New Participant InformationDate* MM slash DD slash YYYY Last Name* First Name* Middle Name Address* City* State* Zipcode* Occupation Date of Birth* MM slash DD slash YYYY Age* Gender* Male Female Other Telephone* Martial Status* Single Married Other Email* State Issued IDAccepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.Emergency Contact Name* Contact Relation to You* Contact Phone Number* Medical InformationAllergies* Past Medical Problems* Current Medications* Past Surgeries (include C-Sections and year)* Family Medical History* Physician Name Phone Last Menstrual Period MM slash DD slash YYYY Number of Times Pregnant Number of Children Do You Smoke* Yes No Do You Drink Alcohol* Yes No Do You Take Drugs* Yes No InsuranceSubscriber (if different from above) Insurance name Policy# Subscriber's DOB MM slash DD slash YYYY Insurance CardPlease add the front and back of the insurance card. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB, Max. files: 2. PharmacyPharmacy Name Address Phone How did you find out about us? Select All Internet Family Member Radio Friend SignatureSign Here*Consent for TreatmentConsent*I voluntarily consent to the rendering of care, including treatments, administering anesthetics, and the performance of diagnostic procedures. I understand that I am under the care and supervision of Medix Urgent Care Center (MUCC) or Medix Family Health Center (MFHC) and its Physician, NP, or PA. I hereby assign payment directly to MUCC/MFHC, accepting this assignment of medical benefits applicable and otherwise payable to me but not to exceed the provider's regular charges. I understand that I am responsible for the charges not covered by this assignment or for any other charges which the insurance carrier declines to pay. It is further agreed that any credit balance resulting from payment of insurance or other sources may be applied to any other accounts owed to said providers by the insured or family. The provider may disclose all or part of the patient's record to any person or corporation which is or may be liable under a contract to the provider or to a family member or employer of the patient of the provider's charges, including but not limited to Insurance companies, Medicare, Medicaid, Worker's Compensation carriers, welfare funds or patients employer. I acknowledge that I have received a copy of the Notice of Privacy Practices from MUCC/MFHC which describes how my health information may be used or disclosed. I understand that I should read it carefully and that it may change at any time. I agree to the privacy policy.Patient Email Text Message & Video Chat Informed Consent*You may give permission to MEDIX URGENT CARE CENTER(MUCC) to communicate with you by email, text message and video chat. This form provides information about the risks of the afore-mentioned forms of communication, guidelines for same, and how we use them. It also will be used to document your consent for said communication. 1) How we will use email, text messaging and video chat: We use these methods to communicate only non-sensitive and non-urgent issues. All communications to or from you may be made a part of your medical record. You have the same right of access to such communications as you do to the remainder of your medical record. We will not disclose your email, text and video chat communication to researchers or others unless allowed by state or federal law. Please refer to our Notice of Privacy Practices for information as to permitted uses of your health information and your rights regarding privacy matters. 2) Risk of using email, text, and video chat communication: The use of email. text and video chat communication has a number of risks that you should consider. These risks include, but are not limited to the following: a) Email, text and video chat communication can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. b) Senders can easily misaddress an email or text and send the information to an undesired recipient. c) Backup copies of email, text and video chat communication may exist even after the sender and/or recipient has deleted bis or her copy. d) Employers and online services have a right to inspect email, text and video chat communication sent through their company systems. e) Email, text and video chat communication can be intercepted, altered, forwarded or used without authorization or detection. f) Email, text and video chat communication can be used as evidence in court. g) Email, text and video chat communication may not be secure, and lherefore it is possible that a third party may breach the confidentiality of such communications. 3) Conditions of the use of email and text messages: MUCC cannot guarantee but will use reasonable means to maintain security and confidentiality of email, text and video chat communication sent and received. You must acknowledge and consent to the following conditions: a) IN A MEDICAL EMERGENCY, DO NOT USE EMAIL, CALL 911. Do not email for urgent problems. If you have an urgent problem during regular business hours, please call 954-484-S444. Urgent messages or needs should be relayed to us by using regular telephone communication and may include text messages. b) Emails should not be time sensitive. While we try to respond to email messages daily, we cannot guarantee that any particular email will be read and responded to within any particular period of time. If you have not heard back from us within three days, call our office to follow up if we have received your email. c) You should speak to our office directly to discuss complex and/or sensitive situations rather than send email or text messages regarding such situations. d) Email, text and video chat communication may be filed electronically into your medical record. e) Clinical staff will not forward your identifiable email/texts to outside parties without your written consent, except as authorized by law. f) You should use your best judgment when considering the use of email or text messa,.aes for communication of sensitive medical information. Clinical staff are not respoD.Sil>le for the content of messages. g) MUCC is not liable for breaches of confidentiality caused by you or any third party. h) It is your responsibility to follow up with MUCC if warranted. Withdrawal of consent: I undersland that I may revoke this consent at any time by so advising MUCC in writing. My revocation of consent will not affect my ability to obtain future health care nor will it cause the loss of any benefits to which I am entitled. Patient Acknowledgement and Agreement: I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the use of email and text messaging as a form of communication between MUCC and me and consent to the conditions and instructions outlined, as well as any other instructions MUCC may impose to communicate with me by email or text message. I agree to Email and Video Chat policy.
Come in and get your FDLE Background Screening done today!