Patient Questionnaire Form

	Never Can't do it for any length of time	Occasionally up to 33%(0-2.3 hrs/day)	Frequently From 34% to 66%(2.3-5.5 hrs/day)	Constantly More than 67% of the time(5.5+ hrs/day)
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	Not at all	Somewhat	Moderately	Very Much
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TELEHEALTH INFORMED CONSENT

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format. I understand that electronic communication may be used to communicate highlysensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.).

I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to:

It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures.
Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network.
Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures.

I agree that information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care.

I understand that medical information, including medical records, are governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records).

I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed. I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others.

The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me.

Patient Name: Date:

I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit.

I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider.

I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit.

I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications.

To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit.

I understand that due to the state of the current national emergency crisis, telehealth is offered to appropriate patients in an effort to comply with federal and state mandates of isolation and social distancing as an effort to provide protection to everyone.

I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community.

I certify that I have read and understand this agreement with the opportunity to have questions answered to my satisfaction. By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit.

For electronic communication between Santo Steven BiFulco, MD and staff and Patient Name:

Patient or Legal Representative Signature:

Relationship to Patient:

Patient or Legal Representative name:

OFFICE OF INSURANCE REGULATION

Bureau of Property & Casualty Forms and Rates

Standard Disclosure and Acknowledgement Form

Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

1	The services set forth below were actually rendered. This means that those services have already been provided.
2	I have the right and the duty to confirm that the services have already been provided.
3	I was not solicited by any person to seek any services from the medical provider of the services described above. This means that no person has initiated contact with me and/or persuaded me to use the doctor or licensed professional, clinic, or medical institution that provided the services.
4	The medical provider has explained the services to me for which payment is being claimed.
5	If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

The undersigned licensed medical professional affirms the statement numbered 1 above and also:

A	I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.
B	I have explained the services rendered to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.
C	The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.
D	The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732 (15) and (16), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Insured Person (patient receiving treatment) or Guardian of Insured Person:

Name:

Signature:

Date of Signature:

Licensed Medical Professional Rendering Treatment (Signature by his or her own hand):

Name: Signature date:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section 817.234(1)(b), Florida Statutes.

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.

OIR-B1-1571

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR

HEALTH INFORMATION to The Medical Offices of Santo Steven Bifulco, M.D.

Privacy Act and Paperwork Reduction Act Information: The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45CFR Parts 160 and 164, 5 U.S.C. 552a, and 38 U.S.C. 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will be used to locate records for release) is not furnished completely and accurately, The Medical Offices of Santo Steven Bifulco, M.D. will be unable to comply with the request. The Medical Offices of Santo Steven Bifulco, M.D. may not condition treatment, payment, enrollment or eligibility on signing the authorization. The Medical Offices of Santo Steven Bifulco, M.D. may disclose the information that you put on the form as permitted by law. The Medical Offices of Santo Steven Bifulco, M.D. may make a "routine use" disclosure of the information as outlined in the Privacy Act systems of records notices identified as 24VA19 “Patient Medical Record - , The Medical Offices of Santo Steven Bifulco, M.D. ” and in accordance with the Notice of Privacy Practices. You do not have to provide the information to The Medical Offices of Santo Steven Bifulco, M.D., but if you don't, The Medical Offices of Santo Steven Bifulco, M.D., will be unable to process your request and serve your medical needs. Failure to furnish the information will not have any effect on any other benefits to which you may be entitled. The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form.

ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER:

Patient Name:

SSN: date of birth:

TO: The Medical Offices of Santo Steven Bifulco, M.D.(Print or type name and address of health care facility) at 15380 N Florida Ave Tampa Florida 33613 NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL from WHOM INFORMATION IS

BEING REQUESTED: __________________________________________________________

INFORMATION REQUESTED: ANY and ALL treatment and billing records, outside records, radiographic reports, accident reports, initial and final narrative reports, treatment notes and billing ledgers.

PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED: In order for Dr. Bifulco and his staff to prepare a Life Care Plan, initial and final report or prescribe medication if needed.

SIGNATURE OF PATIENT OR
PERSON AUTHORIZED TO SIGN FOR PATIENT (see attached)

date of Signature:

DATE RELEASED: _________________,  RELEASED BY: ______________________,

CONSENT TO MEDICAL TREATMENT

I hereby request and consent to the performance of medical care including various modes of physiotherapy and, if necessary, diagnostic x-rays on me by Medical Offices of Santo Steven BiFulco, M.D. and any therapist or assistant that he may designate.

I understand that the desired results of treatment are not guaranteed. Furthermore, I understand and am informed that, as in all health care, in the practice of medicine there are some risks to treatment. I do not expect the doctors to be able to anticipate and explain all risks and complications and I wish to rely on the doctors to exercise judgment during the course of the procedure which the doctors feel at the time, based upon the fact then known, is in my best interest.

I have been informed that it is not uncommon for patients to have some increased discomfort after a physical examination and/or massage therapy. If l become concerned about this discomfort or develop any new or worsening symptoms I can call the phone number listed above during office hours or respond to a hospital emergency room for immediate attention.

I have also had an opportunity to ask questions regarding my treatment, and by signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

AUTHORIZATION TO RELEASE INFORMATION

I authorize the release of any medical or any other information to the Health Care Financing Administration, my insurance carrier(s), or other entity necessary to determine insurance benefits or the benefits payable for related medical services and/or supplies provided to me by the Medical Offices of Santo Steven BiFulco, M.D. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance carrier(s), or other medical entity, if requested. The original authorization will be kept on file by the Medical Offices of Santo Steven BiFulco, M.D.

PRIVACY PRACTICES ACKNOWLEDGEMENT

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Parent/guardian Sign (IF APPLICABLE):

date of Signature:

Patient Name: Date of injury: Date of visit:

Santo Steven BiFulco, M.D. CLCP

Life Care Plans
Orthopedic, Neurological & Musculoskeletal Rehabilitation Consultations

Welcome to patient questionnaire form

Patient Questionnaire Form

Background- Personal

Subjective Medical Reporting

List your current Medications

List each surgery you have had after the incident

If you are scheduled for any surgeries, please list. Also, include recommended surgeries

Select each type of treatment you have received since the incident

During the incident did you...

Strike your head?

Lose Consciousness?

If you are experiencing pain, please identify the affected body part(s) and rate your pain intensity using a 0-10 scale. (0 indicates no pain, 10 indicates worst pain possible.)

Please list any doctors providing treatment for conditions associated with the incident.

Please select any problems with mental functioning you have experienced since the incident.

Please indicate if you have had any of the following.

Activities of Daily Living(ADL)

Never

Occasionally

Frequently

Constantly

Please indicate the extent to which the mental health issues listed concern you:

Not at all

TELEHEALTH INFORMED CONSENT

OFFICE OF INSURANCE REGULATION

Bureau of Property & Casualty Forms and Rates

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR

HEALTH INFORMATION to The Medical Offices of Santo Steven Bifulco, M.D.

CONSENT TO MEDICAL TREATMENT

AUTHORIZATION TO RELEASE INFORMATION

PRIVACY PRACTICES ACKNOWLEDGEMENT

Santo Steven BiFulco, M.D. CLCP

Life Care Plans Orthopedic, Neurological & Musculoskeletal Rehabilitation Consultations

Welcome to patient questionnaire form

Patient Questionnaire Form

Background- Personal

Subjective Medical Reporting

List your current Medications

List each surgery you have had after the incident

If you are scheduled for any surgeries, please list. Also, include recommended surgeries

Select each type of treatment you have received since the incident

During the incident did you...

Strike your head?

Lose Consciousness?

If you are experiencing pain, please identify the affected body part(s) and rate your pain intensity using a 0-10 scale. (0 indicates no pain, 10 indicates worst pain possible.)

Please list any doctors providing treatment for conditions associated with the incident.

Please select any problems with mental functioning you have experienced since the incident.

Please indicate if you have had any of the following.

Activities of Daily Living(ADL)

Never

Occasionally

Frequently

Constantly

Please indicate the extent to which the mental health issues listed concern you:

Not at all

TELEHEALTH INFORMED CONSENT

OFFICE OF INSURANCE REGULATION

Bureau of Property & Casualty Forms and Rates

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION to The Medical Offices of Santo Steven Bifulco, M.D.

CONSENT TO MEDICAL TREATMENT

AUTHORIZATION TO RELEASE INFORMATION

PRIVACY PRACTICES ACKNOWLEDGEMENT

Life Care Plans
Orthopedic, Neurological & Musculoskeletal Rehabilitation Consultations

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR

HEALTH INFORMATION to The Medical Offices of Santo Steven Bifulco, M.D.