Dr. Albert F. Bravo Gastroenterology / Internal Medicine
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1 Dr. Albert F. Bravo Gastroenterology / Internal Medicine Name: First Middle Last Spouse s name: Please check one: Married Single Widowed Divorced Ethnicity: Race: Language Preferred: Home Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Age: Date of Birth: / / Social Security Number: Employed: Yes No Employer: Name of nearest relative: (In case of emergency - please indicate relationship) Full name of your primary doctor: Telephone: Telephone: Name of health insurance company: HMO PPO (Please provide copy of card) Contract #: Group #: Group Name: Subscriber s Name: Subscriber s Social Security #: Subscriber s Date of Birth: / / Pharmacy Name: BY MY SIGNATURE I AUTHORIZE RELEASE OF ANY PAYMENTS AND MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM AND RELATED CLAIMS. I UNDERSTAND THAT ANY SERVICES NOT COVERED BY MY HEALTH INSURANCE CARRIER WILL BE OWED BY ME. FAILURE TO PAY ANY OUTSTANDING BALANCES WITHIN 60 DAYS WILL RESULT IN COLLECTION ACTION BY LAKE OKEECHOBEE DIGESTIVE DISEASE CENTER, P.A. Patient or Legal Guardian Signature Date
2 Lake Okeechobee Digestive Disease Center Dr. Albert F. Bravo 201 NW 82nd Avenue Suite 307 Plantation, FL NE 19th Drive Okeechobee, FL Name: Reason for Visit: DOB: Phone Number: ( ) Primary Doctor: Please Circle All Medical Problems: Diabetes/High Blood Pressure/ High Cholesterol / COPD/Asthma/ Coronary Artery Disease/ Anxiety / Depression / Epilepsy / GERD/ Irritable Bowel Syndrome/ Migraine/ Sleep Disorders/ Stroke/ Heart Issues List Any Other Medical Problems: Allergic to Any Medications? No Yes, Please List: Family History of Colon Cancer: No Yes If yes list relationship CIRCLE: Married/Single/Separated/Divorced/Widowed Name of Spouse and Contact Number: Do you Smoke or Chew Tobacco? No Yes If yes, How Much Do you Drink Alcohol? No Yes If yes, How Often? Please List All Medications You are Currently Taking: Please List All Surgeries: Any Heart or Lung Surgeries? No Yes Signature: Date:
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5 PREVENTIVE SERVICES EDUCATION SHEET The promotion of healthy lifestyles and the early identification of potential health risks will benefit you and are important to us. In accordance with the current United States Preventive Services Task Force (USPSTF) guidelines, we have put together the following information for your guidance. Please read this preventive education sheet and feel free to discuss any of the topics with your physician. Only you can take appropriate actions to maintain your health and well being. LIFESTYLE CHANGES Diet and Exercise A healthy diet and regular exercise are the most effective ways to maintain good health, promote longevity, and increase your quality of life. Choose a diet low in saturated fat, cholesterol, sugar and salt; eat plenty of vegetables, fruits, lean meats, and grains which provide vitamins, minerals and fiber. Twenty minutes of exercise three times a week (i.e. walking, swimming, etc.) will keep your heart and bones healthy. Substance Abuse Use of tobacco is known to cause heart disease, strokes and lung cancer. Excessive alcohol intake is associated with many illnesses, including cancer, liver disease and impaired judgment (as in driving). Illicit drug use has many risks such as AIDS, hepatitis, heart problems and mental social disorders. Sexual Behavior Certain sexual practices (i.e., promiscuity and unprotected sex) can expose you to potentially fatal diseases such as AIDS, STDs (sexually transmitted diseases), and other common infections. Excessive Sun Exposure Causes skin cancer. Always wear sunscreen when exposed to the sun. The higher the SPF (sun protection factor) you use, the higher the protection level against ultraviolet rays. Injury Prevention Take advantage of the many safety products that are important in preventing serious injury. These include seat belts, bicycle helmets and other protective gear, safe work habits (lifting, bending, etc.), smoke detectors, firearm safety, poison prevention, water safety practices for adults and children, CPR training for household members, etc. Dental Health Brush and floss regularly. See your dentist for routine visits every six months. ADVANCE DIRECTIVES A document that is also called a Living Will, which advises your family and physicians of your desires, should you become incapacitated and unable to make decisions regarding your health care. Have you prepared a living will? Yes No Please sign below and acknowledge that you have read and understand this information. Print Full Name Signature Date
6 Lake Okeechobee Digestive Disease Center, P.A. Albert F. Bravo Gastroenterology/Hepatology CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION Section A: PATIENT GIVING THE CONSENT Name Soc. Sec# - - Address Telephone Date of Birth Section B: To the Patient-Please read the following statement carefully Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations. Notice of Privacy Practices. You have the right to read our Notice of Privacy Practices before signing this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent, we encourage you to read it before signing this consent. We reserve the right to change our privacy practices as described in or Notice of Privacy Practices. If we make changes, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice by contacting: Lake Okeechobee Digestive Disease Center, P.A. 225 N.E. 19 th Drive Okeechobee, FL (863) Right To Revoke. You will have the right to revoke this Consent at any time, by giving us written notice of your revocation, submitted to the Contact person noted above. Please understand the revocation of this Consent will not affect any action we took in reliance of thie Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. SIGNATURE 1,, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations. Signature Date
7 Lake Okeechobee Digestive Disease Center, P.A. Dr. Albert F. Bravo To All Patients of Lake Okeechobee Digestive Disease Center: Please be advised that Dr. Albert F. Bravo is here to assist you with your healthcare needs in the form of diagnoses and treatments of your conditions. Your doctor will perform a physical exam and will possibly order x-rays, laboratory results, MRI, CAT scan, ultrasound, and possibly endoscopic procedures to assist you in your healthcare needs. Please be informed that the Sate of Florida Bill of Patient s Rights indicates that all patients are personally responsible for the follow-up of their results of tests which doctors order for them, and in addition are personally responsible for the follow-up of conditions which are diagnosed on physical exam. The staff and Dr. Albert F. Bravo will not accept responsibility for bad outcomes as a result of patient noncompliance in the form of failing to personally in person follow-up for the results of all studies indicated as well as following up in the office for the results of physical examination abnormalities which have been detected. If for some reason it is impossible for you to show up in person for your appointment and you have to cancel, it will be your responsibility to reschedule a prompt appointment for discussion in person of all your results. We will not give out results of tests over the telephone as this information may be misunderstood by you the patient and may cause confusion in your follow-up, and therefore may have adverse results and poor outcomes in the treatment of your condition. Therefore I as the patient acknowledge that I have read this waiver and I understand that it is my personal responsibility to follow-up on all results and tests as well as physical examination abnormalities which are detected by Dr. Albert F. Bravo harmless against any adverse outcomes which may occur as a lack of my personal follow-up in this office. PATIENT SIGNATURE DATE
M or F Patient s Date of Birth Patient s Social Security Number Sex. Secondary Address: (if have, Northern) Street City State Zip Code
PATIENT REGISTRATION PLEASE PRINT Today's Date: Referred by: Patient s Name: Last First M.I. M or F Patient s Date of Birth Patient s Social Security Number Sex Primary Address: Street Apt/Unit # City
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UPON COMPLETION OF PATIENT REGISTRATION PACKET, PLEASE BRING ALL FORMS TO YOUR APPOINTMENT. YOU MAY ALSO FAX COMPLETED FORMS TO THE OFFICE AT 910-575- 9103. THANK YOU. PATIENT INFORMATION Patient s Name:
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