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New Patient Registration

  • 1 Patient Details
    General Information
    Sex
    Other Information
    Race
    Ethnicity
    Language
    Physical Address
    Mailing Information
    Contact Information
    Marital Status
    Pharmacy Information
  • 2 Emergency Contact ( Person who does not live in your home)
    Contact Information
  • 3 Insurance
    Select Type
  • 4 HEALTH QUESTIONNAIRE
    Past Medical History
    High Blood pressure
    Heart Disease/Heart attack
    Diabetes
    Stroke
    Cancer
    Thyroid problems
    Asthama
    COPD/Lung Disease
    High Cholesterol
    Anemia
    Liver Disease
    Kidney problems
    Migraines
    Alcohol/Drug/Abuse
    Seizures / Epilepsy
    Arthritis
    Depression/Mental Illness
    Do you have any Allergies to Medications and reactions
  • 5 Social History
    Do you smoke?
    If not, are you a former smoker?
    Do you use illegal drugs?
    Do you drink alcohol?
    Do you drink water?
    Do you exercise?
    Are you on a low fat diet?
    Have you ever been a victim of abuse?
    Are you currently employed?
    If No, Please specify reason?
    Please place a checkmark next to any symptom that you are currently having or had in the past.
    General
    Heart
    Lungs
    Gastrointestinal
    Skin
    Musculoskeletal
    Neurological
    Psychiatric
    Eyes
    Ears
    Nose
    Mouth/Throat
    Genitourinary
    Gynecological Women
    Gynecological Men
    Endocrine
  • 6 SCREENING FORM
    Please check the corresponding answers
    Do you use any of the following
    Do you have any of the following
    Do you need aide with walking
    Do you need help with daily living activities-
    How are your Vision?
    How are your Hearing?
    How are your Touch?
    How are your Taste?
    How are your Smell?
    Is there any pain that you have most of the time?
    Other
  • 7 Please fill in below to the best of your knowledge so we may obtain your medical records.
    When was your last: Date? Where?
    Mammogram
    Bone Density(DEXA)
    Colonoscopy / EGD
    Stool Card
    Eye Exam
    Pap Smear
    PSA
    Stress Test / EKG
    Labs
    Immunization
    When was your last: Date? Where?
    Influenza (FLU) Vaccine
    Shingles (Zoster) Vaccine
    Pneumonia Vaccine
    Tetanus Vaccine
    Tuberculosis (PPD) Test
    Women Only
    Men Only
  • 8 Previous Providers/ Specialists
    (Note: If you need referrals in the future, you need to identify your doctors here)
  • 9 E- PRESCRIBING / MEDICATION HISTORY CONSENT FORM

    E- Prescribing is defined as a physician’s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy from the point of care. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. E-Prescribing greatly reduces medication errors and enhances patient safety. The Medicare Modernization Act (MMA) of 2003 listed standards that have to be included in an ePrescribe program. These include

    By signing this consent you are agreeing that West Orlando Internal Medicine can request and use your prescription medication history from other healthcare providers and/ or third party pharmacy benefit payors for treatment purposes

    1. Formulary and benefit transactions - Gives the prescriber information about which drugs are covered by the drug benefit plan.
    2. Medication History Transaction- Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.
    3. Fill status notification - Allows the prescriber to receive an electronic notice from the pharmacy telling them if the patient prescription has been picked up, not picked up, or partially filled.

    Understanding all of the above, I hereby provide informed consent to West Orlando Internal Medicine to enroll me in the E-Prescribing Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

    Signee Info
    Relationship
  • 10 FINANCIAL POLICY

    In order for us to be able to continue to deliver high quality of care, it is necessary to provide a financial policy.PLEASE READ ALL INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW.

    Please present your insurance card(s) at each visit. It is your responsibility to provide us with the correct information so that we may submit to your insurance

    We will collect your deductible, co-payment, or for non-covered services along with any balance due after insurance on your account at the time of your visit. We accept cash, checks, Visa, Mastercard, and Discover.

    If we do not participate with your insurance, we will file your claim as a courtesy and ask that you follow up to make sure payment is made to us in a timely manner. If we do not receive payment from them within 45 days, you will be billed for any unpaid balance. Balances are expected to be paid in full within 30 days. If payment on your account is not received in the alloted time, your account may be referred to a collection agency and reported to the credit bureau. We will assess a 1% monthly interest charge on unpaid balances over 60 days old.
    COLLECTION AGENCIES- In the event your account becomes delinquent and is turned over to a collection agency and/or attorney you will be financially responsible for all associated collection fees and legal fees that West Orlando Internal Medicine, LLC incurs through the process utilized to collect the delinquent balance. Please be advised if your account is turned over to a collection agency you can be discharged from the practice.
    RETURNED CHECKS- Check returned to West Orlando Internal Medicine by the bank will be assessed a returned check fee, in addition to the original amount of the check. You have ten days (10) to clear up the outstanding check. If you do not pay the check plus the returned check fee in the specified time, the check will be sent to the State Attorney's office for further collection.

    MEDICARE PATIENTS- We are participating providers with Medicare and we will submit to Medicare for all your covered services. If you have supplemental insurance, we will also submit that for you. If payment is not received within 30 days of being submitted, we will ask you for the balance due. If you do not have a supplemental insurance, your portion (20% of amount allowed by Medicare) will be collected at each time of service. Each yea you will be expected to pay the allowed amount of your charges until your Medicare deductible is met

    MEDICAID PATIENTS- We are not participating providers with straight Medicaid. We ask that you pay for your services at the time of each visit. We are participating with Wellcare-Medicaid

    HMO-PPO PATIENTS- If we participate with your plan, we will submit your services to the insurance for you. Your co-payment will be collected at the time of service- no exceptions- If your plan requires you to choose a primary care physician, it is your responsibility to make sure you contact your insurance carrier and assign Dr. Osama Ansari as your PCP. If your plan requires you to have an authorization to see a specialist, you will need to obtain that from our office prior to seeing the specialist. We cannot obtain retroactive referrals. If we do not participate with your plan, we will verify your out of network benefits, file your services, and we expect payment of your portion of the services at the time they are rendered.

    SELF-PAY PATIENTS- Patients without insurance coverage will be expected to pay at the time of services, If you are unable to pay in full, you must contact our credit manager prior to seeing the doctor to make a payment arrangement

    NO SHOWS / MISSED APPOINTMENTS/ LAST MINUTE CANCELLATION OR RESCHEDULE- Providers and staff of West Orlando Internal Medicine, LLC rely on the pre-scheduled appointments and plan their day to day activities. Last minute reschedules or cancellations and no-shows disrupt the daily activities and also curtall the ability to schedule another patient in your pre-scheduled slot. If you have to cancel or reschedule your appointment, please provide us with at least 48 hour notice. Therefore any appointments cancelled without proper notice or any missed appointment will result in a fee of $25.00.

    Remember, whether you have insurance or not, you are ultimately financially responsible for payment of your services. If you have any questions regarding our financial policy please contact our office manager at 407.338.3939.

    I have read and acknowledge the financial policy at West Orlando Internal Medicine.

    I hereby authorize my insurance carrier, attorney or any third-party to pay directly to West Orlando Internal Medicine (WOIM) all charges submitted for services incurred by me. I understand I will be responsible for any and charges not paid for by my insurance company. I authorize West Orlando Internal Medicine to release information concerning my medical condition to my insurance company, employer, hospital, physician or attorney for the purpose of processing a claim. I assign payment directly to the providers at WOIM which may be due for me from the Medicare program or any other insurance company, including supplemental insurance, which may cover in whole or in part medical services which I have received. This authorization and assignment shall be valid until I notify West Orlando Internal Medicine in writing of the cancellation. A photocopy of this authorization shall be valid as the original copy.

    Signee information
    Relationship
  • 11 HIPAA NOTICE OF PRIVACY PRACTICES

    My signature on this document acknowledges that I have read the West Orlando Internal Medicine, LLC HIPAA Notice of Privacy Practices.

    LIFETIME AUTHORIZATION

    INSURANCE ASSIGNMENTS AND AUTHORIZATION TO RELEASE INFORMATION

    RELEASE OF INFORMATION - I, the below named patient, do hereby authorize any physicians examining and/or treating me to release any third payer (such as an insurance company or governmental agencies, ie Blue Cross Blue Shield of Florida) any medical, psychiatric condition, alcohol or drug related condition and any records concerning diagnosis and treatment when requested by such third party for its use in connection with determining a claim for payment for such treatment and/or diagnosis.

    PHYSICIAN INSURANCE ASSIGNMENT - I, the below named subscriber, hereby authorize payment directly to any physician examining or treating ,e or any group and /or individual surgical and/ or medical benefits herein specified and otherwise payable to me for the services as described but not to exceed the reasonable and customary charge for theses services.

    MEDICARE/MEDICAID - Patient’s certification authorization to release information and payment request. I certify that the information given by me in applying for my payment under Title XVIII XIX of the Social Security Act is correct. I authorize any holder of medical or other information about meto release to Social Security Administration Division of Family Services or its intermediaries or carries and information needed for this or a related Medicare/Medicaid claim. I hereby certify all insurance pertaining to treatment shall be assigned to the physician treating me.

    PERMIT A COPY OF THIS AUTHORIZATION AND ASSIGNMENTS TO BE USED IN PLACE OF THE ORIGINAL WHICH IS ON FILE AT THE PHYSICIAN'S OFFICE. The assignment will remain in effect until revoked by me in writing.

    CONSENT FOR TREATMENT - I, the below named patient hereby give my consent for treatment to all physicians associated with West Orlando Internal Medicine, LLC

    CONSENT TO DISCUSS MEDICALCONDITION OR RELEASE RECORDS - I, the below names patient, do hereby authorize West Orlando Medicine, LLC to discuss my medical conditions with, or release my medical records to the below named person (s):

    Contact Information
    Relationship