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Patient Forms & Questionnaires

Complete your forms online or print them to bring to your appointment. Filling these forms ahead of time helps us provide you with faster and more personalized care.

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Today’s Date

Last Name

First Name

Middle Name

Address Line 2 City State / Province / Region

Marital Status

Social Security Number

Sex

Date of Birth

Home Phone

Cell Phone

Work Phone

Email Address

Race: Caucasian, Black, Hispanic, Asian, American Indian/Alaskan National, Refused to Report
Ethnicity: Hispanic or Latino, Not Hispanic or Latino, Refused to Report

If You Are Using Home Oxygen, Which Company Do You Currently Use?

If You Are Using a Home Health Agency, Which Company Do You Use?

Which Pharmacy Do You Use? Please Include Pharmacy Name, Street Name (or Cross Streets) and/ or Phone Number

Emergency Contact

Relationship

Phone Number

Insured/ Responsible Party Information
If the insured person is your spouse:

Spouse’s Name

Date of Birth

SSN

If the insured person is a dependent:

Guardian/ Other Name

Date of Birth

SSN

Relationship to Patient

Please provide photo identification and your insurance cards to the front desk upon check-in. At that time, we will take your photo and attach it to your medical record. Your co-pay is due at the time of service. We collect it during our check-in process. If you are not able to pay your co-pay, please notify the front desk upon arrival.

Date

Patient (or Responsible Party) Signature

Financial Form

Mark J. Pamer, D.O., LLC

I hereby give consent for the necessary medical treatment for the above named patient for whom I am legally responsible. This consent for treatment includes medical care provided today and those of subsequent appointments.

Privacy Notice

In accordance with the Health Insurance Portability and Accountability Act of 1996, patients of Mark J. Pamer, D.O., LLC (the Practice), are entitled to the greatest degree of privacy possible. The release of medical information to any insurance carrier, other entities directly associated with the Practice, your primary care provider and/or referral physician in connection with treatment is authorized. This office will strive to ensure that patient information is used only for authorized purposes as agreed by the patient. No other disclosures will be made without written authorization from the patient or guardian. Patients are advised that they have a right to review their medical files upon reasonable notice to the practice and during normal business hours and to make comments to the same. All requests must be made in writing.

Assignment of Benefits

I hereby authorize and assign to the Practice all payments and/or insurance benefits for services rendered. I agree to complete any additional forms which may be required by me in insurance plan for assignment of benefits. I hereby authorize the Practice to release medical information necessary to obtain payment.

Financial Responsibility

I understand that in consideration of the services provided to the patient, I am directly and primarily responsible to pay the amount of all charges incurred for services and procedures rendered at the Practice. It is my responsibility to know and understand my insurance policy. I am responsible for payment of any applicable deductible, copayment or coinsurance prior to the provision of services. I understand that by law, the deductible, copayment, and coinsurance cannot be waived. The Practice will provide me with an estimate of my total financial responsibility. I understand that this amount is only an estimate based on what my insurance plan may pay. In the event that fees exceed the amount of the estimate, I will be financially responsible for the balance. I understand that such payment is not contingent on any insurance, settlement or judgment payment. I further understand that such payment is not contingent on the results of any treatment. The Practice does not refund any payment for services rendered. The Practice will file a claim for payment with my insurance plan as a courtesy to me. If the insurance plan fails to pay the Practice in a timely manner for any reason, I understand that I will be responsible for prompt payment of all amounts owed to the Practice. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL AMOUNTS NOT COVERED BY THE

INSURANCE PLAN(S). I will receive a statement once a month if I have a balance owing. Failure to pay a balance by the third billing statement will result in my account being turned over to the collection process. SHOULD MY ACCOUNT BE REFERRED TO A COLLECTION AGENCY OR ATTORNEY FOR COLLECTION, THEN I WILL PAY ALL COSTS OF COLLECTION, INCLUDING A REASONABLE ATTORNEY’S FEE.

Authorization for treatment/Release of information

In connection with the medical services that I am receiving from the Practice, I hereby authorize the Practice to disclose any/all information concerning my medical condition and treatment (including, but not limited to, super confidential information concerning sexually transmitted diseases, mental health, chemical dependence, or other such information), including copies of applicable hospital and medical records, to:

Any third-party payer covering the medical services with the patient;
Other healthcare professionals and institutions involved in the delivery of healthcare;
The proponent of any legally sufficient subpoena, or in response to a court order;
Employee and agents for the Practice, to the degree necessary to facilitate the provisions of Healthcare Services and provide for such payment of services;
Pharmacies; and
As otherwise required by law

In each case, the Practice shall take reasonable steps to ensure that only the minimum necessary information is disclosed accordance with the above. I have read and understand the above. I further understand that I have been given access to the physician's privacy notice and that copy of which was available for my taking. I have had the opportunity to place special restrictions upon the consent hereby given. I further understand that special requests for restrictions must be submitted to the practice in writing and must be reviewed and approved by the designated Privacy Officer. I also hereby authorize the disclosure of personal health information to the individuals listed below and via answering machine.

To the following individuals:

Name

Relationship

Name

Relationship

I hereby acknowledge that I am responsible, and it is my best medical interest to attend any scheduled appointments and/or follow-up appointments with the Practice, as recommended by my physician. I further understand that if my physician orders/recommend outpatient diagnostic imaging testing, a sleep study, PFTs, or laboratory testing, it is because he/she feels it is a my best interest. Finally, I understand that THE PRACTICE HAS A NO-SHOW FEE IN EFFECT WHICH REQUIRES 24 HOUR NOTICE IF I MUST CANCEL AN APPOINTMENT. If I fail to abide by this policy, I will be responsible for charge of $50 per occurrence. This must be paid prior to seeing the Practice for any other appointments.

This consent is valid from the date executed until revoked in writing by the patient.

Patient Signature

Date

Witness Signature

Date

Arbitration Form

By entering into this agreement the parties to this agreement are giving up their constitutional and statutory rights to have any dispute involving health care services decided before a judge or jury and instead are accepting mandatory and binding arbitration to resolve any dispute.

Arbitration Agreement for Health Care Services

Whereas, on this

day of

The undersigned patient or the patient’s legal representative has entered into this agreement with Mark J. Pamer, D.O., LLC to arbitrate any dispute involving the rendition of healthcare services by Mark J. Pamer, D.O., LLC and its physicians, employees, agents, partners and assigns (Mark J. Pamer, D.O., LLC and its physicians, employees, agents, partners and assigns shall be called “health care provider”) and have agreed to the following terms and conditions.

Article 1. Full Consideration For This Agreement. The undersigned parties agree that this agreement has been made for full consideration, which consideration includes, but is not limited to, their mutual desire to have any healthcare service dispute or controversy resolved in a fair and expeditious manner by use of mandatory and binding arbitration.

Article 2. Health Care Services Are Arbitrable. The undersigned parties agree that any and all issues involving healthcare services rendered by the health care provider including but not limited to dispute or controversy involving malpractice or negligence involving the diagnosis, treatment or care of the patient by the health care provider are arbitrable issues that shall be submitted to mandatory and binding arbitration as provided in this agreement. Further, the undersigned parties agree that any and all disputes or controversy involving healthcare services rendered prior to the execution of this agreement are also arbitrable and shall also be submitted to mandatory and binding arbitration as provided in this agreement.

Article 3. Agreement To Arbitrate Disputes Under Rules of the American Arbitration Association. The undersigned parties agree that any and all disputes or controversy involving healthcare services provided by the health care provider to the patient shall be settled by arbitration administered by the American Arbitration Association in accordance with its Commercial Arbitration Rules and the Supplementary Procedures for Large, Complex Disputes, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof.

Article 4. Notice of Demand to Arbitrate. A party to this agreement shall give written notice of demand to arbitrate controversy or dispute which involves healthcare services provided by the health care provider to the patient, which notice shall specify the allegations or issues in disputes and shall appoint an arbitrator. Within 20 days of receipt of the written demand for arbitration, the responding party shall have the right to name an arbitrator (failing to name an arbitrator within this twenty day period shall be considered a consent to the claimant’s appointed arbitrator). If the responding party has appointed an arbitrator, then within 20 days of the appointment of an arbitrator by the responding party, the two arbitrators shall select a the third arbitrator (provided however if the arbitrators are unable or fail to agree upon a third arbitrator, then the third arbitrator shall be selected by the American Arbitration Association). The third arbitrator shall serve as chair of the arbitration panel. Within a reasonable period of time after the arbitrator(s) has accepted his or her appointment, the arbitrator(s) shall provided an oath or undertaking of impartiality. Provided however, whomever is appointed as an arbitrator shall have experience and knowledge of healthcare service issues.

Article 5. Discovery. Consistent with the expedited nature of arbitration, each party will, upon the written request of the other party, promptly provide the other with copies of documents relevant to the issues raised by any claim or counterclaim. Any dispute regarding discovery, or the relevance or scope thereof, shall be determined by the chair of the arbitration panel (or arbitrator if only one arbitrator is serving). All discovery shall be completed within 60 days following the appointment of the final appointed arbitrator. At the request of the other party, the arbitrator(s) shall have the discretion to order examination by deposition of witnesses to the extent the arbitrator deems such additional discovery relevant and appropriate. Depositions shall be limited to a maximum of three per party and shall be held within 30 days of the making of a request. Additional depositions may be scheduled only with the permission of the chair of the arbitration panel, and for good cause shown. Each deposition shall be limited to a maximum of three hours duration. All objections are reserved for the arbitration hearing except for objections based on privilege and proprietary or confidential information.

Article 6. Location of Arbitration. The place of arbitration shall be within 50 miles of offices of the health care provider.

Article 7. Patient's Right to Cancel Arbitration Agreement. The patient has a right to rescind this agreement by written notice to the healthcare provider within one (1) calendar week after this agreement has been signed and executed. The patient may rescind by merely writing “cancelled” on the face of one of his copies of the agreement, signing his name under such word, and mailing, by certified mail, return receipt requested, such copy to the healthcare provider within such one (1) calendar week.

Article 8. Arbitration is Exclusive Remedy. With respect to any dispute or controversy that is made subject arbitration under the terms of this agreement, no suit at law or in equity based on such dispute or controversy shall be instituted by either party, except to enforce the award of the arbitrator's.

Article 9. General Provisions.

This agreement shall be governed by and interpreted in accordance with the loss of the State of Florida.
This agreement shall be binding on each parties’ assigns, heirs, personal representatives and assigns. Further, the parties intend that this agreement shall bind all parties whose claims may arise out of or relate to treatment or healthcare services provided by the healthcare provider, including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to the claim.
The substantially prevailing party shall be entitled to an award of reasonable attorney fees. Further, the arbitrator(s) shall award to the substantially prevailing party, if any, as determined by the arbitrators, all of its cost and fees. “Cost and fees” mean all reasonable pre-award expenses of the arbitration, including arbitrator’s fees, administrative fees, travel expenses, out-of-pocket expenses such as copying and telephone, court cost, witness fees and attorney fees.
Except as may be required by law, neither a party nor an arbitrator may disclose existence, content, or results of any arbitration hereunder without the prior written consent of both parties.
The damages awardable at arbitration are limited to those available under Florida law.

Both parties to this contract acknowledge that they each have constitutional and statutory rights to have disputes involving healthcare services decided before a judge or jury and instead are accepting mandatory and binding arbitration to resolve any dispute.

Mark J. Pamer, D.O., LLC

Dated this

By Dr. Mark J. Pamer

Patient or Patient’s Legal Representative

By: (Printed name of patient )

Please complete the forms online or print them and bring them to your appointment. Ensure all required fields are completed before submission.

Patient Information

Patient Questionnaire

Financial Forms

Arbitration Forms