George M. Hudson D.O., M.P.A

1537 S. Alafaya Trl

Suite 104

Orlando, FL32828

(321) 235-0970 Office

(321) 235-0971 Fax

George M. Hudson D.O., M.P.A.

Gretchen Daniels ARNP

PATIENT REGISTRATION FORM

(Please Complete Both Sides in Full)

Please Provide Insurance Card(s) to Receptionist for Copying

PATIENT INFORMATION

Name: (please print)______

Social Security#: ______Sex: ____ Age: ____ Date of Birth: ______

Local Address: ______

City, State, Zip Code: ______

Home Phone #: ______Work Phone #: ______

Out of State Address & Phone # (if applicable): ______

Marital Status (circle): S M W D: Name of spouse:______

Patient Employer: ______

Occupation: ______

Emergency Contact Name and Phone #:______

Email: ______

Advanced Directive: All adults in health care settings in the state of Florida have the right to an “Advanced Directive” this is a written or oral statement made and witnesses in advance of a serious illness or injury, stating how medical decisions will be made. An Advanced Directive enables you to state your choice or name someone to make your choice for you, if you should become unable to make decisions about your medical treatment.

Do you have a Living Will? _____ Yes _____ No (If yes, please provide the office a copy).

Guarantor Information (Person Holding Insurance Coverage)

Name (please print) ______Relationship to Patient ______

Local Address: ______

City, State, Zip Code: ______

DOB: ______Day time phone #: ______

Insurance Name & Address: ______

______

ID #: ______Group #: ______

CO-PAY AMOUNT TO BE COLLECTED AT THE TIME OF SERVICE

SIGNATURES REQUIRED

For Medicare Patients: I request that payment of authorized Medicare benefits be made either to me on my behalf, or to Hudson Medical Wellness for any services furnished by that physician. I authorize any holder of medical information about me to release to the Health Care Finance Administration and its agents, any information needed to determine these benefits or these benefits payable for related services.

______

Beneficiary Signature Date

For Non-Medicare Patients: I authorize release of any medical information necessary to process this claim and related claims. I request that payment of authorized benefits be made either to me or on my behalf to the physician for any services furnished to me by that physician.

______

Patient Signature/(If minor) Guarantor Date

All Patients/Guarantor: I agree to pay all charges for members of my family and myself, as applicable, promptly upon presentation thereof. Charges as shown by statements are agreed to be correct unless protested in writing within thirty days. It is agreed that payment will not be delayed or withheld because of any insurance coverage or the pending the claims thereon. Collection: Should the account be referred to a collection agency or attorney for collections the undersigned shall pay reasonable attorney and collection fees. All delinquent accounts bear interest at the highest rate allowed by law.

Signature: ______Date: ______

Laboratory Fees: I understand I may be billed by an outside laboratory for pathology or lab work that is performed in the office, for non HMO or PPO patients. All HMO’s and PPO’s will be sent to the provider contracted laboratory. Please verify laboratory benefits with your insurance carrier for any and all outside laboratory request.

Signature: ______Date: ______

**For your convenience, we offer the following methods of payment. CASH, VISA, MASTERCARD, AMEX and DISCOVER.

PATIENT’S PERSONAL HISTORY

Date: ______

This information will be asked of you again during your initial new patient intake. Please complete the following to the best of your knowledge.

Last Name, First, Middle: ______

Birth Date: ______Birth Place: ______

Date of Last Examination: ______Doctor: ______

Referring Physician: ______

Phone Number #: ______

How did you hear about us: ______

Pharmacy which you prefer: ______

Address and Phone #:______

______

FAMILY HISTORY

Do you know of any blood relative who has or had (Circle and give relationship)?

Heart Disease ___ Diabetes ___ High Blood Pressure _____ Stroke _____ Cancer _____

Glaucoma ___ Epilepsy/Convulsions ____ Bleeding Disorders ____ Prostate Disorders ___

Kidney Disease ___ Thyroid Disease ___ Mental Illness ___ Osteoporosis ____

SOCIAL HISTORY

(Please Circle)

Yes NoDo you regularly smoke? Cigarettes ___ Cigars ___ Pipes ___

Daily, how many ___ Years ___

Yes NoDo you usually drink over 6 cups of coffee or soda per day?

Yes NoDo you regularly drink alcohol? 1oz. daily___ 2oz. daily___ 4oz. daily___ Over 6oz. ___

Beer: 1 bottle daily____ 2 bottles daily___ Over 4 bottles___

Yes No Do you use illicit drugs? IV Drugs___ Marijuana ___ Cocaine ___

Name any drugs to which you are allergic? ______

Current Medications (Please include dosage and doctor who prescribed it when possible):

______

Write the names of any diseases you have had which required hospitalization: ______

______

Write the name and the years of any operations which you have had: ______

______

IMMUNIZATIONS

(List Given Dates)

DTA/DTP: ______TB: ______

TD: ______Hepatitis B: ______

Polio: ______Pneumonia: ______

HIB: ______Flu: ______

MMR (Combined or separate): _____Other: ______

______

FOR CHILDREN ONLY

Last Physical Exam: ______

Most Recent Immunizations: ______

FOR WOMAN ONLY

Pregnant: Yes _____No _____

MEDICAL HISTORY (Please check those apply)

___ Headaches___ Lactose Intolerance___ Depression

___ Shortness of breath___ Gallbladder Disease___ Gout

___ Heart Palpitations___ Prostate Disease___ Scarlet Fever

___ Heart Murmur___ Bowel Irregularity ___ Chronic Rash

___ Chest Pain___ Incontinence___ Dizziness

___ Heart Disease___ Menstrual Problems___ Mumps

___ Venereal Disease___ Measles___ Allergies

___ Frequent Infections ___ Rubella___ Asthma

___ Hepatitis___ Polio___ Bronchitis

___ Anemia___ Diphtheria ___ Pneumonia

___ Arthritis ___ Rheumatic Fever___ Ulcer

___ Diabetes___ High Blood Pressure___ Kidney Disease

To be answered by MEN ONLY: Have you ever had (circle one)

YesNoLoss of sexual activity? For how long ______

YesNoTreatment for genitals (private parts)? ______

YesNoDischarge from penis? ______

YesNoHernia (rupture)? ______

YesNoProstate trouble? ______

Please describe briefly your reason for today’s visit: ______

______

VOICE MAIL MESSAGES

All messages left on the Medical Assistant Voice Mail will be returned within 48 business hours. If you need immediate attention please speak with the front desk for assistance.
All messages left on the Referral Coordinator voicemail will be returned within 72 business hours. If you need immediate attention please speak with the front desk for assistance.
All messages left on the general office voicemail will be returned within 24 business hours if indicated.

FOLLOW UP LAB WORK

The medical assistants do not call patients whose lab work shows all levels within normal ranges. Should the provider need for you to be seen for a follow up on your lab work he/she will indicate at the time of your appointment and/or a medical assistant will call you once the lab work is received and leave a message requesting you make this appointment. If you have any questions about needing to make an appointment, please call the office for clarification.
Please note: Our office will not provide copies of lab work until it has been reviewed by the provider and all necessary appointments have met. This may result in a delay of prescription refills.

OFFICE FINANCIAL POLICY

All medical fees including but not limited to: co-payments, deductibles, co-insurance, and any outstanding balances are due at time of visit, before receiving services.

Verification of your benefits is made prior to your appointment. These benefits are just an estimate and not a guarantee of payment.

If you have more than one insurance plan covering your health care services, Federal Laws determine which plan pays first and which plan pays second. Neither you nor the office can choose which plan will pay first. We will file the claim first with the plan that law determines as primary and after their payment, you must coordinate your secondary insurance plan for payment. We do not bill to secondary insurances.

I understand that my insurance plan is a contract between me, the insurer, and the insurance company. Hudson Medical Wellness is not a party to that contract. Therefore, payment for the treatment is ultimately your responsibility, regardless of insurance coverage. Please note that since we are not a party to your insurance contract, you are responsible for contacting your insurance carrier to settle any disputes or claim denials.

We do not retain benefit information for lab services done outside of our office. Please make sure you verify these benefits prior to completing any lab work requested by the provider.Effective January 1, 2013 the office will no longer mediate any outstanding balances between you, the patient and the laboratory. Make all requests for changes in your lab work to the Medical Assistant.

Please present any changes or new insurance cards at the time of check-in.

I understand that there will be a charge of $30 for all checks, electronic authorizations or debits returned by the bank for non-payment.

If you are unable to keep an appointment, please notify the office within 24 hours or at the minimum, on the scheduled date prior to your appointment time. Failure to do so may result in a $25.00 charge to your account. All missed appointment fees must be paid prior to your next appointment.

Our office disapproves of late arrivals. If a patient is more than 10 minutes late to his/her appointment without notification prior to arrival, we will be required to reschedule.

Our office does not see patients for treatment related to an automobile injury and/or workers compensation injury. If you have questions regarding where to receive treatment please contact your insurance carrier and or claims representative.

There is a $25 administrative fee, per page, for all forms to be completed by provider or the office administration. Be aware that physicals requested by Military, Employer or a Cosmetic Surgery Clearance is not covered by insurance and prices will be discussed prior to being seen. Please present forms to the front desk at time of appointment for charge amount.

I have read and acknowledge the above information:

______

Signature (Patient/Guarantor)Date

1537 S. Alafaya Trl.

Suite 104

Orlando, FL32828

(321) 235-0970 Office

(321) 235-0971 Fax

Notice of Privacy Practices

As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1966 (HIPAA)

Hudson Medical Wellness, in order to comply with HIPAA Privacy Regulation, has adopted a policy that requires our physicians and staff to obtain authorization from the patient to use and / or disclose any individually identifiable health information for any of the following categories:

Treatment, Treatment Options and Benefits and Services. Our practice may use your health information to treat you or to inform you of potential treatment options or alternatives.
Payment. Our practice may use and disclose patient information in order to bill and collect payment for the services and items you may receive from us.
Health Care Operations, Disclosures Required by Law and any Special Circumstances. Our practice may use and disclose patient information to operate our business, conduct evaluations or cost management and business planning activities.
Appointment Reminders. Our practice may use patient information to leave name and number messages on an answering machine, voicemail or with a live person answering the phone.
Your initial here ______consents that the staff of Hudson Medical Wellness may leave a detailed message. You must also specify what information may be left and with whom by noting the information below.

______On an answering machine or voicemail at home or cell phone.

______On an answering machine or voicemail at work.

______With a specified individual (name) ______

______I DO NOT CONSENT TO MESSAGES BEING LEFT AT HOME, WORK, OR WITH ANY OTHER PERSON. I WISH TO BE CONTACTED DIRECTLY.

I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. If I do not sign this consent,

Hudson Medical Wellness may decline to provide treatment to me.Release of Information to Family and Friends. Our practice may release your information to a friend family member that is involved in your care. Please sign the Authorization below and provide the specific names to who protected health information may be given.

Authorization to Release Protected Health Information

I, ______, hereby authorize Hudson Medical Wellnessto release my protected written and verbal health information to the following:

Family Members or Friends:

______

School or Employer:

______

Friend, Guardian or Legal Adult that I authorize may bring my minor child to their appointment:

______

READ CAREFULLY

My signature below acknowledges my understanding of the following:

I have the right to review the Notice Of Privacy Practices prior to signing this consent.
I understand that medical/ behavioral health records are confidential. By signing this authorization I am allowing the release of my information to the persons/ agencies indicated above.
I understand that signing this authorization is not a condition of receiving treatment here.
I understand that I have a right to receive a copy of this authorization.

______

Patient Signature/ Parent or Legal Guardian:

______

Date:

George M. Hudson, D.O., M.P.A 1537 S.Alafaya Trl

Gretchen Daniels ARNP Suite 104

Orlando, FL32828

Tel (321) 235-0970

Fax (321) 235-0971

CONSENT FOR RELEASE OF MEDICAL RECORDS

PATIENT INFORMATION (PLEASE PRINT):

NAME:______DATE OF BIRTH:______

ADRESS: ______

(Street) (Apt#)

______

(City) (State) (Zip Code)

TELEPHONE:______SSN:______

INFORMATION REQUESTED:

ALL MEDICAL RECORDS
EKG REPORTS/ RADIOLOGY REPORTS
PATHOLOGY REPORTS
HOSPITAL RECORDS
CONSULTATIONS
OTHER: ______

I hereby authorizeHudson Medical Wellness to obtain copies of my health records from:

FACILITY/DOCTOR NAME: ______

ADDRESS: ______

______

TELEPHONE: ______FAX: ______

Please send medical records to:

Hudson Medical Wellness

1537 S. Alafaya Trl

Suite 104

Orlando, FL32828

Tel (321) 235-0970

Fax (321) 235-0971

BY MY SIGNATURE I AUTHORIZE RELEASE OF MEDICAL RECORDS

______

(Patient/Guardian Signature) (Date)

THIS REQUEST EXPIRES ON: ______