Do yo have a family history of|
|Yes||No||Who||Do yo have a family history of Colon Cancer||Yes||No||Who|
|High Cholesterol||Yes||No||Who||Prostate Cancer||Yes||No||Who|
|Heart Problems||Yes||No||Who||Psych/drug/alcohol problems||Yes||No||Who|
|Stroke||Yes||No||Who||High blood pressure||Yes||No||Who|
|Do you currently use tobacco or nicotine?||No,never||Yes,cigarettes||Yes,cigars|
|No,former smoker||Yes,smokeless tobacco||Yes,cig/vapes|
|If you do use tobacco, how often/howmuch do you use?||I am interested in quitting|
|Do you drink alcohol?||No||Yes||If so, how much/often?|
|Do you currently exercise?||No||Yes||How much/often?|
|What is your marital status?||Single||Divorced||Widowed||Separated||Married||Engaged|
|Who lives with you in your home?|
|Do you have childrens?||Yes||No||What are their names?|
|Are you employed?||Yes||No||Retired||Separated||Where employed?|
|Do you attend religious services?||Yes||No||Where attend?|
|What are your hobbies?|
|How did you hear about our practice?|
|Do you currently see any of your family members?|
Consent for medical care and treatment|
I understand that my condition may require diagnosis and treatment. I hereby voluntarily consent to such treatment services, and procedures as ordered by my doctor, his/her consultants associates and his/her designee. I also understand student nurses and others in professional training programs may be among the individuals who provide care to me.
I authorize DR. Pspillon and his assistants/designee to discuss my medical history, diagnosis, treatment and prognosis as provided in the notice of privacy practices. In understand this may include information regarding testing, examination and treatment for HIV. AIDES related illiness, mental health and drug, alcohol or chemical abuse. I have the right to add anyone or any organization that do not wish to have my medical information by requesting in writing at any time (Digital or hardcopy form).
I understand there are times when the law allows Dr. Papillon and his/her assistants/designee to release information regardless of whether or not I give my consent as outlined in the notice of privacy practices. For example, Dr. Papillon and his assistants/designee my release information to doctors, nurses and other who provide me with health care or are prospective health care providers; to government agencies as authorized by law to insurance companies or others who are responsible for paying my medical bills or to a court of law that issues a subpeona or court order. I understand this information may be released either orally or in document form.
I understand and acknowledge that FL law provides id any health care worker is exposed to my blood or other bodily fluid, Dr. Papillon and his/her assistants/designee may perform tests, with or without my consent, on my blood or other bodily fluid to determine the presence pf any communicable diseases, including but not limited to, Hepatitis, HIV/AIDS and Syphillis. I understand that such testing is necessary to protect those who will be caring for me while I am a patient of Dr. Papillon. I understand that the results of tests taken under these circumstances are confidential and do not become a part of my medical records.
I acknowledge that it may be difficult for the physician(s), his/her assistants, or his/her designee to personally communicate with the patient regarding labratory/diagnostic test results, etc. It is the policy of Flex 4 Medical Center to leave a call back request on the patient's telephone answering machine.
NO GUARANTEE: I acknowledge that the practice of medicine is not exact science and that Dr. Papillon has made no quarantees or warranties to me as to the result of treatments or examination.
It is the policy of Flex 4 Medical Center not to release confidential medical information to patient's family members. We cannot discuss your medical condition, or release diagnostic test results to anyone without your consent. I hereby give consent that information regarding my medical conditions, including labratory and diagnostic test results can be given to:
Notice of privacy practices|
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
This notice is being provided to you in accordance with the requirements of the Standards of Privacy of individually identifiable Health Information Portability and Accountability Act(HIPAA) and by the amendments to the HIPAA Privacy Rules made by the Health Information Technology for Economic and Clinical Hesalth Act of 2009 (HITECH Act).
I acknowledge that I have been provided with Flex 4 Medical Center Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this consent. I understand that F4M reserves the right to change its Notice of Privacy Practices and prior to implementation will mail a copy of any revised notice to the address I have provided.
By signing this form, I consent to F4M use and disclosure of my health information for treatment payment and health care operations.
Patient informed consent for electronic medical services
F4M has implemented an electronic health record in part to meet the U.S. Department Health and Human Services initiative to improve health information technology, toward the goal of improving quality of health care. Our electronic health record integrates your clinical record with appointments, registration, and billing and makes this information available to the clinicians who are involved in your care.
In connection with its ecectronic communication systems, F4M has also implemented and has in place privacy ans security policies and procedures to minimize risk of ininadvertant or unaithorized disclosure, corruption and/or loss or distortion of data, but as with all record keeping systems, wether paper or digital, some risks remain of loss, inadvertant disclosures or errors in the recorded data.
I have read and understand the information provided regarding Electronic Medical Services, have discussed it with my physician, his/her assistants, or designee, and all of my questions have been answered to my satisfaction.
I hereby give my informed consent for the use of Electronic Medical Services in the course of my diagnosis and treatment and consent to the electronic communication of my personal health care information to other entities for treatment payment or health care operations, including electronic transfer of medical data to other medical practitioners participating in my medical care.
Informed consent for prescriptions
F4M continues its position as the network exchange for the flow of vital patient information to physicians and other health care providers. It is essential to improve patient safety and the continuity of care with electronic connectivity between payers, physicians and pharmacists. F4M Electronic Health Record(EHR) provides secure access for patients with commercial prescription coverage in the United States.
Prescription eligibility, benefit, formulary and medication history information is provided for consenting patients to authorized physicians at the point of care. Electronic prescriptions are delivered in real-time to pharmacists in the retail and mail order settings.
I consent to electronic prescriptions and acknowledge that F4M will use electronic connectivity between payers, physicians and pharmacists.
|Authorization for release of patient's protected health information (PHI)|
|This information is to be release|
Copy of all records
||Continuance of care|
|Records to be faxed or electronically transmitted.|
I understand the information released as a result of the Authorization may be subject to re-disclosure and no longer protected by federal or state laws applying to medical information release.
I understand that there may be a fee for copying of my medical records if it it is to be used for other than continuance of health care with another provider.
I understand that this Authorization may be revoked in writing at any time. I understand that revocation will apply only to releases of information made after the date of my revocation.
Unless otherwise indicated, this authorization will expire twelve(12) months from the date of signature. A photocopy of this authorization will be considered as valis as the original. I understand that I will be provided a copy of this Authorization upon request.
I understand and agree that my medical record will be maintained in an electronic medical record(EMR) format and that records may be transmitted electronically via fax, email, Internet or data transfer system.
Menu links 2021 Flex 4 Medical