New Patient Registration - Adult

I, the patient or patient's legal representative, agree to allow Celebration Primary Care and its providers to provide all health care services to me or to the individual I am representing that are routine or otherwise deemed necessary.

I understand I have the right to refuse consent to any proposed procedure or treatment at any time prior to receivingit.

I understand that any treatment involving material risks will be explained to me and that I will have the opportunity to ask questions about the associated risks, alternatives, and prognosis before allowing the treatment to be performed.

I agree that no guarantees have been given to me or the individual I am representing as to the outcome of any treatment.

I authorize my provider and Celebration Primary Care to photograph me or the individual I am representing for medically-related documentation or identification purposes.

ePrescribing is a physician's ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy from the practice. ePrescribing greatly reduces medication errors and enhances patient safety. Understanding all of the above, I, the patient or patient's legal representative, hereby authorize the physician and/or staff of Celebration Primary Care to enroll me in the ePrescribe Program.

I, the patient or patient's legal representative, authorize the physician and/or staff of Celebration Primary Care to request and obtain my prescription medication history from other healthcare providers, the pharmacy benefit manager, and/or any third-party pharmacy payors for treatment purposes.

I, the patient or patient's legal representative, authorize the providers and/or staff of Celebration Primary Care to release tomy insurance company or its representative any information including the diagnosis and records of any treatment or examination rendered to me during medical or surgical care. I authorize and request the insurance company to pay directly to Celebration Primary Care the amount due for medical or surgical services. I understand that I, the patient or patient's legal representative, am financially responsible for any services deemed non-covered by my insurance company.

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by requesting the same at the front desk.

By signing this form, you acknowledge that our practice may use and disclose your Protected Health Information (PHI) for treatment, payment, and healthcare operations. You have the right to request, in writing, that we restrict the use or disclosure of your PHI for treatment, payment, or healthcare operations.

By my signature below, I, the patient or patient's legal representative, acknowledge that I had the opportunity to review Celebration Primary Care's Notice of Privacy Practices.

We cannot discuss your health information with anyone other than yourself unless you authorize us to do so. Please list below names of the individual(s) you authorize the providers and office staff of Celebration Primary Care to discuss care with.

We all need good preventive care! Early detection and prevention are key to maintaining good health and often saves money. Preventive care includes exercise, healthy eating, and getting regular wellness exams with your doctor.

What are preventive services?

Typically, the following services are considered preventive services:

• Review of your health history and family health history
• Physical exam (must be one year from previous exam)
• Vaccinations / Immunizations
• Men's and Women's Health Screenings (i.e. mammogram, pap smear)
• Screening exams (i.e. blood pressure, cholesterol screening, diabetes screening, STD screening)
• Education about wellness, diet, exercise, and prevention
• *** Other routine screening labs/services may be ordered by your physician and, as every insurance company differs in coverage, it is the patient's responsibility to make sure these are covered prior to being completed. ***

What if I have a medical problem to discuss?

Per insurance regulations, an annual preventive exam is not the same thing as a normal office visit. An annual preventive exam does not include a discussion of a new medical problem or detailed evaluation of chronic medical conditions. Due to those regulations and our desire to run on time, we may ask you to schedule a separate visit to address these concerns. This will allow your physician time to adequately address your medical problems.

By signing below, you acknowledge that you have read and understand the policies stated above.

Payment is required for all services at the time they are rendered, including deductibles, co-payments and any outstanding balances. I, the patient or patient's legal representative, understand that I am financially responsible for all services rendered and for the following reasons:

• I do not have the proper referral at the time of service.
• My referral is invalid or expired.
• I have given incorrect or invalid insurance information.
• Expenses are not covered by my insurance company.
• I have not met my deductible.
• The services rendered are deemed medically unnecessary by my insurance company. (This applies to present and future visits.)

I, the patient or patient's legal representative, agree to assign insurance benefits to Celebration Primary Care whenever necessary. Celebration Primary Care will bill participating insurance companies. If Celebration Primary Care has not received payment from my insurance company within 45 days of the date of service, I may be expected to pay the balance in full. I am responsible for ensuring that all charges are paid whether by myself or by my insurance carrier.

If my account must be turned over to collections, a $25.00 collection fee will be added to my account. | understand that I will be financially responsible for all costs and fees related to the collection of my debt.

If it is necessary to cancel an appointment, I am required to call at least 1 business day AND 24 hours before my appointment time. If I am more than 15 minutes late after my scheduled appointment, this is considered a late arrival, and my visit or appointment may be rescheduled.

Celebration Primary Care reserves the right to charge:

• $50.00 for missed, canceled, or late arrivals to provider visits
• $100.00 for missed, canceled, or late arrivals to procedures

Missed, Canceled, or Late Arrival Fees: (initial) Should I require special accommodation for my appointment, I must notify Celebration Primary Care of the accommodation needed one week prior to the appointment. If I do not provide at least 1 business day and at least 24 hours prior to canceling my appointment or do not show to the scheduled appointment, all charges incurred by Celebration Primary Care are my responsibility.

Per insurance regulations, an annual wellness exam is not a visit to discuss chronic condition(s) or new problem(s I understand that instead of scheduling a separate office visit to address these condition(s) or new problem(s), I have the option of addressing them at the time of my annual wellness exam. Two claims will be submitted to my insurance: one for the annual wellness and one for an office visit addressing my chronic condition(s) or new problem(s If I have a co-pay or co-insurance, I will be responsible for that amount as with my normal office visit.

I understand that if I request (a) specific lab test(s) that is/are not part of the routine physical examination, the lab test(s) may not be covered by insurance. Lab tests usually covered in a routine physical exam include fasting blood glucose, lipid panel and PSA. Lab tests NOT usually covered by insurance at a routine physical examination include complete blood count, complete metabolic panel (including liver function tests), HbA1C, urinalysis, vitamin levels, thyroid levels, hormone levels (including testosterone), auto-immune labs and allergy tests.

I understand that the lab facility processing the specimen(s) is responsible for billing the insurance company for any tests performed. Celebration Primary Care collects specimens for your convenience and sends the specimen(s) to an outside laboratory. Celebration Primary Care DOES NOT process the test. Billing disputes need to be addressed with the lab facility processing the specimen.

By signing below, I understand and accept the Celebration Primary Care Financial Policy as stated above.

Celebration Primary Care is committed to making our billing process as simple and easy as possible. We now require you to provide a credit card on file with our office. We run our payments through our HIPAA-compliant, secure practice management software. Your payment information is stored on their secure servers for future transactions.

The credit card on file will be used to pay account balances after insurance adjudication. Once your insurance has processed your claims, they send an Explanation of Benefits (EOB) to both you and our office showing the total patient responsibility. If you disagree with the patient responsibility amount owed, it is your responsibility to contact your insurance carrier immediately.

Notes:

• If the credit card expires or otherwise becomes uncollectable, please provide us with a new card on file.
• Credits on your account after your insurance claim has been adjusted will be returned to the credit card on file.
• It is the patient's responsibility to know what services are covered by your insurance. You will be responsible for any portion of services that your insurance does not cover.
• All patients will be required to have a credit card on file regardless of insurance or visit type.

By signing below, I, the patient or patient's legal guardian, have read, understand, and agree to the Credit Card on File Policy.

How does the Credit Card on File (CCOF) work?

Your card information is securely protected by the credit-card processing component of our HIPAA-compliant practice management system. This system stores the card information for future transactions using the same technology that credit card companies use. Nothing is changing about the patient responsibility amount. We will bill your insurance company for you, and we have contracts with most insurance companies that help to get you the best possible coverage for your care. CCOF will only cover your responsibility after your insurance pays its contracted share.

How will I know how much you are going to charge me?

You will receive a letter in the mail (or e-mail) from your insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits (EOB This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your insurance company's responsibility and how much of the bill is your responsibility. We also receive a copy of the EOB. Since you would have paid for your medical service before your appointment, you will be unlikely to owe any additional amount after your visit. However, if the insurance determines the patient responsibility is more than what you paid, you will receive an email and text message from us with your patient balance and the option to pay however you like. If the balance is not paid in 30 days, the card on file will be charged.

I always pay my bills, why me?

We must be fair and apply the policy to all patients. We have so many wonderful patients and we know that most of you pay your balances. Unfortunately, this is not always the case.

How does CCOF benefit patients?

It is far more convenient to have a credit card on file. Check-in and Check-out time will be shorter. You no longer will need to call the office or worry about getting around to paying your bill. This process is especially helpful for patients who have HSA cards to pay for their medical care. If you get your statement and want to use a different card, pay by check, or discuss a payment plan, you may still do so as long as you do so promptly.

How does CCOF drive down administrative costs and improve care?

Our staff can spend more time taking care of our patients and their medical needs and less time on processing payments. Please understand that the entire billing process is very time-consuming and costly. Implementing this policy is essential for us to continue to accept insurance.

What if there is a problem with my bill and I don't notice it until after the payment is processed?

We hope that this does not happen. Although we love technology, we routinely review the accuracy of claims processed by insurance and will contact you if we find a problem. If you find a problem, please call us and we will investigate it. If we owe you money, we will refund it promptly to the same card. You may contact our billing team at (321) 449-7746 for any questions or concerns.

What are deductibles and out of pocket maximums?

Your deductible is the amount of money you must pay for eligible healthcare services before your insurance plan covers costs. Your out-of-pocket maximum is the amount you must spend on eligible expenses before your insurer begins covering all your costs.

Qualifying expenses for your out-of-pocket maximum vary by plan but often include: Medical treatments, Copays, Coinsurance, and Deductibles.

The two numbers may be the same. The out-of-pocket maximum is often higher than deductibles. For instance, you may have a $1,500 deductible and a $4,500 out-of-pocket maximum.

When do I have to pay for services?

Any time you receive medical care, except an annual wellness checkup, you will be expected to pay in full for your services until your deductible is met and your maximum out-of-pocket limit has been satisfied. These amounts depend on your insurance plan.

When does a deductible begin?

Your deductible begins at the start of your plan year. Most plan years begin either January 1 or July 1, but plans can start on any date.

How will I know when my deductible has been met?

You can call your insurance company at any time to check on how much of your deductible has been met. Some insurance companies have this information available online. Every time you receive medical services you will receive notification from your insurance company about how much they paid or did not pay for that service. This notification is known as an Explanation of Benefits (EOB).

I understand and agree that I have reviewed, understand and accept the risks and benefits of telehealth services as described below and wish to receive such services. If I am signing on behalf of a minor, incapacitated or otherwise legally dependent patient, I certify that I am a person with legal authority to act on behalf of the patient, including the authority to consent to medical services, and I accept financial responsibility for the services rendered.

1. By using the Celebration Primary Care telehealth portal, I agree to receive telehealth services. Telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications. During my visit, my Celebration Primary Care provider and I will be able to see and speak with each other from remote locations.
2. I understand and agree that:
   • I will not be in the same location or room as my medical provider.
   • My Celebration Primary Care provider is licensed in the state in which I am receiving services. I will report my location accurately during registration.
   • Potential benefits of telehealth (which are not guaranteed or assured) include: (i) access to medical care if I am unable to travel to my Celebration Primary Care provider's office; (ii) more efficient medical evaluation and management; and (iii) during the COVID-19 pandemic, reduced exposure to patients, medical staff and other individuals at a physical location.
   • Potential risks of telehealth include: (i) limited or no availability of diagnostic laboratory, x-ray, EKG, and other testing, and some prescriptions, to assist my medical provider in diagnosis and treatment, (ii) my provider's inability to conduct a hands-on physical examination of me and my condition, and (iii) delays in evaluation and treatment due to technical difficulties or interruptions, distortion of diagnostic images or specimens resulting from electronic transmission issues, unauthorized access to my information, or loss of information due to technical failures. I will not hold Celebration Primary Care responsible for lost information due to technological failures.
   • I further understand that my Celebration Primary Care provider's advice, recommendations, and decisions may be based on factors not within his or her control, including incomplete or inaccurate data provided by me. I understand that my Celebration Primary Care provider relies on information provided by me before and during our telehealth encounter and that I must provide information about my medical history, condition(s), and current or previous medical care that is complete and accurate to the best of my ability.
   • I may discuss these risks and benefits with my Celebration Primary Care provider and will be given an opportunity to ask questions about telehealth services. I have the right to withdraw this consent to telehealth services or end the telehealth session at any time without affecting my right to present or future treatment by Celebration Primary Care.
   • I understand that the level of care provided by my Celebration Primary Care provider is to be the same level of careis that available to me through an in-person medical visit. However, if my provider believes I would be better served by face-to-face services or another form of care, I will be referred to visit the office of Celebration Primary Care, hospital emergency department, or other appropriate health care provider.
   • I have the right to receive face-to-face medical services at any time by traveling to a Celebration Primary Care location that is convenient for me.
   • In case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
3. I consent to, understand, and agree that: I have the right to discuss the risks and benefits of all procedures and courses of treatment proposed by my health care provider(s), together with any available alternatives. Celebration Primary Care will provide care consistent with the prevailing standards of medical practice but makes no assurances or guarantees as to the results of treatment. Before prescribing any controlled substance to me, Celebration Primary Care may review information from the Prescription Drug Monitoring Program in my state of residence regarding my prior receipt of controlled substances. My Celebration Primary Care provider will not prescribe opioids to me during a telehealth visit. I have the right to review and receive copies of my medical records, including all information obtained during a telehealth interaction, subject to Celebration Primary Care's standard policies regarding request and receipt of medical records and applicable law The laws of the state in which I am located will apply to my receipt of telehealth services.

This authorization expires 1 year from the date it is signed.