GARDENS MEDICAL GROUP

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Welcome to Gardens Medical Group. We appreciate that you have selected our practice to provide your medical services. The relationship between a physician and a patient is very important; we have designed every aspect of our practice to provide the best care possible. Enclosed you will find pre-registration and medical history forms as well as other vital information. To expedite your first visit we ask that you complete all the forms prior to your visit. Please bring all forms with you on your first visit. Arrive about 30 minutes prior to your appointment to allow enough time to ensure forms are complete and we can scan your medical insurance card. Please bring all of your medications with you to your first visit. Please bring any referral medical records with you. We make every effort to confirm all appointments by phone, 24 hours prior to the appointment time. We use the phone number given during the registration process. There are times when we are not able to reach everyone to confirm their appointment for different reasons, so please, if for any reason you are unable to keep your appointment, contact our scheduling desk at 561.622.7661 to reschedule your appointment. Again, welcome, we look forward to a long lasting relationship. If you should ever have any questions or concerns, please contact me directly at 561.622.7661. Sincerely, Julie Gatyas Practice Operations Manager 3345 Burns Road Palm Beach Gardens, FL 33410 P: 561.622.7661 POS Reorder # 1714212

PATIENT INFORMATION Welcome to our office. Your time is valuable and being aware of the information below will help your contact with our office run smoothly. *Please fill out the enclosed paperwork/forms and bring them with you to your appointment. OFFICE HOURS: Our hours of operation are 9:00 am to 4:30 pm, Monday through Friday. EMERGENCY SITUATIONS Please remember the physicians and Medical Assistants are seeing scheduled patients throughout the day and it may take some time before a return call can be made. The office functions with a timely and efficient message system so it is not necessary to make repeat phone calls to the office during the course of the day. Other calls will be returned during the course of the day as our schedule allows. Calls received in our office after 3 pm may not be returned until the following day. We will provide you with a list of Urgent Care Centers that we work with. APPOINTMENTS We ask that you notify us at least 24 hours in advance to cancel your appointments. This will give us the opportunity to fill your time slot with another patient in need of an appointment. We reserve the right to charge for appointments broken with less than 24 hours notice. If you have several questions or problems to discuss, this is best handled by scheduling an office visit. Physical exams should be scheduled at least 3-6 months in advance as slots are limited. PRESCRIPTIONS Request prescription refills from your pharmacist who will use our prescription refill line. Plan a 48 to 72 hour turn around for routine refills and call the pharmacy to see if the medication is ready. Please allow yourself enough time for this process when requesting medication for mail order pharmacies. Please ask for refills of prescription medications that you keep on hand, such as allergy medications, when in the office for a doctor visit. Some medications require preauthorization by your health insurance plan. The pharmacist will generally notify you when this is the case. Completing the paperwork for preauthorization of prescription drugs will generally require at least 7 business days. Once our office has completed the paperwork we cannot speed up the process. While waiting for the medication to be approved for coverage, you may need to pay for a small supply out of pocket. This will ensure that you do not run out of medications that you need on a daily basis. TEST RESULTS Due to privacy laws, we encourage you to make an appointment to discuss your test results. We also believe this improves care and complies with HIPAA laws. REFERRALS Managed care referrals generally require a visit with your primary care physician first, unless this is a condition you have previously discussed. Requests for follow-up visits to the specialist may sometimes be handled with a phone call. Please allow at least a week to process any non-emergency referrals. (48 hours is the absolute minimum.) On an HMO plan, if a specialist refers you to another physician or facility (such as physical therapy) you must contact our office for that referral. We require a photo ID when picking anything up from our office, such as prescriptions, sample medications, any letters or notes from the physician. If someone other than you will be picking these things up for you, they must be listed on your PHI designation form and show photo ID before we release anything to them. Thank you for selecting Gardens Medical Group as your medical provider. The Physicians, Management and Staff POS Reorder # 1714213

PATIENT REGISTRATION PATIENT INFORMATION Patient Account # Last Name First Name M.I. Street Address City State Zip SS # Birth Date Sex 9 M 9 F 9 Other Marital Status Race Home Phone Cell Phone Email Patient s Place of Employment Pharmacy Phone Phone Referred by In Case of Emergency, Notify: Name Daytime Phone Relationship to Patient MEDICAL INSURANCE INFORMATION Insurance Cards Must Be Presented At Each Visit Primary Insurance Company Name HMO 9 Yes 9 No Policyholder s Information (If Other Than Patient): Last Name First Name M.I. SS # Birth Date Gender Relationship to Patient Subscriber s Employer Name and Address Secondary Insurance Company Name Policyholder s Information (If Other Than Patient): Last Name First Name M.I. SS # Birth Date Gender Relationship to Patient Subscriber s Employer Name and Address POS Reorder # 1714214

Date: Name: Reason for Visit: Physician: HEALTH HISTORY ASSESSMENT Birth Date: Present / Previous Health Problems: (For family boxes, indicate for mother, father, sister, brother, children) Self Family Self Family Stroke 9 9 Leg / Back / Neck Pain 9 9 *Diabetes 9 9 Hiatal Hernia 9 9 Heart Problems 9 9 Convulsions / Seizures 9 9 Arthritis 9 9 Kidney Disease 9 9 Breathing Problems 9 9 Bleeding Problems 9 9 High Blood Pressure 9 9 Depression / Mental Illness 9 9 *Cancer 9 9 *HIV / AIDS 9 9 Hepatitis 9 9 Phlebitis / Blood Clots 9 9 Thyroid 9 9 List Surgeries / Hospitalizations with Dates: List Previous and Current Conditions Being Treated for (ex. High blood pressure, diabetes): Please list the dates of your last: Mammogram Tetanus Shot Stress Test Colonoscopy Flu Shot TB Skin Test Eye Exam Pneumonia Shot EKG Hepatitis B Shot Have you ever had a blood transfusion? 9 Yes 9 No If Yes, when? SOCIAL HISTORY: Check (3) which substances you use and describe how much: # of Years Quit? When? Caffeine Alcohol Smoking Drugs POS Reorder # 1714215

1. Medication Strength How Do I Take It? 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. POS Reorder # 1714216

PROTECTED HEALTH INFORMATION DESIGNATION FORM Patient Name: Account # You may give Gardens Medical Group written authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose. Please complete the questions below. Only provide information which you consider acceptable as a means of contacting you and your designated contacts. In the case of a serious medical emergency or in cases otherwise permitted or required by law, this written authorization will not be necessary. Please see Notice of Privacy Practices for details. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing PHI about you. My Home Number:. OK to leave message on voice mail? Yes / No My Work Number:. OK to leave message on voice mail? Yes / No My Cell Phone Number:. OK to leave message on voice mail? Yes / No My mailing address for test results, appointments, billing issues: I authorize Gardens Medical Group to disclose my PHI to: You may leave this blank if you do not wish any disclosures be made: Name: Address: Phone Numbers: Relationship to Patient: Can we release any billing information to this person? Yes / No If you would like to authorize more than one person please provide their information on the back of this form. Specific Information: Specific information that you would like us to release or certain information you do not want released to anyone. (If no restrictions, please leave blank.) ADVANCED DIRECTIVES: A Living Will is a document that advises your family and physicians of your desires should you become unable to make decisions regarding your health care. A Health Care Surrogate is a person that you designate to make decisions for your health care in the event that you are unable to. If you have prepared these documents, please give a copy to your doctor to be included in your chart. LANGUAGE: 9 English 9 Spanish 9 Other The guidelines listed above have been reviewed with by Signature (MD, RN or MA) (Print Patient s Name) POS Reorder # 1714217

Internal Medicine and Geriatrics Rohit Dandiya, M.D., F.A.C.P. Internal Medicine and Geriatrics Rodney Herman, M.D. Internal Medicine Edward Jeryan, M.D. Family Medicine Lucero Chueca, M.D., F.A.C.P. Internal and Obesity Medicine Telephone: 561-622-7661 Fax: 561-622-4651 3345 Burns Road, Suite 302 Palm Beach Gardens, FL 33410 MEDICAL RECORDS RELEASE Date: I authorize: To release copies of medical records to: 3345 Burns Road, Suite 302 Palm Beach Gardens, FL 33410 Tel: 561-622-7661 Fax: 561-622-4651 Authorize the release of information of the following portions of my medical record: X-Rays History and physical + Discharge Summary All Labs Colonoscopy / Upper Endoscopy Office / Consult notes A photocopy of this authorization shall constitute a valid authorization. I understand that once my medical records have been released, the medical office cannot retrieve them, and has no control over the use of the already released copies. I hereby release the physician and staff at Gardens Medical Group from any and all liability which may arise as a result of my authorized release of records. Should my case require review by a government agency or another medical professional actively involved in my care to make a final determination, it is with my consent that a copy of these records will be submitted to the agency or medical professional for this review. Patient signature (or legal representative) DOB Print Name Witness Excellence in Primary Care POS Reorder # 1714218

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