New Patient Packet

sender
example@example.com
OFFICE GUIDELINES - PLEASE READ CAREFULLY
By federal law and managed care contract law, this office is required to collect co-payment, co-insurance and deductible for each encounter. Please help us comply with these requirements by making your co-payment today.

We accept cash and most major debit/credit cards, NO CHECKS. Penalty for not following this requirement could result in termination and cancellation of coverage for the patient. If you have a balance in our office and it is not satisfied, we reserve the right to place with a collection agency with a 30% fee added to your balance.

Call us if you need to cancel or reschedule your appointment 24 hours in advance. You may call our office after hours and leave a voicemail. Office visit cancellation fee is $65-ultrasound fee is $40. This fee is expected to be paid before or at your next visit. Our office has a one time forgiveness in which. your office visit fee may be waived. NO SHOW FEES WILL BE ASSESSED.

We ask that you PLEASE FIND ALTERNATE CHILDCARE on the day of your scheduled appointment, if possible, in consideration to other patients.

Because of limited space, ONLY TWO PEOPLE ARE ALLOWED IN EXAM ROOMS. We strongly recommend you NOT bring children into the exam room.

If you are pregnant we ask that you provide a URINE SAMPLE AT EVERY DOCTOR VISIT.

No fee will be applied if medical records are sent to another physician. If patient requests a printed copy of medical records, a $25 minimum fee will be applied according to the number of pages. Family and Medical Leave Act (FMLA) paperwork or any other forms that require Dr.Cabrera's signature will be subjected to a fee of $20 for completion. Please allow up to 15 bussiness days to complete. THANK YOU FOR YOUR COOPERATION!
Date*

MonthDayYear
Date
Signature*
Type Name*
Specializing in Complete Women's Health Care

PATIENT INFORMATION

Upon registering, please present proof of insurance including Medicare and/or Medicaid. Payment is expected at the time of service unless special arrangements are made.
Patient Information
Name*

First NameLast Name
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Marital Status*
Date of Birth:*

MonthDayYear
Date
Age:*
Sex*

MaleFemaleOther
Email*
example@example.com
Driver's License #:
Issued State
Social Security #:*

Patient Employer/School
Employer/School
Occupation*
You can enter student or unemployed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
EXT
May we contact you at work?*

YesNo
If Student:

Full-timePart-time

Insurance Information
Company
Insured's Name
Insured's D.O.B

MonthDayYear
Date
Insured's Address ( if different than patients)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy #
Group #

Pharmacy of Choice
Pharmacy Name*
Pharmacy City*

Street Address

Street Address Line 2

State / Province

Postal / Zip Code

Patient's Significant Other or Guardian
Name*

First NameLast Name
Relationship*
D.O.B*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address (If different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
May we discuss general patient information with this person (appointment date/ time, treatment, payment, etc.)*

YesNo

Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
May we discuss general patient information with this person (appointment date/ time, treatment, payment, etc.)*

YesNo
I certify the above information is correct to the best of my knowledge. I also understand that i am financially responsible for all charges whether or not they are covered by my insurance plan.
Signature*
Date*

MonthDayYear
Date

Dear Patient:

In order to serve you better, please write your three main concerns or questions for the doctor and/ or nurse.
Name*

First NameLast Name
Date*

MonthDayYear
Date

NOTICE OF PRIVACY POLICY AND PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED ANO DISCLOSED ANO HOW YOU CAN GET ACCESS TO TI-IIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Purpose of this Notice

Our office respects the privacy of personal information and understands the importance of keeping this Information confidential and secure. This notice describes our privacy practices with respect to your health information. Our privacy practices apply to current and former patients.

Types of Personal and Health Information We Collect

We collect a variety of personal health information when delivering health care. You provide some of this information when you lnltlally come into our office, such as address, social security number and health history. We also receive additional personal and health Information such as eliglblllty through our transactions with employers, insurance companies and other health care providers. We limit the collection of personal Information to that which is necessary to administer our business, provide quality service and meet regulatory requirements.

How We Protect Personal and Health Information

We treat personal and health information securely and confidentially. We limit access to personal information to only those persons who need to know that information to provide services to patients (I.e., billing clerks and medical assistants). These persons are trained on the lmpoI·tance of safeguarding this Information and must comply with our procedures and applicable law. We meet physical, electronic and procedural security standards to protect personal and health information and maintain internal procedures to promote the integrity and accuracy of that information.

Disclosure of Personal and Health Information

We may share any of the personal and health information we collect with our associates as permitted by law. We may also disclose this information to non-associated entities or individuals as permitted or required by law. Non-associates with whom we may disclose Information as permitted by law Include: attorneys, accountants, auditors, a patient's authorized representative, other healthcare providers, public health authorities, coroners, medical examiners, funeral directors, organ donation organizations, institutional review boards for research purposes, third party administrators, insurers, and law enforcement or regulatory authorities.

We may also disclose any personal and health information we collect in order to provide appointment reminders or to give you information about other treatments or health related benefits and services that may be of interest to you. In addition, in the event that this office is sold or merged with another office, your personal and health information will become the property of the new owner. We do not disclose personal or health information to any third parties without a patient's request or authorization.

Individual Rights to Access & correct Personal Health Information

We have procedures for a patient to access the personal and health information we collect, and other than the information we collect In connection with, or in anticipation of, a lawsuit or legal claim, we will make this information available to the patient upon written request. Our goal is to keep our patient information up"to-date and to correct inaccurate information. We have procedures in place to ensure the Integrity of our information and for the timely correction of incorrect information. If you believe that any personal or health Information we have about you Is not accurate, please let us know by contacting the Office Manager.

Further Information

The practice reserves the right to amend this Notice of Privacy Policy and Practices at any time in the future. Until such amendment is made, the practice is required by law to comply with this notice. Further questions regarding this notice may be directed to the Office Manager by phone: (850)398-8940 or in person at 131 E. Redstone Ave. Suite 102 Crestview, FL 32539.

PRIVACY POLICY AND PRACTICES ACKNOWLEDGEMENT

I have received the Notice of Privacy Policy and Practices and I have been provided an opportunity to review it.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Signature*
Date*

MonthDayYear
Date

SPECIMEN COLLECTION/TESTING CONSENT

Please be advised that during your examination with Dr. Cabrera, there may be specimens (pap smear, culture, biopsy, etc.) obtained. This office does not perform laboratory testing on these; each specimen will be sent to an outside reference laboratory to be interpreted by a licensed pathologist/cytologist. This office does not charge for the collection of these specimens, however, you will receive a statement from the laboratory for services rendered. This office is not associated in any way with the reference laboratory therefore, any questions regarding your statement will need tobe directed to the laboratory performing the service at the phone number on your statement.

*Please be advised that during your examination with Dr. Cabrera a Urine Drug Screen will be performed on Obstetric patients.

I have read the above statement and do hereby consent to testing.
Signature*
Date*

MonthDayYear
Date

CONSENT FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
As required by the Health Insurance Portability and Accountability Act of 1996, this practice may use your health Information for the purposes of treatment, payment or health care operations. The specific uses and disclosures that we intend to make are described in our Notice of Privacy Policy and Practices. You have the right to review this notice prior to signing this consent form. You may request restrictions on the uses and disclosures described in the Notice of Privacy Policy and Practices by describing the requested restrictions in the "Restriction Request Section" of this form. You may revoke this consent at any time by signing and dating the revocation and returning to this office.
CONSENT SECTION
I,blanks (print name) hereby consent to the use and disclosure of my personal health information for the purpose of treatment, payment and healthcare operations, My signature below indicates that I have been given an opportunity to read the Notice of Privacy Policy and Practices and to have any questions answered befoi-e signing. I understand that I may request restrictions on the uses and disclosures of my health information at any time by completing and signing the restriction request of this form. I also understand that this practice is not required to accept my restriction request. I understand that I may revoke this consent at any time by signing the revocation section of this form and returning it to this pI·actice. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this consent.
Signature*
Date*

MonthDayYear
Date
RESTRICTION REQUEST SECTION

I hereby request the following restrictions on the uses and disclosures of my health information.
(Please describe the requested restrictions in detail):
REVOCATION SECTION
I hereby revoke this consent for use and disclosure of health information effective this day of , , 20 .

AUTHORIZATION TO RELEASE INFORMATION
Dr. Sergio J. Cabrera may disclose all or part of this patient's records to any insurance company or association and the Federal or State Government as such information may be necessary for the completion of all health care claims associated with services rendered. I understand this information to be released may include information pertaining to mental or psychiatric related conditions and/or drug or alcohol abuse and HIV/AIDS. A copy shall be as valid as the original.

ASSIGNMENT OF BENEFITS

I hereby authorize payment to Dr. Sergio J, Cabrera, benefits herein specified and otherwise payable to me for any services rendered by the physician subsequent to this date and for such other charges as may be made by physician, I hereby agree to pay the same and also agree that in the event medical coverage is insufficient to pay the indebtedness incurred and should there be any monies over and above the necessary to pay this registration, I agree that said physician may apply this overage against any amount which is owed by myself, spouse or legal dependents of myself or spouse at the time payment is made by my insurance plan.

I certify that the information given by me in applying under Title XVII of the Social Security Act Is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this related medical claim(s). I request this payment of Authorized Benefits be made on or in my behalf to stated physician. A copy shall be valid as the original. I, the undersigned, certify that I have read the foregoing and am the patient, or duly authorized by the patient as the patient's general agent, to execute the above and accept its terms. I certify that this assignment of benefits shall remain in effect for the lifetime of this patient unless revoked in writing via certified mail to 131 E. Redstone Ave, Suite 102 Crestview, FL 32539.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

PERSONAL REPRESENTATIVE/CONFIDENTIAL COMMUNICATION REQUEST
In accordance with the Health Information Portability and Accountability Act of 1996, you have the right to request a personal representative to act on your behalf and that communications concerning your personal health information is made through confidential channels. This practice will not question your request and make every effort to accommodate all reasonable requests.
1. Please list family members or other persons, if any, we may inform or discuss your general medical condition and diagnosis (including treatment, payment and health care operations) with.
Name

First NameLast Name
DOB

MonthDayYear
Date
Name

First NameLast Name
DOB

MonthDayYear
Date
2. Please print the address where you would like your statements and any other correspondence from our office sent.
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. Please print the telephone number(s) where you want to receive calls and/or text messages about appointments. I am fully aware that cell phones are not considered a secure/private line.
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Please indicate if confidential messages (i.e., appointment reminders, lab results, etc,) can be left on your voicemail or answering machine.

YesNo
Signature
I understand that I may revoke this designation at any time. I understand revocation must be in writing and furnished to this office personally or via certified mail. I understand that any such revocation does not apply to the extent that persons authorized have already acted in reliance on this designation.
Date

MonthDayYear
Date

AUTHORIZATION FOR RELEASE OF MEDICAL

You can skip this if you do not need to authorize the release to another medical facility
Clinic Name: SERGIO J. CABRERA, M.D. F.A.C.0.G.

Clinic Address: 131 E. Redstone Ave. Suite 102 Crestview, FL 32539

Tel: 850-398-8940 Fax: 850-398-8943
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SS#
Receive Records From
Release Records To
Please send a copy of my records as indicated for date(s) of treatment Type a label

	Check Box
Operative Records
Lab Reports
H&P
Radiology Reports
Prenatal Records
Discharge Summary
Pathology

Signature*
Purpose of releasing medical Information:
Date

MonthDayYear
Date
Witness
Signature
I understand that my express consent is required to release any health information relating to testing, diagnosis and/or treatment of alcohol or drug related medical problems, and the special consent also will apply to HIV/AIDS related diagnoses, sexually transmitted disease and psychiatric disorders/mental health. This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42C.F.R. Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. The authorization can be revoked but not retroactive to the release of information made in good faith.
Date

MonthDayYear
Date
Permission to FAX records for medical emergency?*

YesNo
Should be Empty:

	Month/Year	Epidural/Anesthesia	Weeks Gestation	Hours in Labor	Vaginal/C-Section	Sex	Weight	Live or Stillbirth	Complications
1
2
3
4

	You	Family	Which Family Member (Paternal or Maternal Only)	Which Family Member (Paternal or Maternal Only)
Heart Disease
Hypertension
Headaches
HEENT
Respiratory/Lung Dis.
Breast Disease/Cancer
Jaundice/Hepatitis
Gall Bladder Disease
Bowel Disorders
Kidney Problems
Urinary Tract Problems
GI/Peptic Ulcer Disease
Anemia/Blood Disorders
Blood Transfusions
Varicose Veins/Phlebitis
Diabetes
Thyroid Disease
Cancer
Epilepsy/Neural Disorder
Strokes
Gyn/Pregnancy Problems
Smoking: Cigs per day
Alcohol: oz per Week
Street Drugs
Psychiatry/Mental Disorder
Not aware of any issues

OFFICE GUIDELINES - PLEASE READ CAREFULLY

PATIENT INFORMATION

Patient Information

Patient Employer/School

Insurance Information

Pharmacy of Choice

Patient's Significant Other or Guardian

Emergency Contact Information

HISTORY & PHYSICAL

Please note!!

NOTICE OF PRIVACY POLICY AND PRACTICES

PRIVACY POLICY AND PRACTICES ACKNOWLEDGEMENT

SPECIMEN COLLECTION/TESTING CONSENT

CONSENT FOR THE USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

CONSENT SECTION

RESTRICTION REQUEST SECTION

REVOCATION SECTION

AUTHORIZATION TO RELEASE INFORMATION

ASSIGNMENT OF BENEFITS

PERSONAL REPRESENTATIVE/CONFIDENTIAL COMMUNICATION REQUEST

AUTHORIZATION FOR RELEASE OF MEDICAL

Clinic Name: SERGIO J. CABRERA, M.D. F.A.C.0.G.

Clinic Address: 131 E. Redstone Ave. Suite 102 Crestview, FL 32539

Tel: 850-398-8940 Fax: 850-398-8943

	Hospitalizations/Major Surgeries	Month/Year	Illness/Operation
1
2
3