ALLAF MEDICAL PATIENT INTAKE FORM

DR. WADDAH ALLAF M.D., P.A.

OFFICE POLICIES
1. I agree to follow 24 hours for prescription refills.

2. I understand that prescription refill requests after 4:00pm will not be received and processed until the next business day.

3. I understand that a follow-up visit may be required in order to obtain a refill.

4. I agree to take all medications EXACTLY as instructed. I am NOT allowed to change dosage amounts to alter the time schedule of taking medication without first speaking with Dr. Allaf or his staff.

5. I understand that some medications may not be electronically processed and I will be responsible for taking prescription to the pharmacy.

6. I WILL NOT give, trade, or sell my medications.

7. The following are conditions for immediate termination from the practice:

A) Obtaining narcotics from any other physician while under Dr. Allaf without notification.

B) Altering or forgiving a prescription. (This is a felony and will be reported)

8. Patients may be terminated from the practice with 30 days notice for noncompliance with a medication and/or noncompliance of Dr. Allaf.

9. I MUST keep all appointments as recommended.

10. My provider may choose to provide me with a sample of a prescribed medication; this is a trial sample only. Samples are not for maintenance purposes. A prescription will be electronically sent to your pharmacy. Medication pick up time is depended on YOUR PHARMACY, not Dr. Allaf and his staff.

11. Professional mannerism is to be maintained with ALL staff members AT ALL TIMES.

12. If my insurance requires me to obtain a referral to see Dr. Allaf, I understand that I am responsible for getting referral from my primary physicians office.

13. It is courtesy of Dr. Allaf’s office to obtain referrals from my primary physician.

14. Copays are rendered at time of service NO EXCEPTIONS.

I have read, understand, an agree to the policies above. I understand that if I do not sign this document, my physician may refuse to prescribe my medications.
Patient Name (Printed)*
DOB:*
Patient Signature:*

Clear
Date:*

MonthDayYear
Date

PATIENT INFORMATION FORM
PLEASE PRINT ALL INFORMATION. BE SURE TO COMPLETE AND SIGN IN PROVIDED AREAS.
LAST NAME*
FIRST NAME*
HOME ADDRESS*
CITY, STATE, ZIP CODE*
CELL PHONE*
SECONDARY PHONE
SOCIAL SECURITY NUMBER*
DATE OF BIRTH*
BIOLOGICAL SEX*

MALEFEMALE
EMERGENCY CONTACT NAME*
EMERGENCY CONTACT PHONE*
SECONDARY EMERGENCY CONTACT NAME
SECONDARY EMERGENCY CONTACT PHONE

INSURANCE
PRIMARY INSURANCE NAME
PRIMARY INSURANCE PHONE
PRIMARY INSURANCE MEMBER I.D.
SECONDARY INSURANCE NAME
SECONDARY INSURANCE NUMBER
SECONDARY INURANCE MEMBER I.D.

PHARMACY
PHARMACY NAME*
PHARMACY ADDRESS
PHARMACY PHONE

PRIMARY CARE PHYSICIAN
PRIMARY PHYSICIAN NAME
PRIMARY PHYSICIAN NUMBER
I hereby authorize payment of medical benefits billed to my insurance to Waddah Allaf, M.D. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I also accept responsibility for fees that exceed the payment made by my insurance, if the Practice does not participate with my insurance. I agree to pay ALL copayments, coinsurance, and deductions at the time service is rendered. All appointment cancellations / reschedules must be Ade 24 hours in advance or you will be charged $25.00 cancellations / reschedule fee.
SIGNATURE OF PATIENT OR GUARDIAN*

Clear
Date*

MonthDayYear
Date

MEDICATIONS/ALLERGIES
PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY USING.
DO YOU HAVE ALLERGIES?

YESNO
IF YES, WHAT ARE YOU ALLERGIC TO?

MEDICAL RECORDS RELEASE FORM
PATIENTS NAME:*
DATE OF BIRTH:*

MonthDayYear
Date
SOCIAL SECURITY NUMBER:
TELEPHONE NUMBER:
PLEASE RELEASE MY MEDICAL RECORDS FROM:
NAME OF PROVIDER
PROVIDER'S ADDRESS
TO:

WADDAH ALLAF MD., FCCP, P.A.

20200 W. DIXIE HIGHWAY, SUITE 1108

AVENTURA, FLORIDA 33180

TEL: (305) 949-6003 FAX: (305) 945-2483

PLEASE RELEASE ALL RECORDS, INCLUDING BUT NOT LIMITED TO PROGRESS NOTES, OPERATIVE NOTES, LABORATORY TEST RESULTS, DIAGNOSTICS TESTS AND X-RAYS.

I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS AS PROVIDED ABOVE.
PATIENT'S SIGNATURE*

Clear
DATE*

MonthDayYear
Date

PATIENT CONSENT FORM
WADDAH ALLAF
Patient Consent for Use and Disclosure Of Protected Health Information
I hereby give my consent for Waddah Allaf to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).

(The Notice of Privacy Practices provided by Waddah Allaf describes such uses and disclosures more completely).

I have the right to review the Notice of Privacy Practices prior to signing this consent. Waddah Allaf 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 Waddah Allaf 20200 W Dixie Highway Suite #1108 Aventura, FL 33180.

With the consent, Waddah Allaf may call my home or other alternative 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 calls pertaining my clinical care, including laboratory test results, among others.

With the consent, Waddah Allaf may mail to my home or other alternative 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.”

With this consent, Waddah Allaf may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Waddah Allaf restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Waddah Allaf to use and disclose my PHI to carry out

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Waddah Allaf may decline to provide treatment to me.
I have signed this form to give consent as stated; this form will not affect my ability to get medical care. This form will not affect my health insurance coverage. I can refuse to sign this form. I have read this form. I have signed this form as my own free choice. I understand this form. All my questions have been answered.
Signature of Patient or Legal Guardian*

Clear
Print Patient's Name*
Date*

MonthDayYear
Date
Print Name of Patient or Legal Guardian, if applicable

Copywright © 2002 Gates, Moore & Company. Used with permission. “The HIPAA Privacy Rule: Three Keys Forms.” Bush J. Family Practice Management. February 2003 : 29-33, http://www.aafp.org/fpm/
Should be Empty:

DR. WADDAH ALLAF M.D., P.A.

PATIENT INFORMATION FORM

INSURANCE

PHARMACY

PRIMARY CARE PHYSICIAN

MEDICATIONS/ALLERGIES

PAST MEDICAL HISTORY

SOCIAL HISTORY

MEDICAL RECORDS RELEASE FORM

PLEASE RELEASE MY MEDICAL RECORDS FROM:

PATIENT CONSENT FORM

WADDAH ALLAF

Patient Consent for Use and Disclosure Of Protected Health Information