sunshinedoctors.com - PATIENT INFORMATION FORM

PATIENT INFORMATION FORM
PATIENT INFORMATION
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Soc. Sec. #
Marital Status
Allergies
Driver's License #
Cell Phone #
Please enter a valid phone number.
Patient's Employer
Spouse's Name
Spouse's Work #
Please enter a valid phone number.
Spouse's Employer
Emergency Contact:
Relationship
Address:
Phone #
Please enter a valid phone number.
Referred by (how you heard about us)
BILLING INFORMATION & RESPONSIBILITY
Billing Name
Relationship (If other than patient)
Billing Address
INSURANCE INFORMATION
Name of insured
Relationship to Patient
Primary Insurance Co.
Phone #
Please enter a valid phone number.
ID#
Group
Additional insurance Co.
Phone #
Please enter a valid phone number.
ID
Group #
Note: Payment expected at time of service, unless prior arrangements made
Signature

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Date

MonthDayYear
Date
Name
Date

MonthDayYear
Date

HIPAA DISCLOSURE
Patient consent for use and disclosure of protected Health Information

With my consent, Sunshine Medical Center may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operation (TPO). Please refer to Sunshine Medical Center’s Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Sunshine Medical Center reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Sunshine Medical Center Privacy Officer at 5937 Beneva Road, Sarasota, FL 34238.

With my consent Sunshine Medical Center may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my consent, Sunshine Medical Center may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked personal and confidential. By signing this form, I am consenting to Sunshine Medical Center’s use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon prior consent. If I do not sign this consent, Sunshine Medical Center may decline to provide treatment to me.
Signature of patient or legal guardian

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Patients Name
Print name of patient or legal guardian
Date

MonthDayYear
Date

PAYMENT AUTHORIZATION
ASSIGNMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical/medical benefits to Sunshine Medical Center LLC services rendered by Dr. S. Prakash, in person or under his/her supervision, I understand that I am financially responsible for any balance not covered by my insurance.
Signature of responsible party

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Date

MonthDayYear
Date
AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Dr. S. Prakash to release my medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits
Signature of responsible party

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Date

MonthDayYear
Date
I have received and read the Notice of Privacy Practices for sunshine Medical Center LLC.
Date

MonthDayYear
Date
Signature of responsible party

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LIVING WILL DECLARATION
Declaration, made this Type a label day of Type a label , 2011, I, Name willfully
and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set
forth below, and I do hereby declare:

If at any lime should have a terminal condition and my attending or treating physician and another consulting
physician have determined that there is no medical probability of my recovery from such condition, I direct that
life-prolonging procedures be withheld or withdrawn, when the application of such procedures would serve only
to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration
of medication or the performance of any medical procedure deemed necessary to provide me with comfort care
or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal
right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the
withholding, withdrawal or continuation of life-prolonging procedures, I wish to designate the following person
as my surrogate to carry out the provisions of this declaration:
Print Name and Signature

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Address
Phone
Please enter a valid phone number.
I understand the full import of this declaration, and I am emotionally and, mentally competent to make this
declarant.
Witness
Witness
Address
Address
Phone
Please enter a valid phone number.
Phone
Please enter a valid phone number.

AUTHORIZATION TO RELEASE INFORMATION
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
SS #
I authorize my medical information to be released from:
Physicians Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PLEASE MAIL OR FAX RECORDS TO:
- Sunshine Medical Center LLC
- Soordal Prakash M.D. & Shanthi Prakash M.D.
- 5937 Beneva Road
- Sarasota, Florida 34238
- Office # 941-918-2011 / Fax # 941-918-2046
For the purpose of review/examination of medical history
Type a label Records from previous physicians (history, clinical, summary, recent labs, x-rays, surgeries) from the last three years.

I understand that:
This authorization expires one year from the date signed. I may revoke this consent by written statement at any time to extent that action has taken in reliance thereon. My treatment, payment, enrollment or eligibility for benefit may not be conditioned on signing this authorization, there is potential for re-disclosure by the recipient, and no longer protected.
Signed

Clear
Date

MonthDayYear
Date
Witness

OFFICE POLICY
I agree to abide by the following while I am under the medical care of Sunshine Medical Center:

To keep the office informed of any changes in my address, phone numbers and insurance information, by calling with the new information or giving it to the front desk upon signing in.

Patents under 18 must have a parent or guardian sign an authorization to be treated at each visit. For school age patients, a copy of their immunization record is to be given to the office.

Whenever possible, contact the office for prescription renewals 7-10 days before medication runs out, and to call ahead before picking up written prescriptions.

If for any reason you cannot make your scheduled appointment, please call our office 24 hours prior to cancelling your appointment otherwise you will be billed $25.00 for a missed appointment.

For urgent medical care after hours or on weekends, call the office and leave a voice mail message including your name and phone number. The doctor will return your call promptly, so have your pharmacy phone number handy. For a true medical emergency, call 911 to be taken to Sarasota Memorial or Doctors Hospital emergency room and inform the ER of your doctor's name. The doctor will follow your hospital treatment.

If you need to change doctors, the office has a written request form which must be completed. Your medical records will be copied and you may pick them up when ready or records may be faxed or mailed to the doctor whose name and address you have supplied to us. A charge may be applied.

Medicare assignment of benefits is accepted. Regarding other insurance coverage, please check with the office. Be advised that deductibles and co-payments are your responsibility and are due at the time of service. Other (non-insurance) payment is due at the time of service.

I have read and agree to abide by the policies written above.
Signed

Clear
Date

MonthDayYear
Date
Should be Empty:

	Health Status	Age If Living	Age At Death	Cause Of Death	Illnesses
Father
Mother
Brother(s)
Sister(s)

	B.P.	Pulse	Extremity	Comment
Sitting:
Standing:
Supine:

PATIENT INFORMATION FORM

PATIENT INFORMATION

BILLING INFORMATION & RESPONSIBILITY

INSURANCE INFORMATION

MEDICATIONS

Allergies

Past Medical History

Family History

REVIEW OF SYMPTOMS

Vital Signs

HIPAA DISCLOSURE

PAYMENT AUTHORIZATION

LIVING WILL DECLARATION

AUTHORIZATION TO RELEASE INFORMATION

OFFICE POLICY