MEDICAL RECORDS RELEASE
I insert name*, with a date of birth being date of birth* authorize the release of any and of my medical records listed below from previous provider for the following dates:My Entire Medical Records Please send the above selected records to the following: HOLISTIC PRIMARY CARE OF BREVARD 8032 Spyglass Hill Rd, Suite 102 Melbourne, FL 32940 (321) 757-6899 phone (321) 757-6859 fax Referrals@MedicalPartnersOfFlorida.com Signature* Date* I understand these records may contain information from other healthcare providers, as well as information which are administrative in nature. This information will be given only to those specified on this form and only through the expiration date stated above. I also understand I have the right to revoke this authorization at any time through written notice and that written notice must include: 1) The patient's name, social security number, and DOB; 2) Reference to this specific authorization and the name of those authorized by this form to receive this information;3) A statement that the patient wants to revoke the authorization, the effective date of revocation, and the signature of the patient or legal guardian. I understand that once the above information is disclosed, it may be re-discolsed by the recipient and the information may not be protected by federal laws or regulations. This authorization will expire six months from the date specified above.
RESPONSIBILITY FOR PAYMENT
Consent for Treatment
Thank you for selecting Dr.Tanya Schrumpf, DC, Inc and Medical Partners of FL, LLC. In order to facilitate your treatment, we ask that you read and sign this agreement and authorization.ARRIVAL TO YOUR APPOINTMENT:Acupuncture: 15 minutes prior to appointment time.Massage Therapy: 15 minutes prior to appointment time.Physical Therapy: 15 minutes prior to appointment time.Primary Care, New Patient Appointment: 30 minutes prior to appointment time.Primary Care, Non-New Patient Appointments: 15 minutes prior to appointment time.Arriving early will allow you the time needed to complete any necessary paperwork (if you are a new evaluation) or if you have matters needing to be discussed with the Front Desk.All physical therapy, massage therapy, acupuncture, and primary care appointments have a specific time schedule and early arrival allows for a relaxed and unhurried experience. If late arrival is inevitable, your service(s) may be shortened in order to keep on schedule. The original treatment time will be charged.Our massage sessions are considered a therapeutic hour and are therefore approximately 55 minutes (25 for 30 minutes) in length to allow you time to disrobe and prepare for your massage.CANCELLATION POLICY:Please provide at least 24 hours’ notice if you need to reschedule or cancel a treatment. This gives the front desk enough time to fill the slot. If a patient fails to cancel within 24 hours multiple times (2 or more), all appointments will be removed from the schedule and will have to be rescheduled upon availability. A $20 late cancellation fee will be applied to all late cancellations for Massage Therapy, Acupuncture, and Primary Care appointments after the second late cancellation. If there is a credit card on file, this card will automatically be charged. If there is no credit card on file, a $20 charge will be added to your account and must be paid prior to completing any future appointments.LATE ARRIVAL POLICY:Patients are to arrive no later than 10 minutes past their appointment time. We regret that late arrivals will not receive extension of scheduled appointments. In special cases, and when our schedule will allow, we may be able to accommodate a partial or full appointment. This will be at our discretion and only with proper, advanced notification of your late arrival.NO SHOW POLICY:Patients who fail to call and cancel (no call / no show) appointments, after two occurrences, will be charged a $20 fee. If there is a credit card on file, this card will automatically be charged. If there is no credit card on file, a $20 charge will be added to your account and must be paid prior to completing any future sessions.SCOPE OF PRACTICE:We are a multidisciplinary practice that incorporates a team of practitioners to treat our patients all under one roof. Our treatment methods include chiropractic care, physical therapy, acupuncture, primary care, and medical massage. All of our practitioners are licensed professionals, held to the highest standards of the Florida State Board.Massage Therapy is a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, with the intention of positively affecting the health and well-being of the client.It is the responsibility of the patient to report any changes in health, current medical treatments and/or conditions to their therapist.BEHAVIORS AND BOUNDARIES:Patients may choose to leave on as much clothing as needed for comfort, refuse any massage methods, stop massage at any time and are free to leave; the therapy door is never locked.The patient will always be modestly draped. Only the area being massaged will be undraped. The patients will be kept informed of the area to be massaged.The patients are responsible for practicing proper hygiene and a state of cleanliness at the time of their appointment.The therapist may refuse treatment if a contraindication is present such as a medical condition that can hinder your treatment and further injure you, contagious disease or sickness, or drug/alcohol consumption.Sexual advances are prohibited and not tolerated toward any of our staff. If advances of any kind are made the session/visit will be terminated immediately, the appointment will be charged in full, and the patient will be discharged from the practice.CONFIDENTIALITY AND CONVERSATION:The discussion between the massage therapist and the client is confidential. The client may or may not choose to talk during the massage.Any health information disclosed, observed or treated will be kept confidential under HIPAA law.Please sign below if you agree to the terms stated above:
FINANCIAL AGREEMENT
I insert name*, have requested medical services and consent to treat from Medical Partners of FL, LLC, and any service provider or physician within Medical Partners of FL, LLC employment, on behalf of myself and/or my dependents. I understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.I herby assign all major medical benefits, including personal injury protection (no fault) benefits if applicable, to which I am entitled. I hereby authorize and direct my insurance carrier(s) to issue payment check(s) directly to Medical Partners of FL, LLC for any medical services rendered to myself and/or my dependents. This assignment is strictly for purposes of direct billing and payment to Medial Partners of FL, LLC. I understand I am responsible for any amount not covered by insurance.Notice of privacy practices: By signing this document, I also acknowledge that I have been offered a copy of the organization's notice of privacy practices. This acknowledgement is required by the health insurance Portability and Accountability Act (HIPPA) to insure that I have been made aware of my privacy rights.Not all insurance plans cover all services. In the event your insurance plan determines a service to be "not covered". you will be responsible for the complete charge. Payment is due 30 days upon receipt of a statement from our office.secondary insurance as a courtesy, we do file with secondary insurance carriers, however in the event that the second insurance carrier does not pay within ninety(90) days, patient will be billed.If it becomes necessary to collect any amount due through an attorney or collection agency, then the patient agrees to pay responsible costs of collection, including attorneys fees, whether suite is filed or not.your insurance company may require a copayment/copayment to be paid to Medical Partners of FL, LLC when you seek medical services. In turn we are contractually obligated to collect any deductible, co-payment, or co-insurance from our patients. Medical Partners of FL, LLC collects towards deductibles in advanced. All patients with a deductible with be expected to pay per appointment towards that deductible.Our office will verify your health insurance benefits. The insurance verification is only a summary of benefits and does not guarantee coverage and payments. It is each patients responsibility to provide Medical Partners of FL, LLC with updated insurance information when applicable. Payment is due at the time of services are rendered; we accept cash, personal checks, major credit cards. return checks are subject to a thirty five(35) dollar NSF fee or 5% of the face value of the check and yo will lose the privilege to write checks in this office in the future.By signing below you acknowledge that you are responsible for the payment of any co-payment, coinsurance, or deductible for health services provided to you, or your dependent.I, the patient, promise and attest that I will pay the required deductible, co-payment, or coinsurance to Dr. Tanya Schrumpf, DC Inc and Medical Partners of FL, LLC within thirty (30) days from receiving a bill.. Patient statements are mailed when explanation of benefits are received from your insurance company.
HIPAA PRIVACY POLICY
I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:
I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.Privacy Rule of Patient Consent AgreementConsent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))I understand that:I have the right to review this Practice’s Notice of Information practices prior to signing this consent; that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;I have the right to object to the use of my health information for directory purposes;I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested;I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.
CANCER QUESTIONNAIRE
AUTHORIZATION FOR TREATMENT OF A MINOR
MINORS ONLY
I here by authorize blanks and whomever he or she may designate as assistants to administer medical care as deemed necessary to:blank
PELVIC EXAMINATION CONSENT
FEMALE PATIENTS ONLY
I understand by law my health care practitioner requires written informed consent to perform a Pelvic Examination on me. I have been informed that I will be receiving a Pelvic Examination. Description of the ExaminationA “Pelvic Examination” mean an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs using any combinations of modalities which may include, but may not be limited to, the health care provider’s gloved hand or instrumentation.I have been informed as to the nature and process of the Pelvic Examination. Any and all questions have been answered to my satisfaction.I hereby give my informed and voluntary consent to receive a Pelvic Examination.
APPOINTMENT / MEDICATION CONSENT
Thank you for trusting us with your health care needs! All appointments that we schedule for you are important to keep.
If any appointments are not attended, future appointments will be cancelled and any medications are subject to not being refilled.