North Florida Regional Thyroid Center

Patients Name:

First Name	MI.	Last Name

Sex:

Social Security #:

Contact Information:

Home Phone:(Example:999-999-9999)

Work Phone:

Date of Birth:

Month

Day

Year

Spouse
Information:

Name

Contact #

Patient Address:

Primary Insurance:

Company Name:

Insurance Group/Policy Number:

Name:

Emergency Contact Name:

Relationship:

Contact #:

Home

Work:

This is an agreement between North Florida Regional Thyroid Center, as creditor and the Patient/Guardian.By executing this agreement, patient is agreeing to pay for services rendered by staff of North Florida Regional Thyroid Center.

Patient understands he/she is responsible for payment of all outstanding charges not covered by primary insurance company.

Co-payments are paid at the time of visit. We do not file Secondary Insurance. We will gladly provide you with the necessary paperwork to file with your secondary insurance company. Please make request for copy of Encounter Form at the check out window.

If patient has no insurance payment in full is due before service is rendered.

Responsible Party Name (other than patient):

Relationship to Patient:

Date:

I authorize the release of any medical information necessary to process my insurance claims. I also authorize benefits to be paid directly to North Florida Regional Thyroid Center on my behalf.

By checking yes in the " I AGREE WITH TERMS " box you confirm that you have read, understood, and ACCEPT ALL TERMS within in this financial agreement.

* Minor cannot authorize agreement. Must be authorized by parent or legal guardian.

If "YES" is not selected here patient will have to agree to financial obligations before services are rendered.

I agree with terms

I authorize Dr. Celeste Hart and/or any qualified staff member to discuss my medical condition or billing information with the following person(s) listed below.

I do acknowledge that a written authorization is required in order to release any medical records to the individuals listed below.

Authorized1:

Name1:

Relationship:

Authorized2:

Name2:

Relationship:

Living

If Deceased please give age & cause of death if known?

Father:

Reason:

Mother:

Reason:

Brother(s):

Reason(s):

Sister(s):

Reason(s):

Do you know of any blood relative that has or had any of the following conditions.

Condition		Relationship
Stroke:
Arthritis:
Hypertension:
Bipolar Illness:
Colitis:
Thyroid Disease:
Diabetes:
Tuberculosis:
Depression:
Severe Allergies:
Leukemia:
Stomach Ulcer:
Cancer:
Asthma:
Anemia:
Kidney Disease:
Bleeding Tendency:
Heart Disease:
Heart Attack:
Epilepsy:
Suicide:

	WHEN
Do you smoke?
Have you ever smoked?
Do you drink coffee?
Do you drink alcohol?
Have you been hospitalized?	When:	Reason:
Have you had a blood transfusion?
Swelling or pain of genitals?
Loss or decrease of sexual activity?
Do you feel fatigued or exhausted?
Does working tire you out?
Feel tired in the morning?
Ever had a nervous breakdown?
Experiencing Depression?
Do you have trouble sleeping?
Do you need or wear glasses ?
Do you have glaucoma?
Are you hard of hearing?

Have you recently:

		WHEN
Been drinking large quanities of water?
Noticed darkening of your skin?
Noticed intolerance to heat or cold?
Hair loss or growth ?
Excessive oily or dry skin (not scalp)
Do you ever have shortness of breath?
Have you ever had tightness of the chest?
Have you had a change in bowel habits?
Blood in stool?
Have you had pains in calves or legs?
Cramps in legs at night?
Varicose veins?
Painfully swollen hot or red joints?

Women Only:

		WHEN
Are you still having regular periods?
Bleeding between periods?
Date of last period ?
Are you on birth control pills ?
Discharge from nipples ?
Lump in the breast(s)?
Yearly paps?
Ever had abnormal paps?
Have you been through menopause?

Men Only:

		WHEN
Discharge from penis?
Prostate problem?
Hernia?

Please list all the medication you are now taking, including over the counter medications .

Medication	Dosage/Strength	Directions (#of times perday)

Pneumonia Vaccine Date:

TB Skin Test Date:

Please list any medications that you are allergic to:

I consent to the use of disclosure of my protected health information by North Florida Regional Thyroid Center for the purpose of diagnosis or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of North Florida Regional Thyroid Center . I understand that consent as evidenced by my signature on this document.

I understand I have the right to request as to how my protected health information is used or disclosed to carry out treatment, payment of healthcare operations of the practice. North Florida Regional Thyroid Center is not required to agree to the restrictions that I may request. However, if North Florida Regional Thyroid Center agrees to a restriction that I request, the restriction is binding on North Florida Regional Thyroid Center.

I have the right to revoke this consent, in writing, at any time, except to the extent that North Florida Regional Thyroid Center has taken action in dependence on this consent.

My protected health information means health info rmation, including my demographic info rmation collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health info rmation relates to my past, present or future physical or mental health or condition and identifies me or there is a reasonable basis to believe the info rmation may identify me.

I understand I have a right to review North Florida Regional Thyroid Center 's Notice of Privacy Policy prior to signing this document. The North Florida Regional Thyroid Center Notice of Privacy Policy has been provided me. The Notice describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the North Florida Regional Thyroid Center . This Notice of Privacy also describes my rights and the North Florida Regional Thyroid Center 's duties with respect to my protected health info rmation.

North Florida Regional Thyroid Center reserves the right to change the privacy polices that are described in the Notice of Privacy Policy . I may obtain a copy of such revision at any time.

Patient or Personal Representative:

Description of Personal Representative:

Date:

By checking the "I AGREE WITH TERMS BOX" below you confirm that you have read, understood and accept all Terms of Consent For Treatment and Confidentiality included within this agreement.

I agree with terms

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