New Patient Packet

Medical Insurance Information
Primary Medical Insurance
Insurance Name*
Policy Number*
Policy Holder*
Subscriber Date of Birth*

MonthDayYear
Date
Relation To The Patient*
Secondary Medical Insurance
Insurance Name
Policy Number
Policy Holder
Subscriber Date of Birth

MonthDayYear
Date
Relation To The Patient
Patient Acknowledgment:

To the best of my knowledge, the information provided above is accurate and complete.
Patient or Authorized Person’s Signature*

Clear
Date*

MonthDayYear
Date

Patient History Form
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Describe the reason for your visit/current symptoms*
Circle of Care: Other Doctors you see
Last Primary Doctor*
Physician Name - Specialty
Current Medications/Supplements

	NAME OF DRUG/DIRECTIONS	Dose	Start Date	Stop Date
1
2
3
4
5
6
7
8
9
10

Other
ALLERGIES:
If you have any known allergies, please check the box

YesNo known allergies
MEDICATION - REACTION

HOSPITALIZATIONS
Have you ever been hospitalized?*

YesNo

	Date/Year	Date/Year	Reason
1
2
3
4
5
6
7
8
9
10

Other

SURGERIES

List of surgeries (please list with estimated dates):

	Date/Year	Surgeries
1
2
3
4
5
6
7
8
9
10

Other

PREVENTATIVE SERVICE HISTORY

Screening Test*

	Date	Results: Normal/Abnormal
Bone Density Any fractures
Cholesterol/LDL
EKG
Diabetes: Hemoglobin A1C
Diabetes: Foot exam
Diabetes: Eye exam
Colonoscopy
Endoscopy
Fecal Occult Blood Test
Glaucoma screening
Cataracts screening
PAP/Pelvic Exam
Mammogram screening
Digital Rectal Exam (DRE)
Prostate Specific Antigen (PSA)

Immunization Name

	Date
Pneumonia Vaccine
Influenza Vaccine
Covid19 Vaccine
Tetanus Vaccine

PATIENT CONSENT FOR TREATMENT
1. I voluntarily consent to all health care treatment and diagnostic procedures provided by Goodwin Medical Center and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care processes is not an exact science and I further state that I understand that no guarantee has been or can be made of the results of the treatment and examinations of Goodwin Medical Center.
2. I consent to the use and disclosure of my/the patient’s protected health information for purposes of obtaining payment for the services rendered to me/the patients, treatment and health care operations and consistent with the Goodwin Medical Center of privacy practices.
3. I give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.
4. I have received a copy of the HIPAA Policy, Financial Policy Notice and the Release of information.
YesNo
Initials*
Printed Name*
Date*

MonthDayYear
Date
Signature*

Clear

12260 Tamiami Trail East

Unit 102 Naples, Florida 34113 | PHONE (239) 692-9096 | FAX (855) 332-6738
Print Name*
BOD*

MonthDayYear
Date
SS#*
Authorize Release Records To:

Name of the Healthcare Provider/Facility: Goodwin Medical Center

Street Address: 12260 Tamiami Trail E Unit 102

City, State and Zip code: Naples, FL 34113

Phone: (239) 692-9096

Fax: (855) 332-6738
I HEREBY REQUEST AND AUTHORIZE RELEASE OF THE FOLLOWING INFORMATION
Please check appropriate areas*

History and PhysicalLast 2 Progress NotesLast EKG/ECHO/Cardiac NotesLaboratory Re ports, last 2Mammo/ PAP/ColonoscopyNeuro. Assessments/Test
I hereby authorize the release of the above information, including psychiatric, alcohol or other drug dependency history or t reatment, and
HIV/AIDS antibody testing results, to and from Goodwin Medical Center. I hereby release the above from all legal liability that may arise from
the release of information requested. If in the judgement of the medical staff disclosure of certain information will be harm ful if released to the
patient, such information may be withheld in accordance with specific state and federal regulations.

This consent will also serve as authorization to disclose information to any person, corporation or agency which is or may be liable for all or part
of the physician charges or who may be responsible for determining the necessity, appropriateness, amount o r other matter related to the
treatment charges, including, but not limited to; insurance companies and /or third -party reviewers. I further authorize disclosure of
information to the program’s insurance carrier when so requested by the carrier.

I understand that I may evoke this consent to release information in writing at any time, except to the extent that action has been taking in
reliance thereon. In any event, upon fulfillment of the above stated purposes, this consent will automatically exp ire one year from the date
signed. I further understand Goodwin Medical Center reserves the right to notify the above -name person, corporation or agency of my
revocation if I revoke this consent to release information.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Patient/Guardian Signature:*

Clear
Date*

MonthDayYear
Date

YOUR INFORMATION, RIGHTS & OUR RESPONSIBILITIES

This notice describes how medical information about you may be used, disclosed and how you can get access to this information. Please review carefully.
YOUR RIGHTS
- Get a copy of your page or electronic medical record.
- Correct your paper or electronic medical record, we may say no to your request & will tell you in writing within 60 days.
- Request confidential communication, we will say yes to all reasonable requests.
- Ask us to limit the information we share or use for treatment, payment or our operations. We are not required to agree upon requests, and we may say “no” if it would affect your care.
- Get a list of those with whom we’ve shared your information, up to 6 years prior to the date of request.
- Get a copy of this privacy notice.
- Choose someone to act for you. Such as your power of attorney or if someone is your medical guardian, that person can exercise your rights and make choices about your health information.
- File a complaint if you believe your privacy rights have been violated, you may contact the office directly on (239) 692-9096. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.
YOUR CHOICES

(you have some choices in the way that we use and share information as we):
- Share details of your condition with friends and family.
- Provide disaster relief.
- Include you in a hospital directory.
- Provide mental health care.
OUR USES & DISCLOSURES

(we may use and share your information as we):
- Treat you, we can use your health information with other professionals who are treating you.
- Run our practice, improve your care, and contact you when necessary.
- Help with public health and safety. We can share your information for the following reasons: for disease prevention, helping product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic violence, preventing or reducing a serious threat to anyone’s health or safety.
- Comply with the law if the state or federal laws require it, including the Department of Health and Human Services if they want to verify that we are complying with the law.
- Respond to organ and tissue donation requests.
- Work with a medical examiner or funeral director in case of death.
OUR RESPONSIBILTIES
- We are required by law to maintain the privacy and security of your protected health information.
- We will inform you promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy.
- We will not use or share your information other than as described above unless you tell us we can in writing.
- For more information see: https://www.hhs.gov/hipaa/index.html
CHANGES TO THE TERMS OF THIS NOTICE

We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request. Signature below states that you have read and understood the information above.
Patient signature*

Clear
Date*

MonthDayYear
Date
OFFICE POLICIES
- Please leave clear telephones messages for all requests, expect a call back within 24hours or less.
- Please be respectful and kind to our staff, we will always strive to give you excellent care.
- We understand that delays can happen, please let us know in a timely manner if you need to change or cancel your appointment.
- For all prescription refills, please call us or send a request 48 hours in advance.
- We have NO tolerance for narcotic misuse.
FINANCIAL POLICY AND DISCLOSURE

Please make sure to provide us with current insurance information, we will not bill yourinsurance, but it is necessary to have the correct information for laboratory tests,diagnostic imaging and outgoing referrals.

ADVANCE DIRECTIVES
Advance directives:
It is a general term that refers to your local oral or written instructions about your future medical care if you become too ill or unconscious and cannot speak yourself. If you can express your own decisions, your advance directives will not be used, and you can accept or refuse any medical treatment. Your advance directive can be cancelled or revoked by you at any time.

A living will:
It is a type of advance directive in which you put into writing your wishes about medical treatment should you be unable to communicate your wishes.

Medical Power of Attorney:
It is a document that lets you appoint someone you trust to make medical decisions about your medical care if you cannot make those decisions yourself.

You can always ask your primary care physician for any questions you might have; your doctor has the knowledge and cares about you to put your concerns at ease.

To comply with the Omnibus Budget Reconciliation Act (OBRA) of 1990 and Chapter 765 of the Florida Statutes, please answer the following questions:
Declaration to Decline Life-Prolonging Procedure (Living Will)*

I have made such a declaration.I have NOT made such a declaration.
Health Care Surrogate*

I have designated a Health Care SurrogateI have NOT designated a Health Care Surrogate
Durable Power of Attorney*

I have appointed a Durable Power of Attorney for Health Care decisions.I have NOT appointed a Durable Power of Attorney for Health Care decisions.
I have been provided information regarding the PATIENT SELF DETERMINATION ACT
Patient printed name*
Patient or representative signature

Clear
Relationship of patient representative (if applicable):_
Date*

MonthDayYear
Date
Should be Empty:

Patient information:

Medical Insurance Information

Primary Medical Insurance

Secondary Medical Insurance

Patient Acknowledgment:

Patient History Form

Circle of Care: Other Doctors you see

Current Medications/Supplements

ALLERGIES:

PAST MEDICAL HISTORY (current and previous diagnosis):

HOSPITALIZATIONS

SURGERIES

FAMILY HISTORY

SOCIAL HISTORY

PREVENTATIVE SERVICE HISTORY

PATIENT CONSENT FOR TREATMENT

12260 Tamiami Trail East

I HEREBY REQUEST AND AUTHORIZE RELEASE OF THE FOLLOWING INFORMATION

YOUR INFORMATION, RIGHTS & OUR RESPONSIBILITIES

YOUR RIGHTS

YOUR CHOICES

OUR USES & DISCLOSURES

OUR RESPONSIBILTIES

CHANGES TO THE TERMS OF THIS NOTICE

OFFICE POLICIES

FINANCIAL POLICY AND DISCLOSURE

ADVANCE DIRECTIVES