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_________________________________________