New Patient Appointment Request Online.

When you arrive at your next meeting we will ask you to complete or update an electronic health form. If you wish to speed your check-in process, you may read the information below prior to your visit. These forms are signed once a year. You do NOT need to fill these out.

Read Only:

Privacy Notice Signature
Patient Information
Online Communications Informed Consent
Conditions of Treatment
Co-Pay & Deductible Policy
No Show Policy
Patient Record of Disclosures

Please note: We are not Medicaid providers. Please contact your insurance to see if we are in network with your policy. 

Planning Your Visit:

1. Plan to arrive at least 20 minutes before your scheduled appointment time.
2. Before an appointment, please confirm that your referring physician has sent a request for consultation and all related medical records. Important related medical records may include relevant labs, pathology reports, x-ray studies, ultrasound reports, thyroid scans, bone density reports, surgical reports, current medications, etc.
3. Bring your insurance card and a photo ID.
4. Bring a form of co-payment with you. We accept cash, check, Visa, MasterCard Discover and American Express.
5. If your insurance requires, please be prepared to apply payment towards your deductible.

Co-Pay & Deductible Policy

Endocrinologists Specialists of South Florida ask that all office visits and services be paid for at the time they are provided. The exceptions to this are patients covered by companies with whom we have signed participating agreements. If your insurance is an HMO, you are required to obtain an authorization from your primary care provider, your family physician, or nurse practitioner before we can see you. This would allow us to see you during a specific period and for a specific number of visits. It is extremely important that we know this information before your appointment. We will make every effort to help you with this. If we do not have an authorization at the time of your visit, you will be asked to sign a waiver that makes you responsible for services performed on that day. If you do not wish to sign the waiver, your appointment will be rescheduled. Please come prepared to pay your co-pay whenever you are seen.

For non-HMO insurances with whom we participate, please come prepared to pay your co-payment and deductibles. Arrangements can be made when expenses require installment payments. If you need to discuss a budget plan, please contact our billing department before your initial appointment and any time thereafter, if the need arises.

Online Communications Informed Consent

Endocrinologists Specialists of South Florida provides our patients the option to communicate with us and view certain demographic material as well as lab results via our Patient Web Portal. You can access your Patient Portal online through our website and we will provide you instructions on how to access this. If you would like to be able to use this feature, please read through the following form and sign at the bottom.

Instructions for Using Online communications

You agree to take steps to keep your online communications to and from our office confidential including:

• Do not store messages on your employer-provided computer; otherwise, personal information could be accessible or owned by your employer
• Use screen savers or close your messages instead of leaving your messages on the screen for passersby to read and keep your password safe and private.
• Do not allow other individuals or other third-party access to your computer(s) upon which you store medical communications. Standard email lacks security and privacy features and may expose medical communications to employers or other unintended third parties.
• Withdrawal of this Informed Consent must be done by written online communication or in writing to our office.

Use good communications etiquette:

• Confirm that your name and other personal information in the message is correct.
• Review the message before sending it to make sure that it is clear, and that all relevant information is included.
• Update your contact information on the network as soon as it changes.

Conditions of Using Online Communications

• Our office will save copies of any online communications in your electronic medical record. This means that appropriate members of our staff will have access to these communications as part of our medical records keeping, treatment and billing.
• You should print or store (on a computer or storage device owned and controlled by you) a copy of all online communications that are important to you.
• Our office will not forward online communications with you to third parties except as authorized or required by law.
• You agree to follow the recommended procedures to ensure your identity is protected to communicate with you and you acknowledge that failure to comply with these procedures may terminate our online communications.
• Online communications will be used for limited purposes only. It cannot be used for emergencies or time-sensitive matters. It should be used with caution. It should not be used to communicate highly sensitive medical information or information that requires immediate attention. If there is other information that you don’t want transmitted via online communications, you must inform us.
• We will make every attempt to respond within 2-3 business days. However, there may be times when this is not feasible, and you understand and agree to accept variations in response times and use other forms of communications with our office if online responses are not satisfactory to you. Please note that online communications should never be used for emergency communications or urgent requests. These should occur via telephone or using existing emergency communication tools.
• While our office will take reasonable precautions to protect your information, we are not liable for improper disclosure of confidential information unless it was caused by our intentional misconduct.
• Follow-up is your responsibility. You are responsible for scheduling any necessary appointments and for determining if an unanswered online communication was not received.
• You are responsible for taking steps to protect yourself from unauthorized use of online communications, such as keeping your password confidential. We are not responsible for breaches of confidentiality caused by you or an independent third party.
• We will not engage in any illegal online communication, including illegally practicing medicine across state lines.

Access to Online Communications

The following pertains to access to and use of online communications:

• Online communication does not decrease or diminish any other ways in which you can communicate or see the providers in our office. It is an additional option and not a replacement. You are encouraged to contact our office via telephone, mail or in person, as always, if you have any questions or needs.
• We will decide which medical topics are appropriate for online communications and with whom we communicate with online.
• We may stop providing online communications with you or change our online services provided at any time without prior notification to you.

Risks of Using Online Communication

All medical communications carry some level of risk. While the likelihood of risks associated with the use of online communications, particularly in a secure environment, is substantially reduced, the risks are nonetheless real and very important to understand. It is very important that you consider these risks each time you plan to communicate with our office and communicate in such a fashion as to mitigate the potential for any of these risks. These risks include, but are not limited to:

• Online communication may travel much further than you planned. It is easier for online communications to be forwarded, intercepted, or even changed without your knowledge.
• Online communication is easier to falsify than handwritten or signed hard copies. A dishonest person could attempt to impersonate you to try to get your medical records.
• It is harder to get rid of online communication. Backup copies may exist on a computer or in cyberspace, even after both of us have deleted our copies.
• Online communication is not private simply because it relates to your own medical information. We use a secure network to avoid using standard email or email systems provided by employers. Employers and online services have a right to inspect and keep online communications transmitted through their system.
• Online communications are also admissible as evidence in court.
• Online communications may disrupt or damage your computer if a computer virus is attached.

Patient Acknowledgement and Agreement

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of online communications between my provider and me, and consent to the conditions outlined herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that my physician may impose to communicate with patients via online communication. I have had the chance to ask questions that I had and to receive answers. I have been proactive about asking questions related to this consent agreement. My questions have been answered and I understand and concur with the information provided in the answers.

Conditions of Treatment

1. Insurance Verification and/or Pre-Authorization – Many insurance companies require pre-authorization for various procedures. Endocrinologists Specialists of South Florida will assist the patient in obtaining the necessary pre-authorizations when needed, but it is ultimately the patient’s responsibility to determine if your insurance company requires this. Failure to obtain necessary pre-authorization or second opinions may result in a reduction or rejection of benefits by the insurance company.

1. Assignment of Insurance Benefits – I hereby authorize my insurance company to pay Endocrinologists Specialists of South Florida directly. I understand that I am responsible for charges not covered by my insurance company including late penalty charges. I agree that a photocopy of this authorization is as effective as the original.

1. Confidentiality – Confidential information expressly identifies the medical nature of the service rendered to a patient, and includes all information and records obtained during treatment. It includes information from history and physician examination, diagnosis, treatment rendered, laboratory and radiology results, progress notes, and miscellaneous medical reports.

1. Medicare authorization: Patient’s certification authorization to release information and payment request – I certify that the information given in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about the patient named above to release such information to the Social Security Administration or its intermediaries or carriers, effective from (today’s date) _______________ forward.

1. Authorization for disclosure of Information for Purpose of Service Reimbursement – I hereby authorize Endocrinologists Specialists of South Florida to disclose all or part of the medical record of the above patient to any company that may be responsible for payment of all or part of that patient’s medical charges. Disclosure of the medical record may be necessary to determine eligibility for benefits and to obtain reimbursement for health care services. I hereby release Endocrinologists Specialists of South Florida from all legal responsibility or liability that may arise from disclosure of these records. I understand that I may revoke this authorization at any time in writing.

1. Financial Agreement – I understand that in consideration of the services rendered, I am obligated to pay Endocrinologists Specialists of South Florida in accordance with its regular rates, terms, or contractual agreements. I understand that I am responsible for any service “not covered” by insurance and that the obligation to pay for medical services may not be deferred for any reason. If the account is referred to any agency for collection, I agree to pay all collection expenses.

1. I have read and understand this financial agreement. I have had an opportunity to ask questions and, at my request, received a copy of my signed form. I accept the responsibility of its terms.

Patient Record of Disclosures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their Protected Health Information (PHI). The individual is also provided with the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner (check all that apply):

• Home Phone
  • OK to leave message with detailed information OR
  • Leave message with call-back number only
• Cell Phone
  • OK to leave message with detailed information OR
  • Leave message with call-back number only
• Work Phone
  • OK to leave message with detailed information OR
  • Leave message with call-back number only
• Online Communication via Patient Web Portal
  • OK to send me messages on the website regarding my care

(I have read the Online Informed Consent)

• Written Communication
  • K. to mail to my home to my home address
  • K. to mail to my work/office address
  • K. to fax to this number _______________
• Permission to discuss Protected Health Information with the following:
  • Names _____________________ Phone numbers: ________________

Of all the above contact methods of communication, please indicate which method (s) is/are best for you to be contacted regarding appointment reminders, lab results and other communication.

No Show Policy

Our goal here at Endocrinologists Specialists of South Florida is to provide quality service to all our clients in a timely manner. Failure to keep scheduled appointments is costly to both the clinic and you as a patient. This letter is to inform you of our policy concerning “No Shows”.

Patients who are unable to keep their appointments are requested to give 24-hour notice prior to their appointments. We realize this is not always possible and the practice will consider each individual case. Providing such notice allows the clinic time to offer other patients the opportunity to see our providers, thus using the time more efficiently. If an established patient fails to provide notice, it will be necessary to charge a $75.00 fee that will be billed to his/her account. If a patient has confirmed his/her appointment and fails to keep that appointment, there will be a $75.00 fee billed to his/her account. If a patient fails to keep his/her appointments on a regular basis, or has 3 consecutive missed appointments, he/she will be considered dismissed from the practice, and a letter of dismissal will follow.

Patient Record of Disclosures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their Protected Health Information (PHI). The individual is also provided with the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner (check all that apply):

• Home Phone
  • OK to leave message with detailed information OR
  • Leave message with call-back number only
• Cell Phone
  • OK to leave message with detailed information OR
  • Leave message with call-back number only
• Work Phone
  • OK to leave message with detailed information OR
  • Leave message with call-back number only
• Online Communication via Patient Web Portal
  • OK to send me messages on the website regarding my care

(I have read the Online Informed Consent)

• Written Communication
  • K. to mail to my home to my home address
  • K. to mail to my work/office address
  • K. to fax to this number _______________
• Permission to discuss Protected Health Information with the following:
  • Names _____________________ Phone numbers: ________________

Of all the above contact methods of communication, please indicate which method (s) is/are best for you to be contacted regarding appointment reminders, lab results and other communication.