QUALITY CARE MEDICINE, LLC

QUALITY CARE MEDICINE, LLC
Wilhelm Martzian, ARNP-C
4407 6th Street SW
Vero Beach, FL 32968-4061
P: 772.907.5935 - F: 772.217.2761
Name*
Facility
Enter Facility Name
I'm requesting to be seen by Willy Martezian, ARNP-C for any acute and or chronic medical/physical

Signing this form is also stating all medical insurance information provided is correct. I'm responsible for any unpaid balance from the insurance company. I agree to update Quality Care Medicine, LLC immediately with any insurance and/or demographic change.
Name of person signing*
Family/Power of Attorney of Resident Signature*

Clear
Date*

MonthDayYear
Date
Address*
Please provide email & cellular # if you would like access to the patient portal
Cell Phone
Email
example@example.com
Cellular
****If you have Power of Attorney please forward us a copy****
File Upload

Cancelof
Primary Insurance Name*
Patient DOB

MonthDayYear
Date
Medicare or Primary insurance ID #*
Group #
Secondary Insurance Name
Patient DOB

MonthDayYear
Date
Secondary Insurance ID #
Group #

Quality Care Medicine, LLC
4407 6th Street SW
Vero Beach, FL. 32968
Phone: 772-907-5935 Fax: 772-217-2761
Email address: qualitycaremedtc@gmail.com

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient Name*
Date of Birth*

MonthDayYear
Date
Previous Name
I request and authorize from (current/previous Dr.)
Phone
Fax #
*** If records exceed more than 10 pages please mail to the above address or email **

To release healthcare information of the patient named above to:

This request and authorization apply to:

Quality Care Medicine, LLC
Healthcare information relating to the following treatment, condition, or dates:
Last 2 progress notes, labs, and diagnostic test
I authorize the release of my STD results, HIV/Aids testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these tests results to anyone.

YesNo
I authorize the release if any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

YesNo
Name of person signing*
Patient/Family/POA Signature

Clear
Date Signed

MonthDayYear
Date

Mammogram: