Patient Registration

(Please do not leave any field blank; if something does not apply, write "N/A". if unknown, write "unknown")

Responsible Party, Emergency Contact, or Next of Kin:

Additional Responsible Party, Emergency Contact, or Next of Kin:

Policy Holder's SS# Secondary Insurance:

I authorize Home Physicians Group to contact me, and leave messages regarding appointments and other general information, via contact:

Primary Care Treatment and Services:

I understand that I am consenting for Home Physicians Group to treat and provide primary care services to me. This may include ancillary services provided by the HPG Ecosystem: Podiatry, Psychiatry, Pulmonary, Wound Care, Pharmacy, Case Management, Remote Monitoring, etc. Any visit is voluntary and none of my rights to confidentiality or privacy are waived by my consent. I understand that refusal to consent to a Home Physicians Group visit will have no effect on the level or nature of Medicare/Medicaid benefits to which I am entitled.

Chronic Care Management:

If Eligible for services, HPG/Primary Care of Central Florida is designated by me for purposes of providing CCM and for submitting claims for payment to Medicare or my Private Insurance carrier for CCM services. I understand that CCM benefits are included in between Provider Visits.

Patient Choice Acknowledgment:

If I am hospitalized and need skilled nursing services, I request that my care be provided by Home Physicians Group/PC-CFL in all Skilled Nursing Facilities, Assisted Living communities, or at Home.

Student Engagement:

We value our students achieving their experiential training as Medical Practitioner and our company serves as a Preceptorship for medical students completing their residency programs. A student may be present during my visit.

Photographs and Video Release:

I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby release all claims against anyone using this material for educational purposes.

Release of Healthcare information:

I acknowledge and agree that HPG/PCCFL, Inc., may disclose my PHI and medical record information to the people listed on my Patient registry who may be individuals who are my family members, legal representatives, guardians, healthcare surrogates, caregivers, and/or have power of attorney on my behalf. (Please list all applicable names on Patient Registration.

Practice Policies:

By signing this form, you consent to our use and disclosure of protected information about you for treatment, payment, and/ or health care operations as described in this form. You have the right to revoke this consent in writing, except where we have already made a disclosure in reliance prior to your consent.

Notice of Privacy Practices:

We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices and to abide by the terms of this Notice.

Insurance, No Show and Cancelation Policy:

Appointments cancelled with less than 24 hr notice may be subjected to a $15 fee. Patients who are not available for their confirmed visit without a call to cancel the appointment will be considered a NO SHOW subjected to a $15 fee. Medicare, Medicaid, or my private insurance will be billed for medical treatment and services rendered.

MEDICATION REFILL AND CONTROLLED SUBSTANCES POLICY

Our goal is to provide and maintain an excellent provider-patient relationship. Informing you in advance of this policy allows us to preserve a good flow of communication and run an efficient medical office. We must be able to establish a solid medical history for each patient, thus requiring a specific policy for patients who require regular refills for medications and for patients requesting controlled substance prescriptions.

Home Physicians Group has a responsibility to provide quality health care. In the interest of maintaining a good relationship with our patients and delivering quality treatment, it is our hope that you will take responsibility to comply with this policy.

1. All new patients must be established with a Home Physicians Group provider prior to having prescriptions written or refilled.
2. Additional lab tests may be required to determine exact medication dosage; your insurance may or may not cover these tests. Please check with your insurance for any questions regarding specific coverage.
3. If your prescription is a routine medication (prescribed for an ongoing, regular basis and requiring multiple refills), you must be seen for routine follow up appointments for proper monitoring of the condition for which this medication is ordered.
4. If/when you are due for a refill on your routine prescription, you should call your pharmacy to request the refill. They will have sent the appropriate request to the office. This must be done within one week of the medication running out to allow time for the request to be processed, the medication to be refilled and picked up in a timely fashion.

Controlled substances

Controlled substances (pain, sleep, muscle relaxers, stimulants, anti-depressants) are tracked by the State of Florida Prescription Drug Monitoring Program (PDMP Pharmacies and physicians can track your usage by obtaining an online report, which records what medication has been prescribed, by whom, to what capacity, and what pharmacies dispensed the medication and how often.

Prescriptions will be written at the provider's discretion, and random drug screenings will be ordered periodically as required.

Patients with a history of long-term use of controlled substances may be referred to pain management.

Failure to comply with this policy may result in dismissal from the practice.

 

release healthcare information of the patient listed above to:

Home Physicians Group

12301 Lake Underhill Road Ste 215

Ph 321-235-0692 Fax 321-235-0694

Sexually transmitted diseases (STDs) as defined by laws, RCW 70.24 et sq., include Herpes Simplex, Human Papilloma Virus, Genital Warts, Condyloma, Chlamydia, Non-specific Urethritis, Syphilis, VDRL, Chanoid, Lymphogranuloma Venereum, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and Gonorrhea.

I acknowledge and consent to the use of Al-powered scribing tools to assist in the documentation, transcription, and summarization of conversations, meetings, or other communications. I understand that these tools use artificial intelligence to process and generate text and that their accuracy may vary.

By providing this consent, I agree that:

1. Al-generated transcripts or notes may be reviewed for accuracy and completeness.

2. The use of Al scribing tools does not replace professional judgment or human oversight.

3. I retain the right to request modifications, corrections, or deletion of any Al-generated content as appropriate.

4. The confidentiality and security of the information processed by the AI tools will be maintained in accordance with applicable privacy policies and regulations.

I understand that I can revoke this consent at any time by providing written notice.

Chronic Care Management Services Agreement

 The Chronic Care Management (CCM) services that Home Physicians Group will provide me under the agreement include the following:

• Access to my care team 24 hours a day, 7 days per week, for urgent needs, including telephone access and other non-face-to-face means of communication (ie email),
• The ability to get successive, routine appointments with my designated primary care provider or member of my care team, 
• Care Management of my chronic conditions, including timely scheduling of all recommended preventative care services, medication reconciliation, and oversight of my medication management,
• Creation of a comprehensive plan of care for my health issues that is specific to me and congruent with my choices and values,
• Management of my care as I move between and among health care providers and settings, including:         

o   Referrals to other health care providers o Follow-up after I visit an emergency department

o   Follow-up after I am discharged from the hospital or other facility, such as skilled nursing facility

o   Coordination with home and community-based providers of clinical services 

My signature below indicates my understanding and agreement to receive CCM services and that I understand:

• Home Physicians Group is designated by me for purposes of providing CCM to me and for submitting claims for payment to Medicare and other insurers for the CCM services, 
• I will receive a copy of my comprehensive plan of care,
• Home Physicians Group is authorized to electronically communicate my medical information with other treating providers as part of the care coordination involved in CCM services, 
• Medicare and other insurers will only pay one professional/practice for CCM services provided to me during a calendar month
• I revoke all previous consent for CCM services prior to this date
• CCM services are subject to the usual Medicare deductible and coinsurance applied to my Medicare Part B services, and I can revoke this agreement at any time (effective at the end of the current calendar month) and can choose to receive these services from another provider or not to receive CCM services at all after the calendar month in which I revoke this agreement.