Primary Care Of Brevard
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    • Tanya Schrumpf DC, APRN
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Pharmacy Information Request Form

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So that we may keep your primary care physician and/or referring physician informed of your progress under our care, please list the name and address of that physician.
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Medical Records Release
Authorized
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Partial Record Release
Please send the selected information to: Primary Care of Brevard 7955 Spyglass Hill Road Suite A 321-255-6670 phone 321-255-1996 fax Stephanie Haridopolos, MD Tanya Schrumpf, APRN
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By proceeding, I understand these records may contain information from other health care providers, as well as information which are administrative in nature. This information will be given only to those specified on this form and only through the expiration date stated below. I also und erstand I have the right to revoke this authorization at any time through written notice and that written notice must include: 1) The patient’s name, social security number, and DOB, 2) reference to this specific authorization and the name of those authorized by this form to receive this information, 3) a statement that the patient wants to revoke this authorization, the effective date of revocation, and the signature of the patient or legal guardian. I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal laws or regulations. This authorization will expire six months from the date specified above.
Health History
Please complete this Questionnaire. It is designed to give us information about your health, which will allow us to better understand and assist you.
Patient Sex(Required)
In the past 2 weeks, have you been bothered by:
Little interest or pleasure in doing things?(Required)
Feeling down, depressed, or hopeless?(Required)
Review of Systems: Please mark any persistent symptoms you have had in the past few months Read through every section and select "No Problems" if none of the symptoms apply to you. List other concerns above.
General(Required)
Gastrointestinal(Required)
Allergic/Immune(Required)
Breast(Required)
Respiratory(Required)
Skin(Required)
Genitourinary(Required)
Women Only(Required)
Hematologic/ Lymphatic(Required)
Neurological(Required)
Endocrine(Required)
Eyes(Required)
Psychiatric(Required)
Cardiovascular(Required)
Musculoskeletal(Required)
Immunizations: Check off any vaccinations you have had in the past. Add year if known.
Immunizations
List all current medications.
Drug allergies.
Are you allergic to Latex?
Do you take Blood Thinners? (Coumadin, Plavix, Aggrenox, Ticlid, Pletal)
Health Maintenance Screening Tests
Lipid (cholesterol)
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Abnormal
Sigmoidoscopy or Colonoscopy
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Abnormal
Women Only:
Mammogram:
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Abnormal
Pap Smear
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Abnormal
Bone Density Test
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Abnormal
Social History and Status
Work Status
Have you had a work capacity assessment?
Are you disabled through social security?
Alcohol Use
Do you currently consume alcoholic beverages?
Quantity per day?
Have you ever been treated for a drug or alcohol addiction?
Have you ever felt you needed to cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt guilty about drinking?
Have you ever felt you needed a drink first thing in the morning to steady your nerves, or to get rid of a hangover?
Sexual Activity
Are you currently sexually active?
Sexual Partner(s) is/are/have been:
Birth control method:
Personal medical history
Do you currently have, or have you ever had any of the following conditions?
Alcohol/ Drug Abuse
Allergy (Hay Fever)
Anemia
Anxiety
Arthritis (Rheumatoid)
Arthritis (Osteoarthritis)
Asthma
Bladder /Kidney Problems
Blood Clot (Leg)
Blood Clot (Lung)
Blood Transfusion
Breast Lump (benign)
Cancer (Breast)
Cancer (Colon)
Cancer (Other Type)
Cancer (Ovarian)
Cancer (Ovarian)
Cancer (Prostate)
Cataracts
Chicken Pox
Colon Polyp
Coronary Artery Disease
Depression
Diabetes (adult onset)
Diabetes (childhood onset)
Diverticulitis
Emphysema
Fractures (broken bones)
Gallbladder Disease
GERD
Glaucoma
Gout
Gynecological Cond. (Endometriosis)
Gynecological Cond. (Fibroids)
Gynecological Cond. (other)
Heart Attack
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis Other
High Blood Pressure
High Cholesterol
Hip Fracture
Irritable Bowel Syndrome
Kidney Disease/ Failure
Kidney Stones
Liver Disease
Migraine Headaches
Osteoporosis
Pneumonia
Prostate (enlargement)
Prostate (nodules)
Seizure / Epilepsy
Skin Condition (Eczema)
Skin Condition ( Psoriasis)
Skin Condition (Abn. Moles)
Sleep Apnea
Stomach Ulcer
Stroke
Thyroid (Nodule)
Thyroid High (Overactive)/ Hyperthyroidism
Thyroid Low (Underactive) / Hypothyroidism
Other (List)
Other (List)
If you have had any of the following surgeries, please note the year as well as any abnormal findings and/or complications. If you have not had the surgery in question, please leave both fields blank.
Adopted?
If yes and you do not know your family history, please skip the following section. Please indicate which (if any) relatives have had the following diseases. Parent's & siblings are most important.
No Significant history known
Alcoholism / Drug abuse
Alzheimer’s
Asthma
Autoimmune Disease
Bleeding or Clotting Disorder
Cancer Breast
Cancer Colon
Cancer Other Type
Cancer Ovarian
Cancer Prostate
Colon Polyp
Coronary Artery Disease
Depression, Suicide, Anxiety
Diabetes (childhood)
Diabetes (Adult Onset)
Emphysema (COPD)
Genetic Disorder (Explain)
Glaucoma
Heart Disease (CHF)
Heart Disease (Other)
Hepatitis B or C
High Blood Pressure hypertension
High Cholesterol
Hip Fracture
Hypothyroidism/ Thyroid Disease
Kidney Disease
Kidney Stones
Macular Degeneration
Migraine Headaches
Osteoporosis
Other (list)

Hereditary Cancer Questionnaire



Your personal and family history of cancer is important to provide you with the best care possible. Please complete the following chart based upon your personal and family history of cancer. Leave blank what you do not know.
The following relatives should be considered:
Parents, sibligns, half-siblings, children, grandparents, grandchildren, aunts, uncles, nieces, and nephews on both sides of the family.

Do you have a personal history of:

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Breast, ovarian, or pancreatic cancer at any age?
Colorectral or uterine cancer at age 64 or younger?

Do you have a family history of:

Breast cancer at 49 or younger
Maternal or Paternal side of the family?
Two breast cancers (bilateral) in one relative at any age?
Maternal or Paternal side of the family?
Three breast cancers in relatives on the same side of the family at any age?
Maternal or Paternal side of the family?
Ovarian cancer at any age
Maternal or Paternal side of the family?
Pancreatic cancer at any age
Maternal or Paternal side of the family?
Male breast cancer at any age
Maternal or Paternal side of the family?
Metastatic prostate cancer at any age
Maternal or Paternal side of the family?
Colon cancer at 49 or younger
Maternal or Paternal side of the family?
Uterine cancer at 49 or younger
Maternal or Paternal side of the family?
Ashkenazi Jewish ancestry with breast cancer at any page
Maternal or Paternal side of the family?
Do you have a family history of other cancers?
Have you or anyone in your family had genetic testing for hereditary cancer?

Health Consult

Do you have high blood pressure?
Has it been over one year since you last completed blood tests?
Has it been over one year since your last visit to an eye doctor?
Was it normal?
Colon Cancer?

Immunizations

Men

Family history of Prostate (or other male specific) cancer?

Women

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Was it normal?
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Was it normal?
Family history of breast, cervical, ovarian or uterine cancer?
Please bring a copy of the most recent above stated reports along with your immunization record to your appointment.
Assignment of Insurance Benefits; Appointment of Authorized Representative; Privacy; Payments; Appointments
Assignment of Insurance Benefits -- Appointment as Legal Authorized Representative: I (i) assign all applicable health insurance payments and benefits, and all rights and obligations that I and my dependents have under my health plan to the Millennium Medical Management, LLC (“Provider”); (ii) authorize payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to Provider; and (iii) appoint Provider as my authorized representative (“Authorized Representative”) with the power to (i) file medical claims, appeals and grievances with the health plan; (ii) file appeals and grievances with the health plan; (iii) institute any necessary litigation and/or complaints against my health plan naming me as plaintiff in such lawsuits and actions if necessary (or me as guardian of the patient if the patient is a minor); and (iv) discuss or divulge any of my personal health information or that of my dependents with any third party including the health plan. I also understand that Provider is not responsible for the terms of the contracts which I have with my health benefit plan or insurance companies. I certify that the health insurance and coverage information I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I am fully aware that having health insurance and/or Medicare coverage does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that (i) I am responsible for all amounts not covered by my health insurance and/or Medicare, including co-payments, co-insurance, and deductibles; and (ii) with respect to Medigap/Secondary Insurance, should my insurance or not pay all or part of the secondary balance, I am responsible for all remaining allowed charges. Authorization to Release Information: I authorize my Authorized Representative and any holder of medical or other information about me to (i) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments (including the Social Security Administration or its Medicare Administrative Contractors if I am a Medicare beneficiary); (ii) process insurance and other payment claims generated in the course of examination or treatment; and (iii) allow a photocopy of my signature to be used to process insurance and other payment claims. This authorization will remain in effect until revoked by me in writing. I authorize Provider to discuss my medical/health care with the following family members or close friends:
I authorize Provider to discuss my account finances with the following family members or close friends:
ERISA Authorization: I designate, authorize, and convey to my Authorized Representative to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (i) the right and ability to act as my Authorized Representative in connection with any claim, right, or cause of action including litigation against my health plan (even to name me as a plaintiff in such action) that I may have under such insurance police and/or benefit plan; and (ii) the right and ability to act as my Authorized Representative to pursue such claim, right or cause of action in connection with said insurance policy and/or benefit plan (including bu t not limited to the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.503-1(b)(4) with respect to any health care expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. This authoriza tion will remain in effect until revoked by me i n writing. A photocopy of this Authorization shall be as effective and valid as the original.

Payment Policy; Out-of-Network Disclosure/Patient Acknowledgment of Responsibility: I understand that (i) Provider accepts most forms of payment including checks, debit cards, credit cards and credit facilities like CareCredit and MedFin; (ii) Provider reserves the right to charge 1.5% interest per month, compounded daily, after 90 days of non-payment on all outstanding balances; (iii) credit cards and other revolving credit programs have chargeback provisions to allow, for example, return of purchased goods, but that such chargeback features are not appropriate at Provider, such that I waive my rights for chargebacks; (iv) if a chargeback occurs, Provider may initiate legal action to recoup the charges and I will be responsible for all resulting legal fees and other appropriate expenses to recoup those charges; and (v) Provider will ass ess a $50 fee on all checks that are returned as unpaid. I understand that Provider is an out-of-network provider and that, consequently: (i) I am responsible for the difference between charges and payments made by my health plan and any coinsurance and deductible required by my health plan; and (ii) Provider cannot waive any such patient responsibility.

Notice of Privacy Practices: I have reviewed the posted copy of Provider’s Notice of Privacy Practices, which describes how my medical information may be used and disclosed and how I can obtain access to this information, and I understand that a copy for my records is available upon request.
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Cancellation and No Show Policy
At Millennium Medical Management our goal is to provide quality medical care to you and the rest of our patients. In an attempt to be fair to all patients seeking our care, we have implemented a Cancellation and No Show Policy. We understand that there are times when you maymiss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, yo u may be preventing another patient from getting much needed treatment. If you must cancel an appointment we ask that you please call at least 24 hours prior to the appointment, or earlier if possible.

To cancel an appointment, call Patient Services at 321-751-3389 or 1-800-349-6922 (1-800-FIX-MY-BACK). Each cancellation or “no show” is tracked in our system and you will receive a cancellation number. Excessive cancellations and ‘no shows’ may require us to discharge you from the practice. Cancellation Policy/No Show Policy For Doctor Appointment and Surgery

1. Cancellation/No Show policy for Doctor Appointment We understand that there are times when you miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book. If an appointment is not cancelled at least 24 hours in advance you will be charged a forty ($40) dollar fee; this will not be covered by your insurance company.

2. Scheduled Appointments We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time we will either fit you in or give you the option to reschedule the appointment.

3. Cancellation/No Show Policy for Surgery/Procedures Due to the large block of time needed for surgery, last minute cancellations will not allow time needed to schedule another p atient in need of our services. If surgery/procedure is not cancelled at least 48 hours in advance you will be charged an eighty dollar ($80) fee; this will not be covered by your insurance company.

4. Account Balances We will require that patients with no show/cancellation fees pay their account balances to zero ($0) prior to receiving furth er services by our practice. Patients who have questions about their bills or who would like to discuss the charges, may call the Office Manager and review their account and concerns.
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Mutual Agreements, Consents and Resolution of Concerns

1. Privacy and Ratings Millennium Medical Management agrees not to provide medical information for the purpose of marketing directly to Patient. Regardless of legal privacy loopholes, Millennium Medical Management will never attempt to leverage its relationship with Patient by seeking Pati ent’s consent for marketing products for others. We want your feedback. If our office gets it right, tell us. If we could do something better, tell us. We take quality improvement seriously. While there are scores of “rating sites” in cyberspace, many fail to provide useful information. Let’s get it done right. We can make recommendations as to which sites follow minimum standards for fairness and balance. Just ask us.

Millennium Medical Management has invested significant financial and marketing resources in developing the practice. Nothing in this Agreement prevents a patient from posting commentary about Millennium Medical Management - our practice, expertise, and/or treatment - on web pages, blogs, and/or mass correspondence. In consideration for treatment and the above noted patient protection, if Patient prepares such commentary for publication on web pages, blogs, and/or mass correspondence about Millennium Medical Management, the Patient exclusively assigns all Intellectual Property rights, including copyrights, to Millennium Medical Management for any written, pictorial, and/or electronic commentary. This assignment shall be effective at the time of creation (prior to publication) of the commentary. This Agreement shall be for a period of five years from Millennium Medical Management’s last date of service to Patient.

Millennium Medical Management requires all patients in its practice to sign the Mutual Agreement to establish that any anonymous publishing or a iring of commentary will be covered by this agreement. Further, this Agreement will survive for a minimum of three years beyond any termination of the Millennium Medical Management - Patient relationship. Patient and Millennium Medical Management acknowledge that breach of this Agreement may result in serious, irreparable harm. Patient and Millennium Medical Management agree to the right of equitable relief (including but not limited to injunctive relief). Should a breach of this provision result in litigation, the prevailing party in the litigation shall be entitled to reasonable costs, expenses, and attorney fees associated with the litigation.

2. Surgical Consent Modification We recognize that you have a choice in receiving care. We take great pride in our reputation for providing the highest levels of quality medical care to our patients. However, we realize there are times when some patients might not be satisfied with the outcomes of their treatments. Every patient has a right to file a complaint with the Division of Medical Quality Assurance, Board of Medicine. But, that right is not unlimited. For example, those who file complaints in bad faith can be subject to civil liability (Florida Statutes§ 456.073 (11)). In the context of balancing your rights with those of the physician, I, the patient, agree to the following: 1. If a complaint related to my care is ever filed (by my agent or me) with the Division of Medical Quality Assurance, I will only do so in good faith, addressing matters only related to my health and welfare.

2. In particular, I understand that there are risks inherent to any surgical procedure and these risks have been explained to me prior to the procedure. I have signed that consent voluntarily and with my free will. And I have had an opportunity to ask questions and have them answered to my satisfaction. In that context, a complaint to the Division of Medical Quality Assurance, founded on any such realized risks, unless there is clear and convincing evidence to the contrary, will be construed as bad faith.

3. Next, should a complaint be filed with the Division of Medical Quality Assurance related to standard of care, I, the patient, will explicitly request that the complaint be reviewed by a member of my specialty; that specialty being Neurosurgery, Spinal Surgery, Orthopedic Surgery, Pain Management or Neurology.

4. Finally, should the complaint allege facts that can be disrupted by the clear medical record, I, the patient, will voluntarily withdraw my complaint if that portion of the medical record is drawn to my attention. I will have the right to inspect and review the medical record to correct any perceived error in the medical history. Such corrections must be performed within two weeks of the treatment received

3. Resolution of Concerns I understand that I am entering into a contractual relationship with Physician(s) of Millennium Medical Management for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care to patients and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative, agree not to initiate or advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician. Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued, I (the patient) and/or my representative agree to use American Board of Medical Specialties (“ABMS”) board-certified expert medical witness (es) in the same specialty as Physician. Furthermore, I agree that these expert witnesses will be members in good standing of and adhere to the guidelines and/or code of conduct defined for expert witnesses by the AmericanBoard of Neurosurgery, American Board of Interventional Pain Management, American Academy of Pain Management, American Board of Electrodiagnostic Medicine, American Board of Physical Medicine and Rehabilitation, American Board of Orthopeadic Surgery and American Board of Psychiatry and Neurology. Patient/guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician’s reputation and business. Patient/guardian and Physician agree in the event of a breach to allow specific performance and/or injunctive relief.

4. Waiver Article 1, Section 21 of the Florida Constitution reads as follows: Access to court – The courts shall be open to every person for redress of any injury, and justice shall be administered without sale, denial or delay. The Undersigned patient understands and acknowledges that: I have been advised that signing this waiver releases an important constitutional right; and I h ave been advised that I may consult with counsel before signing this waiver; and by signing this waiver I agree that if any controversy arises out of or in any way relating to the current, future or past diagnosis, treatment, or care that I have or will receive from Millennium Medical Management, LLC, it’s physicians, agents or employees or Surgery Center of Viera, LLC, the maximum amount of any non-economic damages that can be awarded in any such action will be $250,000. This limit applies regardless of the number of claimants or defendants in the proceeding. There is no limit on the amount of economic damages that a jury may award; and I have three (3) business days following execution of this waiver in which to cancel this waiver; and I wish to en gage the medical services of Millennium Medical Management, but I am unable to do so because of the provisions of the constitutional limitatio n set forth above.

In consideration of the physician or group of physicians’ agreements to provide medical services to me and my desire to receive medical services from the physician or group of physicians listed below, I hereby knowingly, willingly, and voluntarily waive the right, in an action in a court of law for any controversy, including any malpractice claim, arising out of or in any way relating to the diagnosis, treatment, or care of the patient by Millennium Medical Management, including any partners, agents, employees of the physician or Surgery Center of Viera, LLC, to recover non-economic damages in excess of $250,000; and I have selected Millennium Medical Management as my physician group of choice in this matter and would not be able to retain their medical services without this waiver; and I expressly state that this waiver is made freely and voluntarily, with full knowledge of its terms, and that all questions have been answered to my satisfaction. I understand that this waiver will remain in effect for one year from the date that I have signed this form.

ACKNOWLEDGEMENT BY PATIENT FOR PRESENTATION TO THE COURT The undersigned patient hereby acknowledges, under oath, the following: I have read and understand this entire waiver of my right under the constitutional provision set forth above. I am not under the influence of any substance, drug, or condition (physical, mental, or emotional) that interferes with my understanding of this entire waiver in which I am entering and all the consequences thereof. I have entered into and signed this waiver freely and voluntarily. I authorize Millennium Medical Management to present this waiver to the appropriate court, if required. Unless the court requires my attendance at a hearing for that purpose,

Millennium Medical Management is authorized to provide this waiver to the court for its consideration without my presence.
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