Forms
Please print out the following documents, fill them out, and bring them to your next appointment.
Information
Information
Adult Database
Adult Database
Periodic Health Examination
Periodic Health Examination 2
Periodic Health Examination 2
Consent And Authorization Form
CONSENT AND AUTHORIZATION FORM
Middlebrook Family Physicians
Authorization
I authorize medical and or surgical treatment to be rendered by Middlebrook Family Physicians, including any of the physicians or their assistants on staff. I assume full responsibility for any charges which may result from this treatment. If my insurance does not “cover” a service, or claim is denied for any reason, I agree to pay my bill in full. Bills are due when presented. A billing charge of $10.00 per month will added to my account if my bill is not paid within 30 days. Additionally a fee of $30.00 will be charged for any returned checks. A $10.00 copay service charge will be applied if copay is not paid at the time of service.
Appointment confirmation calls are done as a courtsey. We ask that you make a note of your appointment date and time, and call the office if you are unable to keep appointment. In addition a $25.00 fee will be charged for any missed appointment without adequate notice. If this account is sent to a third party for collection, You will be responsible for any additionals fees which may be incurred in order to collect bill.
I authorize the release of any medical information. A copy of this authorization will be kept on file and used in place of original.
/ /
Signature Date
Privacy
I acknowledge that I have received a copy of Middlebrook Family Physicians notice of privacy practices which summarizes the ways my identifiable health information may be used and siclosed by Middlebrook Family Physicians and states my rights with respect to my medical information. I understand that Middlebrook Family Physicians has the right to revise this information and amend to the Notice of Privacy practices, a revised noticed will be posted, and I may obtain a current Notice of Privacy Practices at any time.
I consent to the use or discloser of my protected health information (PHI) by Middlebrook Family Physicians for the purpose of diagnosing or providing medical treatment to me, obtaining payment for my health care bills or to conduct other health care matters. I also give permission for Middlebrook Family Physicians to receive any of my PHI from another physician or health care facility for the same purpose, I authorize payment of medical benifits directly to Middlebrook Family Physicians.
/ /
Signature
