PATIENT INFORMATION FORM

All Covid-19 related visits are by appointment only, once you submit your paperwork please allow ample time for us to review your information. We will call you back with the available date and time.

PATIENT INFORMATION

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

FAMILY PHYSICIAN

INSURANCE INFORMATION (MUST BE COMPLETED ENTIRELY)

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.

Please Sign Here

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

Section A:

Patient Consent

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) 923-4001

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.

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