Brandon Community Health and Rehabilitation
PATIENT HISTORY
DOB ____/____/______
Age: _____
Sex: M / F
Date: ____/____/20___
Social Security # _______-_______-_________
Patient Name: Last______________________________M____First_______________________________
Address____________________________________ City __________________St ______Zip__________
Marital Status: M / S / D / W
Drivers License #____________________________State Issued_______
Phone: Primary (____) ______-_______ Secondary (____) _____-________ Work (____) _____-_______
Cell____Home____
Cell____Home____
Can we leave a confirmation message on machine Y N
Which number would you prefer we call to verify appointments?
Some calls may be the day appointment is scheduled#_______________________________
Emergency Contact Information: Name: ____________________________________________________
Phone (____) _____-_______ Secondary Phone (____) _____-_______ Relation: ___________________
Please list any person(s) authorized for disclosure of health information regarding my care:
(effective __________days/weeks/months or until _______________________________
Otherwise effective for 1 year)
________________________________________________relation:____________________
________________________________________________relation:_____________________
Primary Speaking Language:________________________________________________________
Patient Signature:______________________________________________Date:___________20____
AUTOMOBILE INSURANCE INFORMATION
Insurance Company Name: _____________________________________________ Date of accident ____/_____/________
Phone (____) ______-_______ Policy # ______________________________ Claim #_____________________________
Insured's Name_____________________________________ DOB__________ Relation to Patient ___________________
Adjuster Name : ______________________________________Phone (_____) _______-_________ Ext:______________
HEALTH INSURANCE INFORMATION
Insurance Company Name: ________________________________Phone (____) _____-______ Ext._____
Address_____________________________________ City ________________State _____Zip__________
Policy # __________________________________Group/Claim #_________________________________
Insured's Name___________________________ DOB__________ Relation to Patient _________________
Phone: Home (____) ______-_______ Cell (____) ______-________ Work (____) ______-__________
ATTORNEY INFORMATION
Attorney Group Name: ___________________________Attorney’s Name: _________________________
Phone #1: (____) _____-______ Phone #2: (_____) _____-________ Fax # : (____) _____-_________
Address __________________________________ City _______________State ______ Zip___________
Benefits:
80% / 20%
Deductible Amount:
100%
OFFICE USE ONLY:
Other %:______
$___________
Med Pay:
AF
Y
N
NAF
PIP Medical Claims Address: _____________________________________________________________
_____________________________________________________________________________________
Other drivers insurance______________________________
Treatment Consent, Assignment and Release Form
Consent for Treatment: I authorize Brandon Community Health and Rehabilitation L.L.C. or Physician(s) who treated me to furnish the
necessary medical treatment, procedures, drugs, supplies or therapy as may be ordered by the attending physician(s), his or her assistant,
designees or therapist. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made
to me as to the result of the services or treatments.
Assignment and Release: I hereby authorize the facility and or any treating physician(s) to release to any third party payor (such as an
insurance company, its designated review agency or a government agency or attorney) only such medical information as may be necessary to
determine benefits entitlement and to process payment claims for health care services provided to me, commencing on this date. The facility
and any physician(s) rendering service at the facility is authorized to release information from my medical records to any skilled nursing
facility or other health care facility to which I may be treating at. All pertinent information will be disclosed unless specific information to be
excluded is set forth below. This authorization shall be valid only for the period of time necessary to process payment claims pertaining to
this medical procedure or stay only and only valid on that date only.
For all treatment as the result of a motor vehicle accident, the undersigned patient hereby assigns the rights and benefits of insurance of the
applicable personal injury protection, and/or medical payments, to Brandon Community Health and Rehabilitation L.L.C. or Physician(s)
who treated me, for services, treatment, procedures, drugs, therapy and/or supplies rendered for treatment of personal injuries sustained in my
motor vehicle accident. The undersigned agrees to pay any applicable deductible or co-payment not covered by PIP or other coverage.
This assignment includes, but is not limited to, all rights to collect benefits directly from the insurance company for services that I have
received and all rights to proceed against the insurance obligated to provide benefits in any action including legal suit if for any reason the
insurance company fails to make payments of benefits which I am due. Specifically, this assignment includes the rights to collect payment
for the reasonable costs connected with copying and mailing records to the insurer at the insurers request in accordance with Florida Statue
627.736(6). This assignment also includes the right to recover any attorney’s fees and costs for such action brought by the provider as
patient’s assignee.
I authorize and direct my insurance company to provide Brandon Community Health and Rehabilitation L.L.C. or Physician(s) who treated
me, and/or their attorney and updated PIP/Med. PIP payout record as needed and a copy of my declarations page and/or policy that was in
effect at the time of the motor vehicle accident for which I am receiving treatment.
I hereby instruct the insurance carrier that in the event the subject medical benefits are disputed for any reason, including medical
reasonableness and or necessity, that the amount of benefits claimed by Brandon Community Health and Rehabilitation L.L.C. or
Physician(s) who treated me, is to be set aside and not disbursed until the dispute is resolved. As part of this assignment of rights and
benefits, I further instruct the insurance carrier its legal rights. In consideration for the above assignment I will not have to pay for the charges
at the time of service.
I understand I am financially responsible for the full amount due of all charges; regardless of my insurance status. I realize that the facility
may take whatever steps are necessary to collect the balance due, including use of a collection agency. I agree to pay all collection costs,
including attorney fees, and/or including fees on appeal. I hereby authorize the facility to release necessary information to secure the payment
of benefits. I authorize the use of this signature on all my insurance submissions. I also authorize the release of any information pertinent to
my case to an insurance company adjuster, attorneys involved in this case, or any physician requesting my information. I further authorize ant
physician or institution that previously attended me to furnish medical records or information which may be requested by Brandon
Community Health and Rehabilitation L.L.C. or Physician(s) who treated me.
I understand and agree that the facility is not responsible for personal valuables or belongings brought into the center, or claimed to have been
brought into the center by me or my agent. Personal valuables or belongings include, but are not limited to, clothing, personal hygiene
products, toiletries, dentures, glasses, prosthetic devises (such as hearing aides, artificial limbs, or assist devices such as: canes walkers, or
wheelchairs). Credit cards, jewelry and money. I understand the facility discourages bring personal valuables to the center. Valuables not
claimed within 90 days will be discarded.
By my signature on this document, I acknowledge receipt of a Patients Bill of Rights and Responsibilities brochure pursuant to Florida Statue
381.026. prior to or at time of exam, evaluation or treatment. A photocopy of this assignment will be considered as effective and valid as the
original. I authorize Brandon Community Health and Rehabilitation L.L.C. or Physician(s) who treated me to initiate a written complaint to
the insurance commissioner for any reason on my behalf. I have read the information herein and it is true to the best of my knowledge and
belief.
I have read this form and answered the questions to the best of my knowledge. I hereby request and authorize this office / facility / clinic
to perform the necessary exams for the care and management to this complaint.
PATIENT SIGNATURE: _______________________________________________________________DATE: ____________20_______
WITNESS: __________________________________________________________________________DATE: _____________20______
LEGAL GUARDIAN SIGNATURE:______________________________________________________DATE:_____________20______
PAST MEDICAL HISTORY
Heart Disease
Hypertension (high blood pressure)
Y
Y
N
N
Diabetes
Y
N
Insulin
Pills
Diet Control
Cancer
Chemotherapy
Seizures(epilepsy)
Y
Y
Y
N
N
N
Y
N
Y
N
Y
N
Dilantin Y N
Phenobarbital Y N
Tegretol Y N
Asthma
Y N
Inhaler Y N
Steroids Y N
Chronic Obstructive Pulmonary Disease Y N
(emphysema, bronchitis)
Stroke
Y N
Bleeding
Y N
Anemia
Y N
Dementia(Alzheimer’s)
Y N
Blood Disorder
Y N
HIV
Y N
Hepatitis A Y N
Hepatitis B Y N
Hepatitis C Y N
Currently pregnant
Y N
# of pregnancies _______
# of births
_______
Surgeries: Please List with approx dates_________________________
_________________________________________________________
_________________________________________________________
FAMILY HISTORY
Heart Disease
Y N
Hypertension
Y N
(high blood pressure)
Y N
Cancer
Y N
Diabetes
Y N
Stroke
Y N
Aneurysm
Y N
Other:_____________________________________________________
SOCIAL HISTORY
Smoker
Y N
# of packs a day_________
Alcohol
Y N
drinks per day___________
Recreational
Y N
Drugs
Y N
(specify)___________________________________________________
ALLERGIES
Penicillin
Y N
Sulfa
Y N
Other_____________________________________________________
MEDICATIONS
Please list all prescribed medications_____________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Please list any over the counter medications_______________________
__________________________________________________________
__________________________________________________________
Anything else we need to know about your medical history:
PLEASE MARK BELOW AND RATE YOUR PAIN OR DISCOMFORT FROM (1-10)
____________________________
Patient Signature
1 LOWEST
10 HIGHEST
Brandon Community Health and Rehabilitation
NOTICE OF LIEN / LETTER OF PROTECTION
PATIENT NAME: _________________________________________________________DATE______________20_____
I do hereby authorize Brandon Community Health and Rehabilitation L.L.C. to furnish you, my attorney, with a full
report of myself in regard to the above-referenced accident in which I was involved.
I hereby authorize and direct you, my attorney, to pay directly to Brandon Community Health and Rehabilitation
L.L.C. sums as may be due for services rendered me by reason of this accident and to withhold such sums from any
settlement, judgement, or verdict as may be necessary to adequately protect and fully compensate said Brandon
Community Health and Rehabilitation L.L.C.. I hereby further give a lien on my case to Brandon Community Health
and Rehabilitation L.L.C. against any and all proceeds of my settlement, judgement, or verdict which may be paid to
you, my attorney, or myself, as a result of the injuries for which I have been treated or injuries in connection
therewith.
I fully understand that I am directly and fully responsible to Brandon Community Health and Rehabilitation L.L.C.
for all medical bills submitted by Brandon Community Health and Rehabilitation L.L.C. for services rendered me and
this agreement is made solely for Brandon Community Health and Rehabilitation L.L.C. to give additional protection
and in consideration of Brandon Community Health and Rehabilitation L.L.C. awaiting payment. I further
understand that such payment is not contingent on any settlement, judgement or verdict by which I may eventually
recover said fee.
I agree to promptly notify Brandon Community Health and Rehabilitation L.L.C. of any change or addition of
attorney(s) used by me in connection with this accident, and I instruct my attorney to do the same and to promptly
deliver a copy of this lien to any such substituted or added attorney(s). A photocopy of this authorization shall be
considered as effective and valid as the original.
Please acknowledge this letter by signing below and returning to Brandon Community Health and Rehabilitation
L.L.C. I have been advised that if my attorney does not wish to cooperate in protecting Brandon Community Health
and Rehabilitation L.L.C., Brandon Community Health and Rehabilitation L.L.C. will not await payment and declare
the entire balance immediately payable, I further understand the cost of my treatment and believe charges to be a
reasonable and necessary expense, I also direct my attorney to pay Brandon Community Health and Rehabilitation
L.L.C. the full cost of treatment in my case.
________________________________________
PATIENT SIGNATURE
____________20_____
DATE
The undersigned being attorney of record for this patient does hereby agree to observe all the terms of the above and
agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect
and fully compensate Brandon Community Health and Rehabilitation L.L.C. Attorney further agrees that in the event
this lien is litigated that the prevailing party will be awared fees and costs.
________________________________________
______________20___
ATTORNEY SIGNATURE
DATE
Please date, sign and return one copy to Brandon Community Health and Rehabilitation L.L.C.
162 W Robertson Street Brandon Florida 33511 Phone (813) 681-6100 Fax (813) 681-6199