I hereby guarantee payment of all charges incurred for services rendered at South Florida Rheumatology. Further, I hereby guarantee payment of all attorney’s fees, court costs and collection charges incurred in the event that collection action is initiated by South Florida Rheumatology and authorize the review of my consumer report if deemed necessary. I authorize South Florida Rheumatology to contact me by the use of any automatic dialing system or by pre-recorded forms of voice/messaging systems. Further, I authorize South Florida Rheumatology to contact me via cellular phone and electronic mail owned or used by the patient or responsible party. I understand that professional fees (Radiologist, Pathologist, Anesthesiologists, Surgeons, Consulting, Admitting and Attending Doctors) will be billed separately by their office.
I understand that this consent is subject to revocation at any time except to the extent that action has been taken in reliance thereon. I certify that I have read the foregoing, received a copy thereof, and I am the patient, the patient’s legal representative or duly authorized by the patient as the patient’s general agent to execute the above and accept its terms. I also fully understand the consent contained in this record and voluntarily execute it.
Answer each line and question in the space provided. Circle/check the best answer. This survey will help the doctor evaluate, diagnose and treat you. Write your comments & questions on next page.
ABOUT YOUR ARTHRITIS OR PROBLEM
First Diagnosed as * By Dr. * Where? * .
I have been made aware of South Florida Rheumatology’s privacy practices as described in the Notice of Privacy practices. Further, in accordance with South Florida Rheumatology’s privacy practices and to protect the confidentiality of my protected health information (PHI), I hereby direct that disclosure of my PHI may be restricted. Specifically, no documentation of any information related to my stay or treatment, including but not limited to any documents or other materials prepared for peer review, risk management, or quality assurance purposes, is to be disclosed under any circumstances, redacted or otherwise to anyone not affiliated with South Florida Rheumatology, for any purpose other than payment or licensure/accreditation requirements, without my expressed written consent or the expressed written consent of my authorized representative. The notice of privacy practices is located at SouthFloridaRheumatology.com.
If for some reason you can't make your scheduled appointment, please give us notice of cancellation at least 24 hours in advance; otherwise, a $50 fee will be applied to your bill. When you arrive, you will be asked to check in and to fill out necessary paperwork.
If your insurance, address, or phone number has changed, please let us know so we can give you new paperwork to update your records.
If your need for an appointment is urgent and we have to work you in to our busy schedule, please note that there will be a wait time, as scheduled patients must be seen first.
It is important for you to bring in all current medications for every visit, so we can avoid problematic medicine interactions and dosages.
If you need a refill on a medication we prescribe, have your pharmacy contact our office on weekdays when your chart is available to our physicians.
If you have any questions concerning our billing processes and requirements please call (954) 961-3252.
With HMOs and certain insurance plans, you will need to get a referral from your primary physician before scheduling your visit with our offices. If you need one of our doctors to prepare forms such as insurance forms, personal letters, or specific medical records, certain fees will apply:
The following fee schedule applies for Doctor preparation of certain forms, personal letters and medical record copies.
Insurance Forms- $25/form and upFamily Medical Leave - $25/each and up3. Medical Records- $1/page for the first 25 pages, then .25/each additional page.