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

Please select who is requesting Our 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).

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.

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

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