MD Precision Health 1st English

MDteleme Precision Health

6840 SW 40th Street, Suite 209, Miami, FL 33155

Phone : (786) 800-2430 | Fax: (305) 763-8379

Text Only (786) 442-1584
You have registered as a patient who will pay privately with MDteleme Precision Medicine. This indicates that you will be paying for the service with either cash, a check, or a debit or credit card at the time of the service. We shall not submit claims to the insurance company for any of the services supplied in accordance with this agreement.
Fecha

MesDíaAño
Fecha
Visit Type*

Telemedicine. (By Computer or Phone)In Office (Physically in Office)
Please select who is requesting Our Services?*

The Services are for me (I'm the Patient).I'm the Legal Guardian of the person needing Services.
Legal Guardian Information*
Patient Full Name*

NameLast Name
Patient Date of Birth*
month / day / year
Do you have MEDICARE as Primary Health Insurance? (65 or older or disability).*

Yes.No.
Advance Beneficiary Notice of Noncoverage (ABN)
G. OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. the Telemedicine Service listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.OPTION 2. I want the D. the Telemedicine Service listed above, but do not bill Medicare. MDteleMe may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.OPTION 3. I don’t want the D. the Telemedicine Service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
MDteleme Warning!

You have chosen Option 3. Meaning...

You DO NOT WANT to use the D. Telemedicine Service listed above.
Patient Phone Number*
Email
(An email Address is required if you would like to be registered for Virtual Consultation)
Address*

Street

Street

CityState

Zip Code
Gender*

MaleFemaleOtherRather not say
Weight and Height*
Photo of your ID (please take it readable) / NO Need if you are an establish patient
RELEASE OF HEALTH INFORMATION

In case you cannot reach me, I authorize an RMB / MDteleMe representative to try to contact me, using my Emergency Contact and provide strictly necessary information related to the immediate care of my medical condition.
Do you have an Emergency Contact? (in case we cannot reach at you)*

YesNoAlready Provided in previous Consultations
Please note that providing Emergency Contact information would facilitate faster communication with you.
Emergency Contact Information*
Pharmacy (medications will be electronically sent to the pharmacy)/ only if New or need Update

Pharmacy Name/Type

Address

CityState

Zip Code
Marital Status

SingleMarriedDivorcedLegally SeparatedWidowed
Ethnicity

Hispanic/LatinoBlack/African AmericanWhiteAsianNative AmericanOtherRather not say
Do you use any of the following? Check all that applies.

AlcoholTobaccoCaffeineRecreational Drugs
Medication Allergies?*

NoYes
Which medication are you allergic to?

AntibioticPain MedicationSeizure MedicationsSulfaLocal AnestheticsOthers (Discuss with Provider)
Specify which Medication, you are allergic to:
Allergies to Other Substances, Medications or Food

NoYes
Specify which other Medication, Substances or Food you are allergic to:
Type of Allergic Reaction

RashShortness of BreathSwellingAnaphyilaxisOther (Discuss with Provider)
Which other reactions you've had? Please Describe...
Medical Condition (Do you have any Chronic Medical Condition?)*

NoYesI am a stablish patient to the office
Select which Medical Condition

DiabetesHigh Blood PressureThyroidHeartAsthmaMental illness (anxiety, depresion, bipolar, ...)AnemiaSeizuresOther(s) (discuss with provider)
Describe which other Medical Condition...
Medications, are you taking any?*

NoYesI am a stablish patient to the office
Which Medication(s)?
Any Surgeries?*

NoYesNone new since previous visits
Which Surgeries?

AppendicitisGallbladderHysterectomyThyroidHeartKidneysTonsilsHerniaC-sectionOther
Describe which other Surgeries you've had.
Mother, Alive?*

NoYesI Already provide this information to the office
Mother, Any Medical Condition?

No Medical ConditionHigh Blood PressureDiabetesHeartThyroidCancerRespiratory Chronic ConditionOther
Any other Medical Condition not listed before?
Father, Alive?*

NoYesI Already provide this information to the office
Father, Any Medical Condition?

No Medical ConditionHigh Blood PressureDiabetesHeartThyroidCancerRespiratory Chronic ConditionOther
Any other Medical Condition not listed before?
Any Family History of Cancer?*

NoYesI Already provide this information to the office
Explain which type of Cancer and family member...
Responsibility to pay for the services to be received

I understand that:
- Benefits for some or all of the services provided by the Clinic are not included in the health plan under which I am covered
- Despite the above, I do not wish for the Clinic to file a claim with my insurace Company for the services provided to me.
- Until I am able to notify the Clinic in writing, I will pay for all of the services I get from the Clinic of MDteleMe | Tarifas with MdTeleme Precisiom Medicine.
- While choosing to pay for my own services, any payment I make to the Clinic will not be considered sufficient to satisfy any deductible that may arise as a result of my medical insurance plan with the Company, unless the terms of my plan allow otherwise.
- I read this Self-Pay for Services Selection Form and have had the opportunity to ask any questions I might has about it.
- To my complete satisfaction, whatever questions I could have had about this form has been answered.
- After asking the clinic about the payment options and after considering them, I choose to pay for the services on my account.
- If the patient is under the age of 18 or cannot sign for himself, the patient's signature or that of the responsible party is required
Terms and Conditions (you need to read and accept to receive services)
BUSINESS HOURS*

I understand unusual circumstances will sometimes require the office hours to be changed without notice. I understand the pre-recorded telephone message will let me know when to call back for routine requests and what to do in case of an urgent medical need (one that does not require emergency treatment). I understand that I should call 911 in the event of a medical emergency or proceed to the closest emergency room for treatment.
PRESCRIPTIONS AND/OR REFILLS*

The choice of medications will be made in consultation with your mental health provider. As your genetic interpreting professional, I do not prescribe medications for mental health disorders and any recommendations should be discussed with your healthcare provider. Consult your healthcare provider for personalized guidance based on this genetic testing report.
PATIENT FORMS COMPLETION*

I understand that an office visit may be necessary if I request the provider complete certain forms for me. There may also be a nominal fee, payable in advance, for the completion of these forms. I understand these requests may take up to 14 days for processing.
Labs and Testing*

This is to inform you that the laboratory tests conducted with MdTeleMe Precision Medicine are considered special labs and are not be covered by insurance. These special labs may include specific diagnostic tests, advanced screenings, or experimental procedures that fall outside the scope of typical insurance cover. By signing you acknowledge and understand that any associated costs will not be covered by your insurance plan, and you agree to assume responsibility for any applicable charges.
I have read and agree to the following terms and disclaimers stated above. Signature: This consent is valid for the next 4 days (96 hours) from the date of your Signature.*
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