charged $25.00 for missed appointments unless the appointment was cancelled 24 or more hours in advance.
PRIVACY AND SECURITY
CENTRAL FLORIDA TOTAL HEALTHCARE holds all information pertaining to the care and treatment of our patients in the strictest confidence. All information in the patient’s medical record is maintained with the utmost care and respect to preserve privacy and confidentiality. CENTRAL FLORIDA TOTAL HEALTHCARE fully complies with the Federal Government’s mandated HIPAA requirements for patient confidentiality and privacy of healthcare information. As a new patient, you will be asked to review and protected health information without authorization. Only a patient can provide the authorization to release records necessary for CENTRAL FLORIDA TOTAL HEALTHCARE to disclose protected health information for instances not related to your ongoing treatment and/or payment of claims. A patient may request to view a copy of their medical record in the office.
All payments are due at time of services rendered. Dr. JOSE LOPEZ MD and providers of CENTRAL FLORIDA TOTAL HEALTHCARE have a legal obligation to the insurance companies they are contracted with to collect copayments, deductibles and coinsurance. Once a balance reached 90 days old, w/o payment activity will be transferred to a third party for further collections or other actions.
WHAT IF MY CHILD NEEDS TO SEE A PROVIDER
A parent or legal guardian must accompany patients who are minors on the patient’s first visit. This accompanying adult is responsible for payment on the account.
IF YOU HAVE INSURANCE COVERAGE
Please provide insurance card to CENTRAL FLORIDA TOTAL HEALTHCARE staff and will bill these companies directly and will follow up on outstanding balances. You will be responsible for payment of your designated co-pay at each visit to the office BEFORE you see the doctor. You are responsible to present updated referral authorizations from your insurance carrier when required.
IF YOU DO NOT HAVE HEALTH INSURANCE
You are responsible for payment of your bill at the time of your visit. We accept personal checks, credit cards and cash. A payment of $150.00, $100.00, estimate, is due before your visit. The balance will be due when your visit complete. If your bill exceeds $200.00, a payment plan can be worked out at the time of the visit. Please ask for our payment agreement form.
“I understand and agree that regardless of my insurance coverage, I am responsible for the balance of this account for any professional services rendered. I certify that the above information is true and correct to the best of my knowledge. I will notify the office of any changes in my insurance status. I also agree that if I am unable to pay my bill promptly, I will call the billing department to make timely payment arrangements. I understand that if my account becomes delinquent and CENTRAL FLORIDA TOTAL HEALTHCARE incurs any collection charges, they will be my responsibility”.
IF THE PATIENT IS A MINOR
“By consenting to care at CENTRAL FLORIDA TOTAL HEALTHCARE, I am agreeing that I will take responsibility for the payment of the medical bills. I will provide the office with all information necessary and will communicate with the office regarding any changes in responsibility”.
I HAVE READ AND UNDERSTAND THE OFFICE, COLLECTION POLICIES OF CENTRAL FLORIDA TOTAL HEALTHCARE
LIST OF MEDICATIONS
CONSENT FOR PURPOSE OF TREATMENT, PAYMENT, HEALTH CARE OPERATIONS AND NOTICE OF PRIVACYPRACTICES
I consent to the use or disclosure of my protected health information by CENTRAL FLORIDA TOTAL HEALTHCARE, for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations. I understand that diagnosis or treatment of me by Dr. JOSE LOPEZ MD may be conditioned upon my consent as evidence by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. CENTRAL FLORIDA TOTAL HEALTHCARE is not required to agree to the restrictions that I may request. However, if CENTRAL FLORIDA TOTAL HEALTHCARE agrees to a restriction that I request, the restriction is binding between CENTRAL FLORIDA TOTAL HEALTHCARE and
I have the right to revoke this consent, in writing, at any time.
My "Protected Health Information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review CENTRAL FLORIDA TOTAL HEALTHCARE Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices is available to me. The Notice of Privacy Practices described the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my medical claims or in the performance of health care operations of CENTRAL FLORIDA TOTAL HEALTHCARE. The Notice of Privacy Practices for CENTRAL FLORIDA TOTAL HEALTHCARE is also available at the front desk of the clinic. This Notice of Privacy Practices also describes my rights and the CENTRAL FLORIDA TOTAL HEALTHCARE duties with the respect to my protected health information. I authorize CENTRAL FLORIDA TOTAL HEALTHCARE to obtain medical Rx from pharmacies
CENTRAL FLORIDA TOTAL HEALTHCARE reserves the right to change the privacy practices described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I acknowledge that CENTRAL FLORIDA TOTAL HEALTHCARE provided me with a written copy of their Notice of Privacy
I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions, which explains how my medical information will be used as disclosed.
I am giving authorization to CENTRAL FLORIDA TOTAL HEALTHCARE to disclose my medical and insurance information to the below person(s
PAST MEDICAL TREATMENT:
PURPOSE FOR THIS REQUEST:
TYPE OF RECORDS REQUESTED:
AUTHORIZATION VALID FOR: (Check one)
I understand that:
NOTE: Medical records are faxed in cases of medical necessity only.
NOTICE OF PRIVACY PRACTICES AND POLICIES
PLEASE REVIEW IT CAREFULLY.
CENTRAL FLORIDA TOTAL HEALTHCARE is required by law to maintain the privacy of your health information and to provide individuals with notice of its legal duties and privacy practices with respect to health information. CENTRAL FLORIDA TOTAL HEALTHCARE is required to abide by the terms of the Notice currently in effect. CENTRAL FLORIDA TOTAL HEALTHCARE reserves the right to change the terms of its notice and to make the new notice provisions effective for all PHI that it maintains.
This Notice of Privacy Practices and Policies outlines our practices, policies and legal duties to maintain confidentiality and protect against prohibited disclosure of protected health information (“PHI”) under the privacy regulations mandated by the Health Insurance Portability and Accountability Act (“HIPAA”) and further expanded by the Health Information Technology for Economic Clinical Health Act (“HITECH”).
PHI includes your demographic information such as name, address, telephone number, and family; past, present, or future information about your physical or mental health or condition; and information about the medical services provided to you, including payment information, if any of that information may be used to identify you. Your PHI may be maintained by us electronically and/or on paper.
This Notice describes uses and disclosures of PHI to which you have consented, that you may be asked to authorize in the future, and that are permitted or required by state or federal law. Also, it advises you of your rights to access and control your PHI.
We may amend this Notice of Privacy Practices and Policies periodically. The new notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices or you may obtain a copy by accessing our website at www.centralfloridaheartcare.com, by calling the office, 407-790-7860 and requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.
We regard the safeguarding of your PHI as an important duty. The elements of this Notice and any authorizations you may sign are required by state and federal law for your protection and to ensure your informed consent to the use and disclosure of PHI necessary to support your relationship with CENTRAL FLORIDA TOTAL HEALTHCARE.
If you have any questions about CENTRAL FLORIDA TOTAL HEALTHCARE Notice of Privacy Practices and Policies, please contact the Jessica Agostini at 407-392-1919.
2. SAFEGUARDING PHI WITHIN OUR PRACTICE
We have in place appropriate administrative, technical, and physical safeguards to protect and to secure the privacy and security of your PHI. We orient our staff to the regulations and policies developed to protect the privacy of your PHI, and review their obligation to maintain privacy and security annually. We hold medical records in a secure area within our practice, and our electronic medical record system is monitored and updated to address security risks in compliance with the HIPAA Security Rule. Only staff members who have a legitimate "need to know" are permitted access to your medical records and other PHI. Our staff understands the legal and ethical obligation to protect your PHI and that a violation of this Notice of Privacy Practices and Policies may result in disciplinary action in accordance with our Human Resource policies.
3. USES AND DISCLOSURES OF PHI
As part of our registration materials, we will request your written consent for our practice to use and disclose your PHI for the following types of activities:
4. ELECTRONIC EXCHANGE OF PHI
We may transfer your PHI to other treating health care providers electronically. We may also transmit your information to your insurance carrier electronically.
5. USES AND DISCLOSURES OF PHI BASED UPON YOUR WRITTEN AUTHORIZATION
Other uses and disclosures of your PHI will be made only with your specific written authorization. This allows you to request that CENTRAL FLORIDA TOTAL HEALTHCARE disclose limited PHI to specified individuals or companies for a defined purpose and timeframe. For example, you may wish to authorize disclosures to individuals who are not involved in treatment, payment, or health care operations, such as a family member or a school physical education program. If you wish us to make disclosures in these situations, we will ask you to sign an authorization allowing us to disclose this PHI to the designated parties.
6. USES AND DISCLOSURES OF PHI PERMITTED OR REQUIRED BY LAW
In some circumstances, we may be legally permitted or required to use or disclose your PHI without your consent or authorization. State and federal privacy law permit or require such use or disclosure regardless of your consent or authorization in certain situations, including, but not limited to:
7. YOUR RIGHTS REGARDING PHI
8. COMPLAINT PROCEDURE
9. Effective Date. This Notice is effective as of September 23, 2013.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received and understand Central Florida Heart Care’s Notice of Privacy Practices containing a description of the uses and disclosures of my health information. I further understand that Central Florida Heart Care may update its Notice of Privacy Practices at any time and that I may receive an updated copy of Central Florida Heart Care’s Notice of Privacy Practices by submitting a request in writing for a current copy of Central Florida Heart Care’s Notice of Privacy Practices.
If completed by patient's personal representative, please print name and sign below.
FOR CENTRAL FLORIDA TOTAL HEALTH CARE OFFICIAL USE ONLY
Complete this form if unable to obtain signature of patient or patient's personal representative.
Instructions for Completing IHS Form 810
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
a.Only information related to -- specify diagnosis, injury, operations, special therapies, etc.
b. Only the period of events from -- specify date range, e.g., Jan. 1, 2002, to Feb. 1, 2002.
c. Other (specify) -- e.g., CHS, Billing, Employee Health.
d. Entire Record -- complete record including, if authorized, the sensitive information (alcohol and drug abuse treatment referral, sexually transmitted diseases, HIV AIDS-related treatment, and mental health other than psychotherapy notes
e. IN ORDER TO RELEASE SENSITIVE INFORMATION REGARDING ALCOHOLIDRUG ABUSE TREATMENT/REFERRAL, HIV/AIDS-RELATED TREATMENT, SEXUALLY TRANSMITTED DISEASES, MENTAL HEALTH (OTHER THAN PSYCHOTHERAPY NOTES), THE APPROPRIATE BOX OR BOXES MUST BE CHECKED BY THE PATIENT.
f. Psychotherapy Notes ONLY -- IN ORDER TO AUTHORIZE THE USE OR DISCLOSURE OF PSYCHOTHERAPY NOTES, ONLY THIS BOX SHOULD BE CHECKED ON THIS FORM. AUTHORIZATIONS FOR THE USE OR DISCLOSURE OF OTHER HEALTH RECORD INFORMATION MAY NOT BE MADE IN CONJUNCTION WITH AUTHORIZATIONS PERTAINING TO PSYCHOTHERAPY NOTES.
IF THIS BOX IS CHECKED WITH OTHER BOXES, ANOTHER AUTHORIZATION WILL BE REQUIRED TO AUTHORIZE THE USE OR DISCLOSURE OF PSYCHOTHERAPY NOTES ONLY.
Psychotherapy notes are often referred to as process notes, distinguishable from progress notes in the medical record. These notes capture the therapist's impressions about the patient, contain details of the psychotherapy conversation considered to be inappropriate for the medical record, and are used by the provider for future sessions. These notes are often kept separate to limit access because they contain sensitive information relevant to no one other than the treating provider.
Section V, if a different expiration date is desired, specify a new date.
Section V, Please sign (or mark) and date.
A copy of the completed IHS-810 form will be given to you.
Public reporting burden for this collection of information is estimated to average 20 minutes per response including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of Information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Indian Health Service, 801 Thompson Ave., TMP Suite 450, Rockville, MD 20852, RE: PRA 0917-0030. Please DO NOT SEND this form to this address.