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NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM

PATIENT INFORMATION (ADULT)

First
MI
Last
Address *
Address
City
State/Province
Zip/Postal

PATIENT INFORMATION (CHILD)

PLEASE FILL IF PATIENT IS A CHILD:

PARENT / LEGAL GUARDIAN

Please, fill if parent/guardian of patient.

REFERRING SOURCE

Full Name

INSURANCE *** MUST BE FILL ***

COVID-19 PATIENT SCREENING FORM

Hamilton Anxiety Rating Scale (HAM-A)

Patient Name
Patient Name
First
Last

Bellow is a list of phrases that describe certain feeling that people have. Please select one of the five responses for each of the 14 questions.

0 = Not Present 1 = Mild 2 = Moderate 3 = Severe 4 = Very Severe
Worries, anticipation, of the words, fearful anticipation, irritability.
Feeling of tension, fatiguability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax.
Of dark, of strangers, of being alone, of animals, of trafic, of crowds.
Difficulty in falling to asleep, broken sleep, unsatisfying sleep, and fatigue on walking, dreams, nightmares, night terrors.
Difficulty in concentration, poor memory
Loss of interest, lack of pleasure in hobbies, depression, early walking, diurnal swing.
Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone.
Tinnitus, blurring of vision, hot and cold flashes, feeling of weakness, pricking sensation.
Tachycardia, palpitations pain in chest, throbbing of vessels, fainting feelings, missing beats.
Pressure or constriction in chest, choking feeling, sighing, dyspnea.
Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation.
Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence.
Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension, headache, raising of hair.
Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc.

Patient Depression Questionnaire (PHQ-9)

Patient Name
Patient Name
First
Last

Over the last 2 weeks, how often have you been bothered by any of the following problems?

0-4 Minimal or non Monitor; may not require treatment 5-9 Mild 10-14 Moderate (Use clinical judgment {symptom duration, functional impairment} to determine necessity of treatment) 15-19 Moderate severe 20-27 Severe (Warrants active treatment with psychotherapy, medications, or combination)

YOUR HEALTH CARE PROVIDER, INSURER, OR PLAN MAY REQUIRE A PHYSICIAN REFERRAL OR PRIOR AUTHORIZATION AND YOU MAY BE OBLIGATED FOR PARTIAL OR FULL PAYMENT FOR SERVICES PROVIDED.

AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION

Name
Name
First
Last
Tipe Initials

New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

I,
( the term “I” refers to the Patient or Parent/Legal Guardian of child) understand that as part of my healthcare, “Carrousel Health Care Corporation,” originates and maintains paper and/or electronic records describing “my” (the term “my” refers to parent and/or child) health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care of treatment. I understand that this information serves as: -A basis for planning my care and treatment, -A means of communication among the many health professionals who contributes to my care, -A source of information for applying my diagnosis and surgical information to my bill, -A means by which a third-party payer can verify that services billed were actually provided, and -A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcareprofessionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: -The right to review the notice prior to signing this consent, -The right to object to the use of my health information for directory purposes, and -The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,payment, or healthcare operations. I understand that “Therapy,” is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that “Therapy,” reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should “Therapy,” change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or if I agree e-mail).
I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via text, fax and/or e-mail.
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HIPPA Release Form

I,
give permission to “CARROUSEL HEALTH CARE CORPORATION.” and all employees to discuss and/or receive medical information including medical records concerning any and all aspects of patient’s previous healthcare by a doctor, physical, occupational or speech therapist, or other medical professional. This release is required to obtain medical information according to the privacy rule detailed in HIPPA (The Health Insurance Portability and Accountability Act of 1996).
Tipe Initials

Florida Patient’s Bill of Rights and Responsibilities Florida Statute 381.026

(1) SHORT TITLE. –This section may be cited as the “Florida Patient’s Bill of Rights and Responsibilities.” (2) DEFINITIONS. –As used in this section and s. 381.0261, the term: 1. a) “Department” means the Department of Health. 2. b) “Health care facility” means a facility licensed under chapter 395. 3. c) “Health care provider” means a physician licensed under chapter 458, an osteopathic physician licensed under chapter 459, or a podiatric physician licensed under chapter 461. 4. d) “Responsibleprovider”meansahealthcareproviderwhoisprimarilyresponsiblefor patient care in a health care facility or provider’s office. (3) PURPOSE. –It is the purpose of this section to promote the interests and well-being of the patients of health care providers and health care facilities and to promote better communication between the patient and the health care provider. It is the intent of the Legislature that health care providers understand their responsibility to give their patients a general understanding of the procedures to be performed on them and to provide information pertaining to their health care so that they may make decisions in an informed manner after considering the information relating to their condition, the available treatment alternatives, and substantial risks and hazards inherent in the treatments. It is the intent of the Legislature that patients have a general understanding of their responsibilities toward health care providers and health care facilities. It is the intent of the Legislature that the provision of such information to a patient eliminate potential misunderstandings between patients and health care providers. It is a public policy of the state that the interests of patients be recognized in a patient’s bill of rights and responsibilities and that a health care facility or health care provider may not require a patient to waive his or her rights as a condition of treatment. This section shall not be used for any purpose in any civil or administrative action and neither expands nor limits any rights or remedies provided under any other law. (4) RIGHTS OF PATIENTS. –Each health care facility or provider shall observe the following standards: (a) Individual dignity. -1. The individual dignity of a patient must be always respected and upon all occasions. 2. Every patient who is provided health care services retains certain rights to privacy, which must be respected without regard to the patient’s economic status or source of payment for his or her care. The patient’s rights to privacy must be respected to the extent consistent with providing adequate medical care to the patient and with the efficient administration of the health care facility or provider’s office. However, this subparagraph does not preclude necessary and discreet discussion of a patient’s case or examination by appropriate medical personnel. 3. A patient has the right to a prompt and reasonable response to a question or request. A health care facility shall respond in a reasonable manner to the request of a patient’s health care provider for medical services tothe patient. The health care facility shall also respond in a reasonable manner to the patient’s request for other services customarily rendered by the health care facility to the extent such services do not require the approval of the patient’s health care provider or are not inconsistent with the patient’s treatment. 4. A patient in a health care facility has the right to retain and use personal clothing or possessions as space permits, unless for him or her to do so would infringe upon the right of another patient or is medically or programmatically contraindicated for documented medical, safety, or programmatic reasons. (b) Information. -1. A patient has the right to know the name, function, and qualifications of each health care provider who is providing medical services to the patient. A patient may request such information from his or her responsible provider or the health care facility in which he or she is receiving medical services. 2. A patient in a health care facility has the right to know what patient support services are available in the facility. 3. A patient has the right to be given by his or her health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis, unless it is medically inadvisable or impossible to give this information to the patient, in which case the information must be given to the patient’s guardian, or a person designated as the patient’s representative. A patient has the right to refuse this information. 4. A patient has the right to refuse any treatment based on information required by this paragraph, except as otherwise provided by law. The responsible provider shall document any such refusal. 5. A patient in a health care facility has the right to know what facility rules and regulations apply to patient conduct. 6. A patient has the right to express grievances to a health care provider, a health care facility, or the appropriate state licensing agency regarding alleged violations of patients’ rights. A patient has the right to know the health care provider’s or health care facility’s procedures for expressing a grievance. 7. A patient in a health care facility who does not speak English has the right to be provided an interpreter when receiving medical services if the facility has a person readily available who can interpret on behalf of the patient. (c) Financial information and disclosure. -1. A patient has the right to be given, upon request, by the responsible provider, his or her designee, or a representative of the health care facility full information and necessary counseling on the availability of known financial resources for the patient’s health care. 2. A health care provider or a health care facility shall, upon request, disclose to each patient who is eligible for Medicare, in advance of treatment, whether the health care provider or the health care facility in which the patient is receiving medical services accepts assignment under Medicare reimbursement as payment in full for medical services and treatment rendered in the health care provider’s office or health care facility. 3. A health care provider or a health care facility shall, upon request, furnish a patient, prior to provision of medical services, a reasonable estimate of charges for such services. Such reasonable estimate shall notpreclude the health care provider or health care facility from exceeding the estimate or making additional charges based on changes in the patient’s condition or treatment needs. 4. A patient has the right to receive a copy of an itemized bill upon request. A patient has a right to be given an explanation of charges upon request. (d) Access to health care. -1. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. 2. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide such treatment. 3. A patient has the right to access any mode of treatment that is, in his or her own judgment and the judgment of his or her health care practitioner, in the best interests of the patient, including complementary or alternative health care treatments, in accordance with the provisions of s. 456.41. (e) Experimental research. — In addition to the provisions of s. 766.103, a patient has the right to know if medical treatment is for purposes of experimental research and to consent prior to participation in such experimental research. For any patient, regardless of ability to pay or source of payment for his or her care, participation must be a voluntary matter; and a patient has the right to refuse to participate. The patient’s consent or refusal must be documented in the patient’s care record. (f) Patient’s knowledge of rights and responsibilities. — In receiving health care, patients have the right to know their rights and responsibilities. (5) RESPONSIBILITIES OF PATIENTS. –Each patient of a health care provider or health care facility shall respect the health care provider’s and health care facility’s right to expect behavior on the part of patients which, considering the nature of their illness, is reasonable and responsible. Each patient shall observe the responsibilities described in the following summary. (6) SUMMARY OF RIGHTS AND RESPONSIBILITIES. –Any health care provider who treats a patient in an office or any health care facility licensed under chapter 395 that provides emergency services and care or outpatient services and care to a patient, or admits and treats a patient, shall adopt and make available to the patient, in writing, a statement of the rights and responsibilities of patients, including the following: SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility’s right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows: A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity, and with protection of his or her need for privacy. A patient has the right to a prompt and reasonable response to questions and requests. A patient has the right to know who is providing medical services and who is responsible for his or her care. A patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English. A patient has the right to know what rules and regulations apply to his or her conduct. A patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis. A patient has the right to refuse any treatment, except as otherwise provided by law. A patient has the right to be given, upon request, full information, and necessary counseling on the availability of known financial resources for his or her care. A patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the health care provider or health care facility accepts the Medicare assignment rate. A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care. A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained. A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment. A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research. A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency. A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his or her health. A patient is responsible for reporting unexpected changes in his or her condition to the health care provider. A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her. A patient is responsible for following the treatment plan recommended by the health care provider. A patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility. A patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider’s instructions. A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible. A patient is responsible for following health care facility rules and regulations affecting patient care and conduct.
Tipe Initials

PATIENT CONSENT OF SERVICE AGREEMENT

I consent that treatment will be rendered at the following locations.