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Welcome Letter

We are honored that you have chosen us as your health care provider. We have exciting news regarding your health management with our practice.

As we continue our efforts to provide our patients with the highest quality of care, we are constantly looking for methods together with our patients to ensure that you are not only aware of, but also involved in the management and improvement of your health.

We are proud to inform you that our practice now offers the opportunity to use the power of the World Wide Web to track the most important aspects of your health care through our office. Our Patient Portal enables our patients to communicate with our doctors, nurses, and staff members easily, safely, and securely via the Internet.

Participating patients are given secure User IDs and passwords, enabling them to access the Patient Portal to view their personal and private documents, including labs and diagnostic test results, educational information, billing statements, and other health information.

Through the Patient Portal, you are able to:

  • Ask questions to doctors, nurses, and staff members
  • Request refills and referralsSchedule appointments
  • View your personal health records
  • Examine your current and past billing statements

. . . all from the comfort of your home, whenever it is convenient for you!



By using the Patient Portal, you no longer have to call the office, leave a message and wait for the return call to get the results of your test; those results will be available to you through the Patient Portal. You can also send a message to the office through the portal and get a prompt reply.




To learn more or to sign up, contact our office today at:



(352) 268 - 0003

Name*

Address*

MM slash DD slash YYYY

Were you referred by someone?*

Do you have a Primary Care Physician?*

Do you have an Advance Directive?*
Do you give consent for CVC have permission to view your prescription history from external sources?*
Can we share your prescription information with other medical providers?*
Can we release medical record information to the insurance company to process the claim?*
Can we release medical records information to providers listed in your chart?*
Can we Electronically Send and Receive Medical Records through Integrated Data Exchange?*
Race*

Insurance Information

Name
MM slash DD slash YYYY
Address

Flu Vaccine*
MM slash DD slash YYYY
Pneumonia Vaccine*
MM slash DD slash YYYY
Smoking / Tobacco Use*
Alcohol Use*
Recreational Drug Use*
Are you sexually active?*
Father

Mother

Brother

Sister

Child
List ALL medications you take, including over the counter (OTC) medications and vitamins [Click the + sign on the right to add additional medications]
Include specific doses and when taken. If you don't know, please contact your pharmacist.
Personal Medical History (Please choose ALL that apply)

Surgical History

MM slash DD slash YYYY

Notice of Privacy and Authorization Form

I acknowledge that if a copy of my personal information is needed for reasons other than immediate treatment, I hereby authorize the release of information to the following: family member, providers, or friends acting on my behalf:

Please choose one of the following options below*
Legal Consent*


Authorization for Treatment / Release of Information


Consent to Treatment: The patient and/or authorized representative d hereby consent to any and all
treatments which may deem advisable by the physician or Tri County Health LLC., Inc. Patient consent to Rx
verification Electronic Data Health Exchange (eEHX Interoperability). Each procedure and diagnostic study will
be discussed in detail with patient before procedure is performed. Additional consent will be required at the
time of procedure.


Assignment of Insurance Benefits: I assign payment directly to Tri County Health LLC, Inc. Insurance
Benefits otherwise payable to me, I understand that I am financially responsible got charges paid by this
assignment. I will assist in the collection of my insurance payment got any claims unpaid after 30 days. If after
45 days the claim remains unpaid, I understand the balance will be due from me.


Medicare Patients: I certify that the information given by me in applying for payment under the XVIII
of the Social Security is correct. I authorize Tri County Health LLC, to release to the Health Care Financing
Administration of its intermediaries any information needed for this related Medicare claim, I hereby
authorize payment directly to Tri County Health LLC., Inc for medical benefits otherwise payable to me as
beneficiary of the Medicare Program and such other payments as may be due by other third party payers. I
agree to execute such documents as may be necessary to apply for and obtain payment. I understand that
such services as, but not limited to routine testing may be covered by Medicare unless the physician provides
medical necessity.


Patient/ Guarantor Agreement: I understand that Tri County Health LLC, is not in business expanding
credit. Therefore, it is the policy of Tri County Health LLC. To require payment in full at the time of service. If
unable to pay due balance in full at the time of service, I agree to make prior arrangements with the Billing
Department.



I understand that I am financially responsible for my/ the patient’s account with Tri County Health LLC.
Regardless of my insurance benefits, I authorize copies of this form to be valid as the original.



Legal Consent*

Patient Consent for Use and Disclosure of Protected Health Information


I hereby give my consent for Tri County Health LLC to use ad disclose PHI about me to carry out
treatment, payment and health care operations (TPO).


I have the right to review the Notice of Privacy Practices prior to signing this consent. Tri County Health
LLC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices
may be obtained by forwarding a written request to Tri County Health LLC.


With this consent, Tri County Health LLC may call y home or other alternative location and leave a
message o voice mail or e-mail/text me, publish my records to patient portal in reference to any items that
assist the practice in carrying out TPO. This may include appointment reminders, insurance issued, and
concerns with my clinical care, such as laboratory test results, diagnostic imaging, Integrated Data records
Exchange (eEHX), Marketing, etc.


With this consent, Tri County Health LLC, may mail to my home or other alternative location any items
that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements if
they are marked “Personal and Confidential”.


With this consent, Tri County Health LLC, may text or e-mail to my home or alternative location, any
items that assist the practice in carrying out TPO, such as appointment reminders, patient statements, and
medical records. I have the right to request that Tri County Health LLC restrict how it uses or discloses my PHI
to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound
by this agreement.


By agreeing to this form, I am consenting to allow Tri County Health LLC to use and disclose my PHI to carry out TPO.


I may revoke my consent in writing except to the extent that the practice has already made disclosures
based upon my prior consent. If I do not sign this consent, or later revoke it, Tri County Health LLC, may
decline to provide treatment to me.



The below questions are required to be asked by State Law for Census

Sexual Orientation*

Gender Identity*

This field is for validation purposes and should be left unchanged.

A CVC FL Company

Accepting New Patients Wildwood, FL & Summerfield, FL

  • About
  • Services
  • Providers
  • Contact
  • Careers

(352) 268-0003

reception@tricountyhealthllc.com

 Open: 8am – 5pm Monday – Friday

17190 SE 109th Terrace Road
Summerfield, FL 34491

 

4056 FL-44

Wildwood, FL 34785

(Freedom Plaza)

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