South Florida RheumatologyRheumatology, all medical benefits, if any, otherwise payable to me for...
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South Florida Rheumatology 4700 Sheridan St, Suite C, Hollywood, FL 1 SW 129th Ave #401 Pembroke Pines, FL 1040 Weston Rd. Suite 215 Weston, FL Last Name: ____________________________________ First Name:________________________________ Home Address: ____________________________________ APT #____________ City:__________________________________ State:_______________ Zip:________ Home Phone:_______________________ Work:___________________ Mobile:_____________ Email Address:____________________________________________________________________ Race: (check box) White Asian Black/African American Hawaiian Pacific Islander Ethnicity: (check box) Hispanic/Latino Not Hispanic/Latino Language Spoken: Date of Birth:_______________________ Social Security #_________________________ Marital Status: (check box) Single Married Divorced Widowed Sex: (check box) Male Female Family Physician (PCP): ____________________________________ Phone #____________________ Parent or Responsible Party:____________________________________________ or SELF Relationship to Patient:__________________ or SELF, Name of Spouse;_____________________ Employer or Parents Employer: ____________________________________ Phone #____________________ Occupation:____________________________ , Insurance with Employer: (check box) YES NO Health Plan Name:________________________________________ (check box) HMO PPO Health Plan Member Number: ____________________________________ Group #____________________ Emergency Contact Information: Name:______________________________________________ Phone#____________
Transcript of South Florida RheumatologyRheumatology, all medical benefits, if any, otherwise payable to me for...
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South Florida Rheumatology
4700 Sheridan St, Suite C, Hollywood, FL 1 SW 129th Ave #401 Pembroke Pines, FL
1040 Weston Rd. Suite 215 Weston, FL
Last Name: ____________________________________FirstName:________________________________
HomeAddress: ____________________________________ APT#____________ City:__________________________________ State:_______________ Zip:________HomePhone:_______________________ Work:___________________ Mobile:_____________EmailAddress:____________________________________________________________________Race:(checkbox)�White�Asian�Black/AfricanAmerican�Hawaiian�PacificIslanderEthnicity:(checkbox)�Hispanic/Latino�NotHispanic/Latino LanguageSpoken:DateofBirth:_______________________ SocialSecurity#_________________________MaritalStatus:(checkbox)�Single�Married�Divorced�WidowedSex:(checkbox) �Male�Female FamilyPhysician(PCP): ____________________________________Phone#____________________ParentorResponsibleParty:____________________________________________ or�SELFRelationshiptoPatient:__________________ or�SELF,NameofSpouse;_____________________ EmployerorParentsEmployer: ____________________________________Phone#____________________Occupation:____________________________ ,InsurancewithEmployer:(checkbox)�YES�NOHealthPlanName:________________________________________ (checkbox)�HMO�PPOHealthPlanMemberNumber: ____________________________________Group#____________________EmergencyContactInformation:Name:______________________________________________Phone#____________
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NumberofChildren:__________Ages:________________
Do you smoke?
Yes No
Do you drink alcohol?
Yes No
Do you use street/recreational drugs?
Yes No
If Yes: How many packs a day? How many years? _______ Quit Date: ______
If Yes: How much? ____________ How often? _____________ Quit Date: _____ In a recovery program?
If Yes: What? _________________ How often? ___________ Quit Date: ____
In a recovery program?
Family History
Mother Father
Living?
Yes No
If no age at age of death? ____________________
Living?
Yes No
If no age at age of death? ____________________
Medical Conditions Medical Conditions
Do youhavea family historyof:YesNoOsteoporosisIfYes,Who:_________________________________YesNoRheumatoidArthritisIfYes,Who:_________________________________YesNoOsteoarthritisIfYes,Who:_________________________________YesNoGoutIfYes,Who:________________________________YesNoOtherConnectiveTissueDisease
IfYes,What:______________________________Who:_____________________________
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Family Medical History
ListallRelevantHistory,IncludeGrandparents,Parents,SiblingsandChildren
1. _____________________________________________________________________2. _____________________________________________________________________3. _____________________________________________________________________4. _____________________________________________________________________5. _____________________________________________________________________
____________________Adopted,historyunknown____________________NorelevantFamilyHistory
SocialHistory
CaffeineConsumption(typeandamount)____________________________________AlcoholConsumption(type,amountandfrequency)___________________________TobaccoUse(type,amountandfrequency)__________________________________RecreationalDrugUse_____________________________________________________Reasonfortoday'svisit________________________________________________________
_____________________________________________________________________________MedicationAllergies____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________Pharmacy_______________________________________Phone#___________________
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Medical HistoryPleaselistyourmedicalconditions:____________________________________________ ______________________________________________
____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ______________________________________________Hospitalizations&Surgeries-PleaselistallYear Operation/Illness Year Operation/Illness____ ______________________________________ ______________________________________________ ______________________________________ ______________________________________________ ______________________________________ ______________________________________________ ______________________________________ __________________________________________Allergies-Pleaselistanyallergiestomedications,foods,x-raydyes,environmentalitems,adhesivetapes.Example:Penicillincausesrash,eggscausehives,Pollencausessneezing.Allergy Reaction________________ _________________________________________________________________________ ________________ _________________________________________________________________________
________________ _________________________________________________________________________ ________________ _________________________________________________________________________ ________________ _________________________________________________________________________ ________________ _________________________________________________________________________ Medications(listallmedicationsyouarenowtakingorhavetakeninthelast2weeks)NameofMedication Doses/Timesperday Reasonfortaking Howlong?_______________________ ______________________ ____________________________________________________________________ ______________________ ____________________________________________________________________ ______________________ ____________________________________________________________________ ______________________ ____________________________________________________________________ ______________________ ____________________________________________________________________ ______________________ ____________________________________________________________________ ______________________ ____________________________________________________________________ ______________________ ___________________________________________
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LIFETIMEAUTHORIZATIONFORINSURANCEPAYMENT
I,theundersigned,haveinsurancecoverageandassigndirectlytoSouthFloridaRheumatology,allmedicalbenefits,ifany,otherwisepayabletomeforservicesrendered.IunderstandthatIamfinanciallyresponsibleforallchargeswhetherornotpaidbyinsurance.IherebyauthorizeSouthFloridaRheumatologytoreleaseallinformationnecessarytosecurethepaymentofbenefits.Iauthorizetheuseofthissignatureonallmyinsurancesubmission.IamresponsibleforanyfeesorlegalfeesthatSouthFloridaRheumatologyincursforthefullcollectionofpayments.
IhavebeenprovidedwithanoticeofPrivacyPracticesofSouthFloridaRheumatology,thatHIPPAoutlineswhatwillbedonewithmyProtectedHealthInformation.
PatientName/Guarantor(pleasePrint)____________________________________________
Patient/GuarantorSignature_____________________________________________________
SouthFloridaRheumatologyRepresentative________________________________________
Patient/GuarantorDateofBirth___________________________________________________
Date_________________
Authorization
IherebyauthorizemyinsurancecompanytopaydirectlytoSouthFloridaRheumatologyanyandallmedicaland/orsurgicalbenefitsotherwisepayabletomefortheirprofessionalservices.
IacknowledgethatIampersonallyresponsibleandliabletoSouthFloridaRheumatologyforanyandallmedicaland/orsurgicalfeesbilledbythem.ShouldSouthFloridaRheumatologyacceptpaymentbydirectassignmentfromMedicareoranyotherinsurancecompany,IunderstandthatIamresponsibleandliableforanyandalldeductibleexpensesand“co-insurance”notcoveredbyMedicareormyprimaryinsurancecompany.Iunderstandthatanyoverpaymentonmypartwillberefundedtomepromptly.
IacknowledgethatIampersonallyresponsibleforfullpaymentofall“non-covered”services,andIamresponsibleforallreturnchecksandIagreetopaya$50.00percheckperincidentfeeforeachreturnedcheck.IfIamplacedintocollectionsorImyaccountgoestolitigation,Iagreetoberesponsibleforallcollectionandattorney’sfees.
Iherebyauthorizereleaseofallmedicalrecordstomyprimarycarephysician,tootherphysicianstowhomIamreferredformycare,andtomyinsurancecompanyorplan.
LIFETIMESIGNATURE:________________________________DATE:______________________PLEASENOTE:YOUMUSTPRODUCEYOURINSURANCECARDTOFRONTDESKATEVERYVISIT
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Office Hours
Hollywood 4700 Sheridan St # C, Hollywood, FL 33021
Call (954) 961-3252 Hours of Operation
Monday 8:30am-5:00pm Tuesday 8:00am-5:00pm
Wednesday 8:00am-4:30pm Thursday 8:00am-5:00pm
Friday 8:00am-3:30pm Closed Saturday & Sunday
Weston Office
1040 Weston Rd Suite 215, Weston, FL 33326
Call (954) 961-3252 Hours of Operation
Monday 8am-1pm Tuesday 8:30am-5pm
Wednesday 8:30am-5:00pm Thursday Closed
Friday 7:00am-2:30pm Closed Saturday & Sunday
Pembroke Pines
1 SW 129th Ave #401, Pembroke Pines, FL 33027
Call (954) 961-3252 Hours of Operation
Monday Closed Tuesday 8:30am-5:00pm
Wednesday Closed Thursday 8:30am-5:00pm
Closed Friday, Saturday & Sunday
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Co-Payments Due at the time services are rendered
Appointments
If for some reason you can't make your scheduled appointment, please give us notice of cancellation at least 24 hours in advance; otherwise, a $50 fee will be applied to your bill. When you arrive, you will be asked to check in and to fill out necessary paperwork.
Changes
If your insurance, address, or phone number has changed, please let us know so we can give you new paperwork to update your records.
Work-ins
If your need for an appointment is urgent and we have to work you in to our busy schedule, please note that there will be a wait time, as scheduled patients must be seen first.
Medications
It is important for you to bring in all current medications for every visit, so we can avoid problematic medicine interactions and dosages.
Refills
If you need a refill on a medication we prescribe, have your pharmacy contact our office on weekdays when
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your chart is available to our physicians.
Billing Questions
If you have any questions concerning our billing processes and requirements please call Tina at (954) 961-3252.
HMO's and Referrals
With HMOs and certain insurance plans, you will need to get a referral from your primary physician before scheduling your visit with our offices. If you need one of our doctors to prepare forms such as insurance forms, personal letters, or specific medical records, certain fees will apply:
Forms and Records
The following fee schedule applies for Doctor preparation of certain forms, personal letters and medical record copies.
1. 1. Insurance Forms- $25/form and up
2. 2. Personal Letters- $25/each and up
3. 3. Medical Records- $1/page for the first 25 pages, then .25/each additional page.
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Dr. Charles Kahn, Dr. Wayne Riskin & Dr. Yesenia Santiago-Casas
Dr. Kahn, Dr. Riskin and Dr. Santiago-Casas comprise South Florida's Leading Practice for Rheumatology because of their dedication to be the best rheumatologists in Hollywood. They take everything into consideration before giving a diagnosis or administering treatment.
If for some reason your primary physician cannot handle a particular medical issue, you may need to be referred to a specialist, such as one of our rheumatologists in Pembroke Pines or Hollywood.
In the meantime, thank you for following our office protocol. Doing so will make your visit and continuing medical care a more pleasant experience. We look forward to serving you.
Please Sign X_________________________________________
