ENGLISH - Intake Form (New Patient / Annual

ROSABEL M BENCOMO M.D P.A

6840 SW 40th Street, Suite 209, Miami, FL 33155

Telemedicine: (786) 800-2430 | Office: (786) 222-8807 | Fax: (305) 763-8379
Visit Type*

Office Visit.Telemedicine. (By Computer or Phone)
Please select who is requesting Our Services?*

The Services are for me (I'm the Patient).I'm the Legal Guardian of the person needing Services.
Legal Guardian Information*
Patient Full Name*

NameLast Name
Patient Date of Birth*
month / day / year
Do you have MEDICARE as Primary Health Insurance? (65 or older or disability).*

Yes.No.
Advance Beneficiary Notice of Noncoverage (ABN)
G. OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. the Telemedicine Service listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.OPTION 2. I want the D. the Telemedicine Service listed above, but do not bill Medicare. MDteleMe may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.OPTION 3. I don’t want the D. the Telemedicine Service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
MDteleme Warning!

You have chosen Option 3. Meaning...

You DO NOT WANT to use the D. Telemedicine Service listed above.
Patient Phone Number*
Email
(An email Address is required if you would like to be registered for Virtual Consultation)
Address*

Street

Street

CityState

Zip Code
Gender*

MaleFemaleOtherRather not say
Weight and Height*
Photo of your ID (please take it readable)*
Photo of your Insurance Card (if any)*
RELEASE OF HEALTH INFORMATION

In case you cannot reach me, I authorize an RMB / MDteleMe representative to try to contact me, using my Emergency Contact and provide strictly necessary information related to the immediate care of my medical condition.
Do you have an Emergency Contact? (in case we cannot reach at you)*

YesNo
Please note that providing Emergency Contact information would facilitate faster communication with you.
Emergency Contact Information*
Pharmacy (medications will be electronically sent to the pharmacy)

Pharmacy Name/Type

Address

CityState

Zip Code
Marital Status

SingleMarriedDivorcedLegally SeparatedWidowed
Ethnicity

Hispanic/LatinoBlack/African AmericanWhiteAsianNative AmericanOtherRather not say
Do you use any of the following? Check all that applies.

AlcoholTobaccoCaffeineRecreational Drugs
Medication Allergies?*

NoYes
Which medication are you allergic to?

AntibioticPain MedicationSeizure MedicationsSulfaLocal AnestheticsOthers (Discuss with Provider)
Specify which Medication, you are allergic to:
Allergies to Other Substances, Medications or Food

NoYes
Specify which other Medication, Substances or Food you are allergic to:
Type of Allergic Reaction

RashShortness of BreathSwellingAnaphyilaxisOther (Discuss with Provider)
Which other reactions you've had? Please Describe...
Medical Condition (Do you have any Chronic Medical Condition?)*

NoYes
Select which Medical Condition

DiabetesHigh Blood PressureThyroidHeartAsthmaMental illness (anxiety, depresion, bipolar, ...)AnemiaSeizuresOther(s) (discuss with provider)
Describe which other Medical Condition...
Medications, are you taking any?*

NoYes
Which Medication(s)?
Any Surgeries?*

NoYes
Which Surgeries?

AppendicitisGallbladderHysterectomyThyroidHeartKidneysTonsilsHerniaC-sectionOther
Describe which other Surgeries you've had.
Have you had a Colonoscopy done? Please answer if you are 50 years or older. A Colonoscopy is a procedure performed by a gastroenteorologist for an early colorectal cancer screening.

NoYes
When did you have the Colonoscopy done? Check all that applies.

Less than 10 years ago.More than 10 years ago.I was told it was Normal, I need to repeat in 10 years.I was told I need to repeat the procedure in 3 to 5 years. (This is a recommendation doctors do if polyps are found)
When did you have a Pap Smear done? (Recommended for 21 years and older)

Less than 12 Months.More than 12 Months.I'm older than 21 years and I have never had a Pap Smear.
Was the Pap Smear Result Normal?

YesNo
Have you had any Mammography? (Recommended for 40 years or older)

Less than a Year.More than a Year.I'm 40 years or older and I have never had a Mammogram.
Was the Mammography Result Normal?

YesNo
Mother, Alive?*

NoYes
Mother, Any Medical Condition?

No Medical ConditionHigh Blood PressureDiabetesHeartThyroidCancerRespiratory Chronic ConditionOther
Any other Medical Condition not listed before?
Father, Alive?*

NoYes
Father, Any Medical Condition?

No Medical ConditionHigh Blood PressureDiabetesHeartThyroidCancerRespiratory Chronic ConditionOther
Any other Medical Condition not listed before?
Any Family History of Cancer?*

NoYes
Explain which type of Cancer and family member...
Terms and Conditions (you need to read and accept to receive services)
Signature (Please Sign if you agree to Our Terms and Conditions)*
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