MD Precision Health 1st English

MDteleme Precision Health

6840 SW 40th Street, Suite 209, Miami, FL 33155

Phone : (786) 800-2430 | Fax: (305) 763-8379

Text Only (786) 442-1584

You have registered as a patient who will pay privately with MDteleme Precision Medicine. This indicates that you will be paying for the service with either cash, a check, or a debit or credit card at the time of the service. We shall not submit claims to the insurance company for any of the services supplied in accordance with this agreement.

Fecha

Visit Type

Please select who is requesting Our Services?

Legal Guardian Information

Patient Full Name

NameLast Name

Patient Date of Birth

month / day / year

Do you have MEDICARE as Primary Health Insurance? (65 or older or disability).

Advance Beneficiary Notice of Noncoverage (ABN)

G. OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. the Telemedicine Service listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

MDteleme Warning!

You have chosen Option 3. Meaning...

You DO NOT WANT to use the D. Telemedicine Service listed above.

Patient Phone Number

Email

(An email Address is required if you would like to be registered for Virtual Consultation)

Address

Street

CityState

Zip Code

Gender

Weight and Height

Photo of your ID (please take it readable) .

RELEASE OF HEALTH INFORMATION

In case you cannot reach me, I authorize an RMB / MDteleMe representative to try to contact me, using my Emergency Contact and provide strictly necessary information related to the immediate care of my medical condition.

Do you have an Emergency Contact? (in case we cannot reach at you)

Please note that providing Emergency Contact information would facilitate faster communication with you.

Emergency Contact Information

Pharmacy (medications will be electronically sent to the pharmacy)/ only if New or need Update

Pharmacy Name/Type

Address

CityState

Zip Code

Marital Status

Ethnicity

Do you use any of the following? Check all that applies.

Medication Allergies?

Which medication are you allergic to?

Specify which Medication, you are allergic to:

Allergies to Other Substances, Medications or Food

Specify which other Medication, Substances or Food you are allergic to:

Type of Allergic Reaction

Which other reactions you've had? Please Describe...

Medical Condition (Do you have any Chronic Medical Condition?)

Select which Medical Condition

Describe which other Medical Condition...

Medications, are you taking any?

Which Medication(s)?

Any Surgeries?

Which Surgeries?

Describe which other Surgeries you've had.

Mother, Alive?

Mother, Any Medical Condition?

Any other Medical Condition not listed before?

Father, Alive?

Father, Any Medical Condition?

Any other Medical Condition not listed before?

Any Family History of Cancer?

Explain which type of Cancer and family member...

Responsibility to pay for the services to be received

I understand that:

Benefits for some or all of the services provided by the Clinic are not included in the health plan under which I am covered

Despite the above, I do not wish for the Clinic to file a claim with my insurace Company for the services provided to me.
Until I am able to notify the Clinic in writing, I will pay for all of the services I get from the Clinic of MDteleMe | Tarifas with MdTeleme Precisiom Medicine.
While choosing to pay for my own services, any payment I make to the Clinic will not be considered sufficient to satisfy any deductible that may arise as a result of my medical insurance plan with the Company, unless the terms of my plan allow otherwise.
I read this Self-Pay for Services Selection Form and have had the opportunity to ask any questions I might has about it.
To my complete satisfaction, whatever questions I could have had about this form has been answered.
After asking the clinic about the payment options and after considering them, I choose to pay for the services on my account.
If the patient is under the age of 18 or cannot sign for himself, the patient's signature or that of the responsible party is required

Terms and Conditions (you need to read and accept to receive services)

BUSINESS HOURS

I understand unusual circumstances will sometimes require the office hours to be changed without notice. I understand the pre-recorded telephone message will let me know when to call back for routine requests and what to do in case of an urgent medical need (one that does not require emergency treatment). I understand that I should call 911 in the event of a medical emergency or proceed to the closest emergency room for treatment.

PRESCRIPTIONS AND/OR REFILLS

PATIENT FORMS COMPLETION

Labs and Testing

This is to inform you that the laboratory tests conducted with MdTeleMe Precision Medicine are considered special labs and are not be covered by insurance. These special labs may include specific diagnostic tests, advanced screenings, or experimental procedures that fall outside the scope of typical insurance cover. By signing you acknowledge and understand that any associated costs will not be covered by your insurance plan, and you agree to assume responsibility for any applicable charges.

I have read and agree to the following terms and disclaimers stated above. Signature: This consent is valid as long as you remain a patient of our office