Preferred Doctor: *

Dr. Laura Fernandez Ortiz

Dr. Carolina Villanueva

Patricia Beharrie, ARNP

Preferred Language: *

English

Spanish

Creole

Other

Patient’s Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Race

Am-Indian/Alaskan

Asian

Hawaiian/Pacific Islander

Black/African American

White

Hispanic

Other

Patient Resides with

Mom

Dad

Both Parents

Mother's Full Name

First Name

Last Name

Mother's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physicians Release and Assignment + Financial Agreement *

Physicians Release and Assignment: I authorize the release of medical and other information necessary to process and receive payment on health insurance claims and request payment of benefits be made to the provider. A copy of this authorization may be used in lieu of the original. Financial Agreement: I understand that I am financially responsible for any charges incurred for the services provided. If I have health insurance coverage and my provider is in-network, I understand that I am financially responsible for co-payments, deductibles, and co-insurance associated with covered services. If my provider is out of network, I understand that I may be responsible for higher out of pocket amounts. I understand if I choose to have non-covered services done I will be responsible for payment in full. If my account is sent to collection s due to non-payment I agree to pay all fees and expenses incurred in collecting any. Recorded Messages:

Yes

No

Do not leave message other than “RETURN CALL”

Date *

MM

DD

YYYY

CONSENT, PERMISSION AND RELEASE FOR USE OF PHOTO, VIDEO AND/OR AUDIO *

I hereby give consent and permission to Shores Pediatrics, LLC to record the appearance, physical likeness and/or voice on videotape, on film, or digital video disk, or other means, and /or take photographs of the appearance of myself. Notwithstanding any prohibition, as may be contained in Section 540.08, Florida Statutes I hereby freely and voluntary consent of the use and publication of my name, participation, picture, and/or likeness by Shores Pediatrics, LLC and/or its employees or agents, as well as the entity seeking this content and photographs, video, and/or audio for any and all purposes including, but not limited to educational, promotional, advertising and trade, through any medium or format, including but not limited to film, photograph, television, radio, digital, internet, or exhibition, at any time from this day forward until I revoke this consent in writing. I acknowledge that Shores Pediatrics, LLC is the sole owner of all rights in, and to this visual and/or sound production and/or photograph(s) and the recordings, thereof, and that has the right used to produce the resulting images and/or sound as often as it finds necessary. I acknowledge that the photographs video and/or audio maybe use indefinitely by television, radio, newspapers, magazines, newsletters, brochures, internet, intranet, or in other media once released. Shores Pediatrics, LLC has the right, among other things, to edit and/or otherwise alter the visual or sound recording, or photographs, as needed. I understand I will receive no compensation for the appearance of the above-named person or for participation and said productions. I agree to hold Shores pediatrics, LLC, its employees and other parties harmless against claim, liability, loss, or damage caused by, or arising from my participation in this production. I have read this consent before signing and fully understand the contents, meeting, and impact of this consent I understand that I am free to address any specific questions that I have done so prior to signing this consent.

I consent

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Date

MM

DD

YYYY

APPOINTMENT CANCELLATION / NO SHOW POLICY

Thank you for trusting your medical care to Shores Pediatrics. When you schedule an appointment with Shores Pediatrics we set aside enough time to provide you with the highest quality care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. With that in mind please take note of our Appointment Cancellation /No Show policy found below: Any patient who fails to show up or cancel/reschedule an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $25 fee. We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager who may be able to waive the No Show fee.

I have read and understand the Medical Appointment Cancellation/No Show Policy and agree to its terms.

Date

MM

DD

YYYY

E-MAIL CONSENT FORM

Risk of using e-mail: You and your Healthcare provider have agreed to correspond using electronic mail (e-mail). This form provides guidelines for the intended use of this type of communication and documents your consent. IN A MEDICAL EMERGENCY, DO NOT USE E-MAIL, CALL 911 E-mail Use: Generally, e-mail correspondence should be between the provider and an adult patient 18 years older, or parent or legal guardian of a minor. Privacy and Confidentiality: Unless your provider tells you specifically that the e-mail will be conducted via a secure server, consider e-mail like a postcard that can be viewed by unintended persons. In addition, the content of the email may be monitored by Shores Pediatrics to ensure appropriate use. Discuss with your provider who will process your e-mail messages during business hours, vacations or illness. All e-mails regarding your care will be included in your medical record. Creating a Message: On the “Subject” line, include the general topic of the message, for example, Prescription or Appointment or Advice. In the body of the message, include your name and your identification number (Medical Record Number) or your date of birth. Content of the Message: E-mail should be used only for non-sensitive and non-urgent issues. Types of information appropriate for e-mail include: • Routine follow-up inquiries • Appointment scheduling • Medical Record Discuss with your provider the expected time in which to receive a response. If the expected time is exceeded, call your provider at the phone number below. Ending E-mail Relationship: Either you or your provider may request via e-mail or letter to discontinue using e-mail as a means of communication. Please note that in order to account for the time spent communicating with your healthcare provider, a $75 fee will be charged per consultation (several separate exchanges on the same topic will be charges as one consultation). Disclaimer: Shores Pediatrics, and Dr. Laura Fernandez Ortiz, M.D. are not responsible for e-mail message that are lost due to technical failure during composition, transmission and/or storage.

I have read and understand the information above, and had any questions answered to my satisfaction. I agree to the guidelines for e-mail communication.

Date

MM

DD

YYYY

CONSENT FOR CHILD’S MEDICAL / EMERGENCY TREATMENT AND MEDICAL INFORMATION

In presenting my son/daughter for diagnosis and treatment I hereby voluntarily consent to the rendering of such care, including diagnostic procedures, by authorized staff of Shores Pediatrics of their designees as maybe necessary in my absence.

I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition. I have read this form and certify that I understand its contents.

Name

First Name

Last Name

Mother

Father

Legal Guardian

Son

Daughter

D.O.B.

MM

DD

YYYY

Son

Daughter

D.O.B.

MM

DD

YYYY

Son

Daughter

D.O.B.

MM

DD

YYYY

WHO may bring my child to Shores Pediatrics for medical attention as described above for my child/children aforementioned.

I/We acknowledge that I/We are responsible for all reasonable charges in connection with care and treatment rendered during this period. Any co-payments and/or deductibles will still need to be paid.

Date

MM

DD

YYYY

MEDICAL RECORDS RELEASE AND REQUEST FORM

Medical Office/Practitioner Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Medical Office/Practitioner Phone

(###)

###

####

Patient Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I request that the above-named office/practitioner provide a copy of the specific health and medical information for the patient(s) named to Shores Pediatrics.

I authorize Shores Pediatrics to release the specific health and medical information for the patient(s) named to the outside medical office/practitioner above.

This request applies to the following information to be provided:

Abstract (Health Summary only)

Consultation Reports

Progress Notes

History and Physical

Vaccine Records

Complete Record

HIV

Mental and Behavioral Health information pertaining to any medical history, mental or physical condition, and treatment received.

This authorization will expire on: (Insert Date Below) if date not specified, this release will expire 1 year from date of signature.

MM

DD

YYYY

I understand that there is a charge of $1.00 per page for first 25 pages and $0.25 for every page thereafter for the release of my records. (This only applies if you are requesting us to make copies of records). I understand that if I refuse to consent to disclosure of information, Shores Pediatrics may be unable to serve my child and/or may be unable to provide the most suitable care for my child.

I understand that once Shores Pediatrics releases my health information to the recipient, Shores Pediatrics cannot guarantee that the recipient will not re-disclose my health information to a third party. The third party may not be required to abide by this authorization or applicable federal Florida law governing the use and disclosure of my health information.

Name of Parent or legal guardian

First Name

Last Name

Date

MM

DD

YYYY

Name of Parent or legal guardian

First Name

Last Name

Date [Shores Pediatrics Staff has checked the ID of the signer and ensured that this is the legal representation who has access rights.]

MM

DD

YYYY

(HIPPA) NOTICE OF PRIVACY PRACTICES

HIPPA privacy rules give individuals the right to request a restriction on uses and disclosures of the protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s place of employment instead of the individual’s home.

I understand that I will upon request receive a copy of the HIPPA statement at Shores Pediatrics.

I understand HIPPA privacy practices are also posted in the office waiting area.

Please let us know if it is OK to leave a detailed message containing PHI at:

HOME VOICEMAIL

CELL PHONE VOICEMAIL

EMAIL

Child's Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Date

MM

DD

YYYY