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New Patient Form

Step 1 of 5

Patient Registration Information
Employment Information
Pharmacy Information
Emergency Contact
Meaningful Use Required by the Government
INJURY RELATED INFORMATION
Brief Description of accident / injury
I Certify that the information given by me in applying for payment under my insurance contract (including Title XVII of the Social Security Act) is correct

I authorize release to my insurance carrier, referring physicians and the respective agents, and to agents of my treating physicians ,any information needed including diagnosis and records of any treatment or examination rendered to me to process this claim or for purposes of care and treatment, quality assurance or utilization review.

I request that payment of authorized benefits be made on my behalf. I assign the benefits payable to Brevard Health Center, PL to submit a claim to insurance carrier, including Medicare, for payment to me.

I understand that payment is due on the day of service and I will receive itemized statements of my account reflecting the balance pending with insurance and due from me. I accept the responsibility for final payment on my account regardless of the payment or lack of payment by my insurance carrier. I accept arrangement while counting to receive care and services by Brevard Health Center PL

(OR)

Step 2 of 5

HIPPA CONTACT INFORMATION
In order to assist you in receiving your health information from Brevard Health Center, please complete this form. Initial one:
(initial) Brevard Health Center is pemiitted to share any and all medical information with the
individuals listed below, including test results, sensitive information as stipulated by the State of Florida, and information disclosed during offiee visits.
Brevard Health Center is permitted to share any medical information with the
individuals listed below, including test results, sensitive information as stipulated by the State of Florida, and information disclosed during office visits except
Persons authorized to receive my medial information
(full name, relationship, and phone number):
You may notify me with test results, appointment reminders and other information regarding my health information as follows:
I understand and direst that this authorization will remain in effect until it is revoked by me in writing

(OR)
This authorization is not valid for the request of printed copies of your medical records. You and only you (or your legal personal representative) mast sign a Health Information Release Form to obtain copies of your medical records.

Step 3 of 5

Brevard Health Center
Past Medical History
Family History
Social History
Cigarettes
Pipe / Cigar
Chewing
Alcohol / Consumption

Step 4 of 5

BREVARD HEALTH CENTER, PL
298 Michigan Avenue -- Suite 101
Melbourne, F L 32901
Telez (321)215-6399 Fax: (321)215-6789

Step 5 of 5

Authorization for Release of Protected Health Information
I hereby authorize - The Following Physician to release/disclose my Protected Health Information to Brevard Health Center
include any Federal and State protected information under Florida
Statue 394.d59(9) psychiatric information, Florida Statute 397.053 and Florida Statute 396.112,
Drug and/or Alcohol Abuse information and Florida Statute 38160999 (2) Human
immunodeficiency Virus test results (AIDS and related conditions).
I understand that authorizing the disclosure of this protected health information is voluntary. I
understand that I may inspector copy the information to he used. or disclosed, as provided in
CPR 164.524. l understand that any disclosure of information carries with it the potential for an
unauthorized rediclosure and the information may not he protected by federal confidentiality
rules. If I have questions about disclosure of protected health information , l may contact
Brevard Health Center.
I understand and direct that this authorization remains in effect for 6 months or until I revoke it
in writing. I herby release Brevard Health Center, PL and its employees from any and all
liability that may arise from the release of this protected health information as I directed.

(OR)

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