Follow Up Sign In Sheet

ROSABEL M BENCOMO M.D P.A / MDteleMe

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

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

Sign-in Sheet for Follow up visit

Today's Date*

Visit Type*

Office Visit.Telemedicine. (By Computer or Phone)

Please select who is requesting Our Services?*

For me (I am the patient).For someone under my care. I'm the Legal Guardian of the person requesting 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).*

No.Yes.

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.

Patient Phone Number*

Email address (you need an email address to receive telemedicine services)

example@example.com

Home Address*

Street

CityState / Province

Zip Code

MEDICAL CARE SERVICES PERFORMED CERTIFICATION*

With my signature below, I certify that I am in Rosabel Bencomo MD PA (RMB) Office/ Telemedicine Waiting Room platform to receive Medical Care Services.

Signature (Please Sign if you agree to Our Terms and Conditions)*