NEW PATIENT PACKET

PRACTICE POLICY:

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.

CANCELING/RESCHEDULING APPOINTMENTS:

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.

COLLECTION POLICY

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

MEDICAL HISTORY

SOCIAL HISTORY:

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

PURPOSE FOR THIS REQUEST:

TYPE OF RECORDS REQUESTED:

AUTHORIZATION VALID FOR: (Check one)

I understand that:

• My right to the healthcare treatment is not conditioned on this authorization.
• I may cancel this authorization at any time by submitting a written request to the address provided at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.
• If the person or facility receiving this information is not a healthcare or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed.
• Release of HIV-related information, mental health related care, or substance abuse diagnosis and treatment information requires additional authorization.
• There may be a charge for the requested records.

NOTE: Medical records are faxed in cases of medical necessity only.

NOTICE OF PRIVACY PRACTICES AND POLICIES

PLEASE REVIEW IT CAREFULLY.

1. INTRODUCTION 

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:

 

• TREATMENT. Treatment means the provision, coordination, or management of your health care and related services by CENTRAL FLORIDA TOTAL HEALTHCARE and health care providers involved in your care. Students may be a member of the health care team. It includes the coordination or management of health care by a provider with a third party insurance carrier, communication with lab or imaging providers for test results, consultation between our clinical staff and other health care providers relating to your care, or our referral of you to a specialist physician or facility.
• PAYMENT. Payment means our activities to obtain reimbursement for the medical services provided to you, including billing, claims management, and collection activities. Payment also may include your insurance carrier's efforts in determining eligibility, claims processing, assessing medical necessity, and utilization review. Payment may also include activities carried out on our behalf by one or more of our collection agencies or agents in order to secure payment on delinquent bills.
• HEALTH CARE OPERATIONS. Health care operations mean the legitimate business activities of our practice. These activities may include quality assessment and improvement activities; fraud & abuse compliance; business planning & development; and business management & general administrative activities. These can also include our telephoning you to remind you of appointments, or using a translation service if we need to communicate with you in person, or on the telephone, in a language other than English. When we involve third parties in our business activities, we will have them sign a Business Associate Agreement obligating them to safeguard your PHI according to the same legal standards we follow.

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: 

• EMERGENCIES: If you are incapacitated and require emergency medical treatment, we will use and disclose your PHI to ensure you receive the necessary medical services. We will attempt to obtain your consent as soon as practical following your treatment.
• OTHERS INVOLVED IN YOUR HEALTHCARE: Upon your verbal authorization, we may disclose to a family member, close friend or other person you designate only that PHI that directly relates to that individual's involvement in your health care and treatment. We may also need to use PHI to notify a family member, personal representative or someone else responsible for your care of your location and general condition.
• COMMUNICATION BARRIERS: If we try but cannot obtain your consent to use or disclose your PHI because of substantial communication barriers and your physician, using his or her professional judgment, infers that you consent to such use or disclosure, or the physician determines that a limited disclosure is in your best interests, we may permit such use or disclosure.
• REQUIRED BY LAW: We may disclose your PHI to the extent that its use or disclosure is required by law. This disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
• PUBLIC HEALTH/REGULATORY ACTIVITIES: We may disclose your PHI to an authorized public health authority to prevent or control disease, injury, or disability or to comply with state child or adult abuse or neglect law. We are obligated to report suspicion of abuse and neglect to appropriate regulatory agencies. 
• FOOD AND DRUG ADMINISTRATION: We may disclose your PHI to a person or company as required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations as well as to track product usage, enable product recalls, make repairs or replacements or to conduct post-marketing surveillance.
• HEALTH OVERSIGHT ACTIVITIES: We may disclose your PHI to a health oversight agency for audits, investigations, inspections, and other activities necessary for the appropriate oversight of the health care system and government benefit programs such as Medicare and Medicaid. 
• JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: We may only disclose your PHI in the course of any judicial or administrative proceeding in response to a court order expressly directing disclosure, or in accordance with specific statutory obligations compelling us to do so, or with your permission. 
• LAW ENFORCEMENT ACTIVITIES: We may disclose your PHI to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, or missing person, or complying with a court order or other law enforcement purpose. Under some limited circumstances we will request your authorization prior to permitting disclosure. 
• CORONERS AND MEDICAL EXAMINERS: We may disclose your PHI to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other lawful purpose. 
• FUNERAL DIRECTORS AND ORGAN DONATION ORGANIZATIONS: We may disclose your PHI to enable a funeral director to carry out his or her lawful duties. PHI may also be disclosed to organ banks for cadaveric organ, eye, bone, tissue and other donation purposes. 
• RESEARCH: We may disclose your PHI for certain medical or scientific research where approved by an institutional review board and where the researchers have a protocol to ensure the privacy and security of your PHI. 
• SERIOUS THREATS TO HEALTH OR SAFETY: We may disclose your PHI to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. 
• MILITARY AND NATIONAL SECURITY ACTIVITIES: We may disclose the PHI of members of the armed forces for activities deemed necessary by appropriate military authorities to assure proper execution of military missions. We also may disclose your PHI to certain federal officials for lawful intelligence and other national security activities. 
• WORKER'S COMPENSATION: We may disclose your PHI as authorized to comply with worker's compensation laws. 
• INMATES OF A CORRECTIONAL FACILITY: We may use or disclose PHI if you are an inmate of a correctional facility and our practice created or received your PHI in the course of providing care to you while in custody. 
• US DEPARTMENT OF HEALTH AND HUMAN SERVICES: We must disclose your PHI to you upon request and to the Secretary of the United States Department of Health and Human Services to investigate or determine our compliance with privacy and security laws. 
• DISASTER RELIEF ACTIVITIES: We may disclose your PHI to local, state or federal agencies engaged in disaster relief and to private disaster relief assistance organizations (such as the Red Cross if authorized to assist in disaster relief efforts). 

 

7. YOUR RIGHTS REGARDING PHI 

• RIGHT TO REQUEST RESTRICTIONS FOR CERTAIN OF USES AND DISCLOSURES: You have the right to request that we not use or disclose your PHI unless such a use or disclosure is required by law. Such a request must be made in writing and include the specific PHI you wish restricted as well as the individual(s) who should not receive the restricted PHI. If we agree to your request, we will not use or disclose the restricted PHI unless it is necessary for emergency treatment. However, we not required to agree to your requested restriction except in the case of restricting disclosure of PHI to a health plan as described below. If you request a restriction on certain uses and disclosures of your PHI to a health plan for a particular health care item or service where said health care item or service is paid for out of pocket and in full, we will abide by your request. Such a request inust made be made in writing to the practice Privacy Officer. Your request must describe in a clear and concise fashion the health care item or service you wish restricted.
• Right to Access: You have the right to inspect and obtain a copy of your PHI. You may request copies of your PHI in either paper or electronic form. In very limited circumstances, we may deny access to your PHI. To request access to your PHI, please submit a request in writing to the practice Privacy Officer including whether you want your copy in electronic or paper form. We will respond to your request as soon as possible, but no later than 30 days from the date of your request. If access is denied you will receive a denial letter within 30 days. If access is denied, an appeals process may be available in certain cases. We have the right to charge a reasonable fee for providing copies of your PHI (and for electronic media, if applicable). Furthermore, you may request that a copy of your PHI be transmitted directly to a third party provided such request is made in writing, signed by you and clearly identifies the designated third party and location to send your PHI. 
• RIGHT TO CONFIDENTIAL COMMUNICATIONS: You have the right to request to receive communication of PHI by alternative means or at alternative locations. For example, you may wish your bill to be sent to an address other than your home. Such requests must be made in writing to the practice Privacy Officer. We will not require an explanation of your reasons for the request, and will accommodate reasonable requests. 
• RIGHT TO AMEND: You have the right to request that we amend your PHI. Your request must be made in writing. We will respond to your request as soon as possible, but no later than 60 days from the date of your request. If we deny your request for amendment, you have the right to submit a written statement disagreeing with the denial. Central Florida Total Health Care has the right to submit a rebuttal statement. A record of any disagreement regarding amendments will become part of your medical record and may be included in subsequent disclosures of your PHI. 
• RIGHT TO AN ACCOUNTING OF DISCLOSURES. Subject to certain limitations, you have the right to a written accounting of disclosures by us of your PHI for not more than 6 years prior to the date of your request. Your right to an accounting applies to disclosures other than those made for purposes of treatment, payment, or health care operations. Please make your request in writing to the practice Privacy Officer. We will respond to your request as soon as possible, but no later than 60 days from the date of your request. We will provide you with one accounting every 12 months free of charge. We will charge a reasonable fee based upon our costs for any subsequent accounting requests.  
• RIGHT TO A COPY OF OUR NOTICE OF PRIVACY PRACTICES. We will ask you to sign a written acknowledgement of receipt for our Notice of Privacy Practices. We may update this Notice of Privacy Practices at any time. Upon your request, we will provide you with a current copy of this Notice. 
• RIGHT TO NOTICE OF BREACH. You have a right to receive notice if there has been a breach of your unsecured PHI. 

 

8. COMPLAINT PROCEDURE

• WITHIN OUR PRACTICE: If you have a complaint about the denial of any of the specific rights listed above, about our Notice of Privacy Practices, or about our compliance with state and federal privacy laws you may receive more information about the complaint process by contacting the practice Privacy Officer at 407-392-1919.
• Outside our Practice: If you believe that CENTRAL FLORIDA TOTAL HEALTHCARE is not complying with its legal obligations to protect the privacy of your PHI, you may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights.
• We will not retaliate against you for filing a complaint. 
  

 

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

1. Print legibly in all fields using dark permanent Ink.
2. Section I, print your name or the name of patient whose information is to be released.
3. Section II, print the name and address of the facility releasing the information. Also, provide the name of the person, facility, and address that will receive the information.
4. Section III, state the reason why the information is needed, e.g., disability claim, continuing medical care, legal, research-related projects, etc.
5. Section IV, check the appropriate box as applicable.

   1. a.Only information related to -- specify diagnosis, injury, operations, special therapies, etc.

   2. b. Only the period of events from -- specify date range, e.g., Jan. 1, 2002, to Feb. 1, 2002.

   3. c. Other (specify) -- e.g., CHS, Billing, Employee Health.

   4. 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

   5. 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.

   6. 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.

6. Section V, if a different expiration date is desired, specify a new date.

7. Section V, Please sign (or mark) and date.

8. A copy of the completed IHS-810 form will be given to you.

 

OMB STATEMENT

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.