Patient Information Form

PATIENT INFORMATION FORM

Patients experiencing Covid-19 symptoms (i.e. fever, cough, loss of taste and/or smell) or patients directly exposed to someone Covid-19 positive require pre-registration and will be tested in their car.

All other patients may walk into the facility without an appointment. Please feel free to call 786-923-4000 with any questions.

Select your visit type:

Referring Doctor:

Closest Urgent Care Facility:

Payment Type:

In the last 7 days, have you had fever, cough, shortness of breath, loss of sense of smell or taste?

Yes

If checked yes please explain:

In the last 14 days, have you been in contact with someone who was diagnosed with COVID-19?

Yes

If checked yes please explain:

Have you ever been diagnosed with Covid-19?

Yes

If yes, when were you diagnosed?

PATIENT INFORMATION

First Name

Last Name

Address

City

State

Zip Code

Phone/Mobile:

Social Security #:

Date of Birth:

Marital Status:

Single

Married

Divorced

Widow

Other

How did you hear about FastCare?

Physician/Hospital

Pharmacy/Hotels/Magnet/Drive by

Insurance Co

Web/Yelp/Facebook

Family/Friend

Other

Email:

Reason for today’s visit:

Name of Pharmacy:

Pharmacy address:

Address

City

State

Zip Code

Pharmacy phone #:

CONTACT INFORMATION (IN CASE OF AN EMERGENCY WHO SHOULD BE NOTIFIED)

First Name

Last Name

Relationship:

Phone/Mobile:

Address

City

State

Zip Code

FAMILY PHYSICIAN

First Name

Last Name

Address

City

State

Zip Code

Phone/Mobile:

As a courtesy, your medical notes will be faxed to your primary physician, unless you indicate here:

INSURANCE INFORMATION (MUST BE COMPLETED ENTIRELY)

Primary Insurance:

Name of Insured:

Date of Birth:

Policy #:

Group #:

Relation to Patient:

Upload Insurance card (Front & Back)

Choose File

Upload Driver License or Government Issued Photo ID

Choose File

Upload Prescription

Choose File

ASSIGNMENT, RELEASE, AND FINANCIAL RESPONSIBILITY

I authorize release of medical information to process claims to my insurance company and request that benefits be paid directly to FastCare, LLC. I understand and agree that regardless of my insurance sources, I am ultimately responsible for the balance of my account for any professional services rendered. I authorize the use of my signature on all insurance submissions. I have read all the information on this sheet and certify this information to be true and correct to the best of my knowledge. I ALSO HEREBY CONSENT AND GRANT PERMISSION TO FASTCARE, LLC AND ITS MEDICAL STAFF TO VIEW AND DOWNLOAD MY PRESCRIPTION HISTORY FROM EXTERNAL SOURCES.

Signature of Patient, Parent, Guardian or Personal Representative

Please Sign Here

Date

Print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Section A:

Patient Consent

First Name

Last Name

Address

City

State

Zip Code

Phone/Mobile:

Social Security #:

Section B:

Please read the following information:

Purpose of Consent: By signing this form you will consent to our use and disclosure of your protected health information to carry treatment, payment activities, and health operations, and to your employer for workers compensation purpose if needed.
Notice of Privacy Practices: You have the right to read our Notice of Privacy practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of our 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 carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of our protected health information that we maintain. You may obtain a copy of our notice of Privacy Practice, including any revisions in our Notice, at any time by contacting our office at:

20601 E. Dixie Highway, Suite 340, Aventura, Fl. 33180 or 825 Arthur Godfrey Road, Suite 100, Miami Beach, FL 33140
Phone#: (786) 923-4000

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of revocation submitted to the contact person listed above. Please understand the revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or continue treating you if you revoke this consent.

I 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 of Patient, Parent, Guardian or Personal Representative

Please Sign Here

Date