I authorize the release of any medical information necessary to process my insurance claim. I authorize and request payment of medical benefits directly to my physicians. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me; I understand and agree that regardless of my insurance status I am responsible for any balance of my account.
All questions contained in this questionnaire are protected by privacy acts under HIPPA and will become part of your medical record. Fill in the blanks or check appropriate answers.
Please indicate current vaccinations and DATE received:
List any medical problems that other doctors have diagnosed or check applicable items on list.
Please list the drug and make sure you are specific about your reaction. List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers, eyedrops and nasal sprays
By signing this consent form you are agreeing that your provider at West Volusia Family & Sports Medicine. may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes. You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it. This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation. Understanding all of the above, I hereby provide informed consent to West Volusia Family & Sports Medicine to enroll me in this ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.
ALL QUESTIONS IN THIS SECTION ARE OPTIONAL AND WILL BE CONFIDENTIAL
IN COMPLIANCE WITH PRIVACY POLICIES
The amount of exercise you get on a weekly basis. Please check the appropriate answer.
Are you happy with your weight?
How many caffeinated drinks do you consume?
Do you consume alcoholic beverages?
Please answer questions to the best of your ability.
Do you now or have you ever smoked or chewed tobacco?
Personal questions related to your sexual health
Questions about your health and safety.
Questions about your wishes.
(Please complete to the best of your ability)
Family, Significant others, and friends. Under certain circumstances, we may disclose PHI (Protected Health Information) to family members, other relatives, or close personal friends or others that you identify to improve communication of relevant information (most commonly laboratory results, prescription issues and or changes, appointment scheduling. etc.) to their involvement in your care or payment related to your care; or to notify them of your location, general condition, or death.
In compliance with this office's HIPPA policy, I am authorizing West Volusia Family & Sports Medicine's staff to release PHI as necessary to support and assist in my care. Please list each individual authorized to receive information as stated above and provide us with the information requested.
Please indicate if you wish to have your personal health care information released to your spouse, children, or significant other below:
We are pleased that you have chosen to partner with us in the care of your health; however, in order to insure that you receive the best care possible and are taken care of in the most efficient way, we ask that you review the following office policies.
Lab/Imaging/Sleep Study Follow-Up Policy
Cancellation / No Show Policy