New Patient Forms

Patient Forms and Information
As with any medical office, there are many forms to fill out and information to be offered. Below you will find links to a variety of forms that you may print out and complete prior to an appointment or refer to as necessary during the course of your treatment.

Patient Bill of Rights

Adopted in 1998 by the U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry, and written into legislation specific to Florida, this document outlines the rights and responsibilities of patients. We support and protect the fundamental rights of each patient according to the adopted guidelines.

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Notice of Privacy Practices

Effective April 14, 2003, new privacy laws were established called the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). At your physician’s office, you will be asked to sign a form acknowledging that you have received this Notice of Privacy Practices.

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Acknowledgement of 1) Receipt of Privacy Notice, 2) Exception to the Release, 3) Request to Restrict

This notice verifies that you have been provided with a copy of our Notice of Privacy Practices. To ensure that our records are accurate and complete, this form must be signed while at our office, and will be stored with your records. Additionally, this form provides space for you to indicate any exceptions to disclosure of your Protected Health Information (PHI) as well as any restrictions to your PHI.

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Assignment of Benefits/Financial Responsibilities Form

If time permits, you will receive this form in the mail from your physician’s office. If you have not received one, please feel free to read our online copy and/or print one from this web site. You will be asked to complete this form for your records.

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Insurance/Patient Liability Form

This is a copy of the form you will be required to complete regarding your insurance information and liability.

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Medical Records: Release of Copies of Records

To protect the confidentiality of your medical information, we require written authorization from the patient or legal guardian before records will be copied and provided to anyone. Telephone requests are not accepted, as it is impossible to determine who is calling. Similarly, we will not give information about your medical condition to anyone, even friends and relatives; unless you have given us permission. You are the only one with the authority to release your records, unless you have given power of attorney to another individual. A copy of the legal power of attorney must be provided to us prior to records being released.  When you become a patient of one of our practices, you are asked to sign a release stating that we may provide copies of your records to your insurance carrier(s) for processing of claims or to other health care providers that your physician may refer you to for continued care.

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New Patient History Questionnaire: (North Florida Hematology and Oncology Only)

Knowing your personal medical history is important. Our North Florida Hematology and Oncology office suggests that you fill out this form prior to your appointment, so that you have time to compile and verify information on your personal medical history. At our other practices, your medical history will be obtained through a verbal interview. You may wish to use this form as a reminder of questions that may be asked at your first appointment.

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My Medical Schedule

Medications can be rather confusing; this is a blank form for you to print out from your computer. You can fill in the blanks with the medications you take on a regular basis. It will help you to remember what you are taking, when to take it and why you are taking the medication. Keep a few extra blank copies on hand so that if your medication regime changes, you can make a new list.

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