New Patient Form

New Patient Form

Offices of Dr. Miguel Trevino and Timothy Light
Provider
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Preferred Pharmacy

Please provide Information so we can easily Identify your pharmacy. Ex: Publix Pharmacy on x and x cross street phone number appreciated if known.
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Primary Insurance
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Secondary Insurance
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Medical History

*****PLEASE BE SURE TO SAVE EVERY LINE ITEM****** PLEASE ENTER "NONE" IN FIELD IF NOT RELEVANT
Please create list of any current Medications you are taking:*
Please create list of any known Medical Diagnosis's if any:*
Please create list of any known Allergies:*
Please create list of Past Surgeries:*
Family History*
Please leave any relevant information on any known possible genetic conditions ex. Father Heart Disease, Mother Cancer and high blood pressure.
If you need to upload any relevant Medical Records do so here (10MB File limit)

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CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
I understand that as part of my healthcare, Dr. Miguel E. Trevino MD, PA as well as Dr. Timothy L. Light, DO originate and maintain health records describing my health history, symptoms, examination and test results diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care and treatment
- A means of communication among the many health professionals who contribute to my care
- A source of information for applying my diagnosis and surgical information to my bill
- A means by which a third party payer can verify that services billed were actually provided
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the Practice reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the Practice is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the Practice has already taken action in reliance thereon.

I understand that I can give my permission to have my medial history and current medical file(s) reviewed by Dr. Miguel E. Trevino MD, PA, Dr. Timothy L. Light, DO and Innovative Research Staff, in order to evaluate if I am a possible candidate for any of their research studies; and thereby eligible for all medications, health supervision and visits, in this office, and in some cases financial recompense for my participation, if I should qualify for a study and choose to participate.
I have read the above consent and Accept the Notice of Information Practices
*I would also like to allow the following individuals to have access to my Confidential Health Information that I have listed below (ex. Mother/Father's Legal name, Husband/Spouse legeal name, Daughter/ Son's legal name):
I request the following restrictions to the use or disclosure of my health information:
Signature*
Date*
Print Name

Financial Policy
As your physician, we are committed to providing you with the best possible medical care. In order to achieve this goal, we need your assistance and understanding of our payment policy.

PAYMENT FOR SERVICE IS DUE AT THE TIME SERVICES ARE RENDERED – We accept cash, personal checks, Credit and Debit Cards. Returned checks are subject to a service charge of $20.00 or 5% of the face values of the check, whichever is greater, and you will lose your privilege to write checks in our office.

CANCELED APPOINTMENTS – Patients who do not give 24 hours’ notice for cancellation of an appointment will be charged a $50 no-show fee. Patients who do not cancel appointments within 24 hours may be discharged from the practice after the third no-show.

BLUE CROSS/BLUE SHIELD PPO/HMO/MANAGED CARE COVERAGE – CO-PAYMENT AND DEDUCTIBLE MUST BE PAID AT THE TIME OF SERVICE. Because we are under contract with these insurance companies, we will file your insurance.

MEDICARE – Your deductible and 20% of the allowable charges are due at the time of service. Since we are a Medicare provider we will file your Medicare. If we do not know the Medicare allowable charge for a specific service, we will bill you after Medicare pays. Please bring your Medicare Explanation of Benefits (EOB) showing you have met your deductible.

FINANCIAL AGREEMENT – We will gladly discuss proposed treatment and do our best to answer any questions relating to your insurance. You must realize, however, that:

1. Your Insurance is a contract between you, your employer, and the Insurance Company. We are not a party to that contract.

2. Not all services are a covered benefit in all contracts. Some Insurance companies arbitrarily select certain services they will not cover (eg. yearly physicals).

We must emphasize that as your medical care providers, our relationship and concern is with you and your health, not your insurance company. ALL CHARGES ARE YOUR RESPONSIBILITY FROM THE DATE SERVICES ARE RENDERED. On any balance on your account after 90 days, including those that insurance had not paid, collection action will be taken. We realize that emergencies do arise and may affect timely payment of your account. If such extreme cases occur, please contact us promptly for assistance in the management of your account.

If it becomes necessary to collect any sum due through an attorney, then the patient agrees to pay all reasonable costs of collection, including attorney’s fees, whether suit is filed or not.

If you have any questions about the above information or any uncertainty regarding insurance coverage, please do not hesitate to ask us. We are here to help you.

I have read and understand the above Financial Policy by signing below.
Signature*
Date*
Print Name*

NOTICE OF INFORMATION PRACTICES
1.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO may use and disclose protected health information for treatment, Payment and healthcare operations. Examples of these include, but are not limited to, requested pre-school, life insurance, or sports physicals, referral to nursing homes, foster care homes, home health agencies and/or referral to insurance companies for claims including coordination of benefits with other insurers; and collection agencies. Healthcare operations include, but are not limited to, internal quality control and assurance including auditing of records.

2.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO is permitted or required to use or disclose protected health information without the individual’s written consent or authorization in certain circumstances. Two examples of such are for public health requirements or court orders.

3.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO will not make any other use or disclosure of a patient’s protected health information without the individual’s written authorization. Such authorizations may be revoked at any time. Revocation must be written.

4.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO may at times contact the patient to provide appointment reminders or information regarding treatment alternatives or other health related benefits and services that may be of interest to the individual.

5.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO will abide by the terms of this notice of the notice currently in effect at the time of the disclosure.

6.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO reserves the right to change the terms of its notice and to make new notice provisions effective for all protected health information of the patient. Copies may also be obtained at any time at our office.

7.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO will provide each patient with a copy of any revisions of its Notice of Information Practice at the time of their next visit, or at their last known address if there is a need to use or disclose any protected information of the patient. Copies may be obtained at our office any time.

8.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO Any person/patient may file a complaint to the Practice and to the Secretary of Health and Human Services if they believe their rights have been violated. To file a complaint with the practice, please contact the Privacy Office at the following address and/or phone number: (1573 South Fort Harrison Avenue, Clearwater, FL 33756, Phone (727) 584-8777). All complaints will be addressed and the results will be reported to the Corporate Compliance Officer.

9.      MIGUEL E. TREVINO, MD, PA, TIMOTHY L. LIGHT, DO and BENJAMIN R. DEVRIES, DO The title and telephone number of a person in the office to contact for further information is the Office Manager at (727) 584-8777 ext 209.

10. The effective date of this Notice of December 1, 2002.

You have the right to file a written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of TIMOTHY L. LIGHT, DO/Dr. Miguel E. Trevino MD, PA/Dr. Benjamin R DeVries DO We will not retaliate against you for filing a complaint.

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services, Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

(202)619-0257 or Toll Free: 1-877-696-6775
Should be Empty:

New Patient Form

Preferred Pharmacy

Health Insurance/Payment Information

Primary Insurance

Secondary Insurance

Medical History

CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

Financial Policy

NOTICE OF INFORMATION PRACTICES