Demographics

Insurance Information (MUST)

Confirm insurance eligibility prior to your first appointment by calling our front desk at (561) 364-8056 ext. 2 or emailing a photocopy of your insurance card and driver's license to appointments@mmrhealthcare.com.

Please bring the following documents to your first office visit:

1. Your insurance card

2. Your driver's license

No appointment will be made if insurance card and driver's license information are not received.

In Case of Emergency (ICE) Contact

Health Information

1. Do you currently suffer from any of the following listed in table below:

4. Medical History

9.Family Health History

Please check all that apply:

12. Radiology- have you had any radiology exams done recently? If yes, please indicate: *

13. Do you have a disability that requires assistance or extra room? *

Medication List

Are you on any medications? If yes, please indicate.

Authorization for Release of Medical Records

By completing the following, you are allowing Martha M. Rodriguez, M.D. P.A. to obtain your medical records from any previous physician or medical facility you have received care from. It is important that your clinician of our practice reviews your past medical history.

1. Previous physician/medical practice information whom records are being requested from:

2. Patient Information:

3. Covering the period(s) of health care:

4. Information for disclosure, if included in my records (please initial):

5. If applicable, I also give permission for the following to be disclosed (please initial):

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the provider(s) of care. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to review or contest a claim. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: If I fail to specify an expiration date, event, or condition, this authorization will expire in 90 days. If this authorization pertains to oneself as the patient, the expiration date can be documented as unlimited. If documented as such, it is the responsibility of the individual to notify the practice of any life changes, i.e. guardianship, so that appropriate documentation is given for the change

I understand that any disclosure of healthcare information carries with it the potential for unauthorized and future re-disclosures, as allowed by HIPAA and other federal privacy rules. If I have questions about disclosures of my health information, I can contact my provider of care.

This facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. Fees for copies of medical records in paper or electronic onto disk to be charged in accordance with the State of Florida fee schedule and the actual cost of postage.

Authorization for Release of Hospital Medical Records

I authorize the hospital facility as shown below:

To release any and all information acquired in the course of my examination and/or treatment by him/her to Dr. Martha M. Rodriguez for the purpose of my future examination and/or treatment. Please fax or mail medical record to below address:

Martha M. Rodriguez, M. D.
2015 Ocean Drive, Suite 11
Boynton Beach, FL 33426
Phone:561-364-8056 / Fax: 561-364-8507

Annual Wellness Visit Protocol

MMR Healthcare has a team of doctors and nurse practitioners that serve as our healthcare providers. Once all paperwork is collected and verified, the patient will be assigned a provider. However, all patients, no matter their assigned provider, will be seen by the first available nurse practitioner for an Annual Wellness Visit. An Annual Wellness Visit is done to collect and update information about the patient, including but not limited to medical and family history, health risks, and specific vitals.

This protocol applies only to the Annual Wellness Visit. All follow-up or sick visits will be done by the assigned or agreed-upon provider at the time in which an appointment is made.

Sign below in compliance with the Annual Wellness Visit Protocol.

Consent For Treatment

I (print your name), * Consent Name * voluntarily consent to the rendering of medical care. I understand that I am under the care and supervision of my attending physician at Martha M. Rodriguez M.D., P.A. and it is the responsibility of the staff to carry his/her instructions.

Authorization To Release Information

I (print your name), *Authorization Name * authorize Martha M. Rodriguez M.D., P.A. to release any and all information acquired in the course of my examination and/or treatment for the purpose of insurance, worker’s compensation of Medicare benefit payment, and other physician’s involved in your medical care.

Cancellation Notification

I (print your name), *Cancellation Name * agree to comply with the 24 hour notice to cancel an appointment with Martha M. Rodriguez M.D., P.A.. If I do not notify the office of my cancellation before 24 hours I will be charged a fee of $25.

Statement Of Financial Liability

I (print your name), *Financial Liability Name * guarantee payment of any and all bills rendered for said patient who are not covered or allowable by insurance. Martha M. Rodriguez M.D., P.A. will file the bill to your insurance company provided you supply proper and current information.

Insurance Change Notice

I (print your name), *Insurance Change Name * am aware of my responsibility to notify the receptionist of any changes to my insurance coverage before being seen by doctor or having blood work done. If I fail to notify the office prior to being seen or having blood work done, I will be responsible for all charges incurred.

Preferred Disclosure

In general, the HIPPA privacy gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual also has the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to an address other than your home address.

The physician and staff of Martha M. Rodriguez, M.D., P.A., respect your privacy and wish to make all reasonable attempts to respect your wishes regarding your confidential information. With that in mind, please indicate your preferences for the areas noted below:

I wish to be contacted in the following manner (check all that apply):

Written communication

Other individuals (family, friends, etc.) you may speak to regarding my health care and/or billing information:

Living Will

This declaration states that I, (Name) willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and

I have a terminal condition or I have an end stage condition or I am in a persistent vegetative state,

and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

I understand the full import of this declaration, and I am emotionally and mentally competent to make this
declaration.

The principal's failure to designate a surrogate shall not invalidate the living will..

— This form offered as a courtesy of The Florida Bar and the Florida Medical Association —

Living Wills And Health Care Advance Directives: FAQs

The Florida Legislature has recognized that every competent adult has the fundamental right of self-determination regarding decisions pertaining to his or her own health, including the right to choose or refuse medical treatment or procedures which would only prolong life when a terminal condition exists. This right, however, is subject to certain interests of society, such as the protection of human life and the preservation of ethical standards in the medical profession. To ensure that this right is not lost or diminished by virtue of later physical or mental incapacity, the Legislature has established a procedure within Florida Statutes Chapter 765 allowing a person to plan for incapacity, and if desired, to designate another person to act on his or her behalf and make necessary medical decisions upon such incapacity.

What is a Living Will?
Every competent adult has the right to make a written declaration commonly known as a "Living Will." The purpose of this document is to direct the provision, the withholding or withdrawal of life prolonging procedures in the event one should have a terminal condition. The suggested form of this instrument has been provided by the Legislature within Florida Statutes Section 765.303. In Florida, the definition of "life prolonging procedures" has been expanded by the Legislature to include the provision of food and water to terminally ill patients.

What is the difference between a Living Will and a legal will?
A Living Will should not be confused with a person’s legal will, which disposes of personal property on or after his or her death, and appoints a personal representative or revokes or revises another will.

How do I make my Living Will effective?
Under Florida law, a Living Will must be signed by its maker in the presence of two witnesses, at least one of whom is neither the spouse nor a blood relative of the maker. If the maker is physically unable to sign the Living Will, one of the witnesses can sign in the presence and at the direction of the maker. Florida will recognize a Living Will, which has been signed in another state, if that Living Will was signed in compliance with the laws of that state, or in compliance with the laws of Florida.

After I sign a Living Will, what is next?
Once a Living Will has been signed, it is the maker's responsibility to provide notification to the physician of its existence. It is a good idea to provide a copy of the Living Will to the maker's physician and hospital, to be placed within the medical records.

What is a Health Care Surrogate?
Any competent adult may also designate authority to a Health Care Surrogate to make all health care decisions during any period of incapacity. During the maker's incapacity, the Health Care Surrogate has the duty to consult expeditiously, with appropriate health care providers. The Surrogate also provides informed consent and makes only health care decisions for the maker, which he or she believes the maker would have made under the circumstances if the maker were capable of making such decisions. If there is no indication of what the maker would have chosen, the Surrogate may consider the maker's best interest in deciding on a course of treatment. The suggested form of this instrument has been provided by the Legislature within Florida Statutes Section 765.203.

How do I designate a Health Care Surrogate?
Under Florida law, designation of a Health Care urrogate should be made through a written document, and should be signed in the presence of two witnesses, at least one of whom is neither the spouse nor a blood relative of the maker. The person designated as Surrogate cannot act as a witness to the signing of the document.

Can I have more than one Health Care Surrogate?
The maker can also explicitly designate an Alternate Surrogate. The Alternate Surrogate may assume the duties as Surrogate if the original Surrogate is unwilling or unable to perform his or her duties. If the maker is physically unable to sign the designation, he or she may, in the presence of witnesses, direct that another person sign the document. An exact copy of the designation must be provided to the Health Care Surrogate. Unless the designation states a time of termination, the designation will remain in effect until revoked by its maker.

Can the Living Will and the Health Care Surrogate designation be revoked?
Both the Living Will and the Designation of Health Care Surrogate may be revoked by the maker at any time by a signed and dated letter of revocation; by physically canceling or destroying the original document; by an oral expression of one's intent to revoke; or by means of a later executed document which is materially different from the former document. It is very important to tell the attending physician that the Living Will and Designation of Health Care Surrogate has been revoked.

Where can I go to obtain legal advice on this issue?
If you believe you need legal advice, call your attorney. If you do not have an attorney, call The Florida Bar Lawyer Referral Service at 1-800-342-8011, or the local lawyer referral service or legal aid office listed in the yellow pages of your telephone book.

This information has been prepared by the Consumer Protection Law Committee of The Florida Bar and the Bar’s Public Information Office and is offered as a courtesy of The Florida Bar and the Florida Medical Association.

Designation of Health Care Surrogate

In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care decisions:

If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:

I fully understand that this designation will permit my designee to make health care decisions and to provide, withhold, or withdraw consent on my behalf; or apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility. Additional instructions (optional):

I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility. I will notify and send a copy of this document to the following persons other than my surrogate, so they may know who my surrogate is.

Patient Health Questionnaire-9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Alcohol Screening

Introduction
Because alcohol use can affect health and interfere with certain medications and treatments, it is important that we ask you some questions about your use of alcohol. Your answers will remain confidential, so please be as accurate as possible. Try to answer the questions in terms of ‘standard drinks’. Please ask for clarification if required.

AUDIT Questions Please check the response that best fits your drinking.

1. How often do you have a drink containing
alcohol?

2. How many standard drinks do you have on a typical day when you are drinking?

3. How often do you have six or more standard drinks on one occasion?

4. How often during the last year have you found that you were not able to stop drinking once you had started?

5. How often during the last year have you failed to
do what was normally expected of you because of drinking?

6. How often during the last year have you needed a
first drink in the morning to get yourself going after a heavy drinking session?

7. How often during the last year have you had a feeling of guilt or remorse after drinking?

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?

9. Have you or someone else been injured because of your drinking?

10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?

Supplementary Questions

Do you think you presently have a problem with drinking?

In the next 3 months, how difficult would you find it to cut down or stop drinking?

Drug Use Questionnaire (DAST-10)

The following questions concern information about your potential involvement with drugs excluding alcohol and tobacco during the past 12 months. Carefully read each statement and decide if your answer is “YES” or “NO”. Then, check the appropriate box beside the question.

When the words “drug abuse” are used, they mean the use of prescribed or over-the-counter medications used in excess of the directions and any non-medical use of any drugs. The various classes of drugs may include but are not limited to: cannabis (e.g., marijuana, hash), solvents (e.g.,gas, paints etc…), tranquilizers (e.g., Valium), barbiturates, cocaine, and stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., Heroin). Remember that the questions do not include alcohol or tobacco.

Please answer every question. If you have difficulty with a statement, then choose the response that is mostly right.

These questions refer to the past 12 months only.

Please let us know how you heard about us.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read carefully and file for your records.

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in
your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information
on dates of services, the services provided, and the medical condition being treated.

Health Care Operations: Your health information may be used as necessary to support the day-to-day activities and management of Martha M. Rodriguez, M.D., P.A... For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit
a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Additional uses of information

Appointment Reminders: Your health information will be used by our staff to send you appointment reminders.

Information about treatments: Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health-related products and services that we believe may interest you.

Fund Raising: Unless you request us not to, we will use your name and address to support our fund-raising efforts. If you do not want to participate in fund-raising efforts, please check off the following box.

Individual Rights:

You have certain rights under the federal privacy standards. These include:

• The right to request restrictions on the use and disclosure of your protected health information
• The right to receive confidential communications concerning your medical condition and treatment
• The right to inspect and copy your protected health information
• The right to receive and accounting of how and to whom your protected health information has been disclosed.
• The right to receive a printed copy of this notice

Martha M. Rodriguez, M.D., P.A. Duties

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.

We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any
office visit. The revised policies and practices will be applied to all protected health information we maintain.

Request to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the receptionist or privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request.

Acknowledgement of Receipt of Notice of Privacy Practice

Martha M. Rodriguez, M.D., P.A. reserves the right to modify the privacy practices outlined in the notice. I have received a copy of a Notice of Privacy Practices.

If patient is minor or adult who is unable to sign this form:

Suggested form of a Living Will, Florida Statutes Section 765.303