DRIZ01 Patient Paperwork

Heads up: This form includes fields managed by your provider (marked with 🔒). Some appear empty — if you were expecting these to be pre-filled, please contact your provider for an updated form link.

Patient Information

Please answer all questions to the best of your ability. PLEASE do not leave any blanks.

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

📅

Date

Last 4 digits of Social Security Number *

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone Number

Please enter a valid phone number.

Cell Phone Number *

Please enter a valid phone number.

Email *

example@example.com

Marital Status *

Single

Married

Separated

Divorced

Widowed

Sex *

Male

Female

Race *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Ethnicity *

Hispanic/Latino

Non-Hispanic/Latino

Place of Employment *

Employer's Phone Number *

Please enter a valid phone number.

Insurance Information

Primary Insurance

Policy #

To expedite your benefits confirmation, please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

To expedite your benefits confirmation, please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Is the policy holder DIFFERNET than the patient?

Yes

Policyholder Info (if other than patient)

Policy Holder Name

First Name

Last Name

Policy Holder Date of Birth

📅

Date

Policy Holder Employer

Policy Holder Relationship to Patient

Do you have secondary insurance?

Yes

Secondary Insurance

Secondary Policy #

To expedite your benefits confirmation, please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

To expedite your benefits confirmation, please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Is the SECONDARY policy holder DIFFERNET than the patient?

Yes

Policyholder Info (if other than patient)

Secondary Policy Holder Name

First Name

Last Name

Secondary Policy Holder Date of Birth

📅

Date

Secondary Policy Holder Employer

Secondary Policy Holder Relationship to Patient

Assignment of Benefits

Name of Insured

First Name

Last Name

I hereby assign all medical benefits to which I am entitled to "Infectious Diseases Associates of North Central Florida, LLC".

This applies for all insurance carriers, including Medicare, private insurance and any other health/medical plan, this form will be kept on file.

I understand it is my responsibility to report any changes with insurance.

I authorize the release of any medical or pertinent information necessary to obtain these benefits to my insurance carrier, or any other medical entity for continued medical care.

I understand that I am financially responsible for any amount not covered by my insurance.

(Note: On any balance on your account after 90 days, including those that insurance has not paid, collection action will be taken. We realize that emergencies do arise and may affect the timely payment of your account. If this does occur, please contact us promptly for assistance with managing your account.)

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or Guardian *

HIPAA Compliance Patient Consent Form

Our notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature, indicating you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You might have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The practice has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

Please list any "Authorized Representative", include name, relationship to patient & phone number

	Name	Relationship to Patient	Phone Number
1.
2.
3.
4.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or Guardian *

Patient’s Care Team

Primary Care Physician

Primary Care Physician Phone Number

Please enter a valid phone number.

Referring Physician

Referring Physician Phone Number

Please enter a valid phone number.

Do you see any other Specialist or Physicians?

Yes

Specialist or Physicians

	Physician Name	Reason for this Physician
1.
2.
3.
4.

Do you go to a Wound Care Center?

Yes

If so, which one?

Pharmacy

Name of Pharmacy

Pharmacy Phone Number

Please enter a valid phone number.

Address (intersection, main road, etc)

Recent Hospitalizations

Have you been hospitalized recently (this includes admissions to the hospital & ER visits)?

Yes

Recent Hospitalizations (include admissions to the hospital & ER visits)

	Hospital	Reason	Approximate Date
1.
2.
3.
4.

I attest that the above information is true to the best of my knowledge and belief.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or Guardian *

Medical History

Please check all of the following which pertain to your medical history

Check all that apply

Alcoholism

Allergies/Hay Fever

Anemia

Anxiety

Asthma

Atrial Fibrillation

Blood Transfusion

CAD

Cancer

Cardiovascular Disease

CHF

Chronic Renal Insufficiency

Cirrhosis

Colitis

Colon Polyps

COPD

CRF

Crohn’s Disease

CVA

Diverticulitis

Depression

Diabetes Type 1

Diabetes Type 2

DVT

Epilepsy

Fracture

GI Bleed

Gastrointestinal Disease

GERD

Gout

Heart Murmur

Hepatitis

High Cholesterol

HIV

Hyperlipidemia

Hypertension

Hyperthyroidism

Hypothyroidism

Joint Pain

Kidney Infections

Kidney Stone

Ulcer Disease

Lung Disease

Lyme’s Disease

Migraines

Multiple Sclerosis

Obesity

Old MI

Osteoarthritis

Osteomyelitis

Osteoporosis

Peripheral Vascular Disease

Pneumonia

Pulmonary Disease

Rheumatic Fever

Rheumatoid Arthritis

STD

Thyroid Disease

TIA

Tuberculosis

Venereal Disease

Liver Disease

Emphysema

Back Pain

Other Medical History not listed above

Surgical Procedures

Have you had any surgeries in the past?

Yes

Surgical History

	Check all that apply	Details
Appendectomy
Breast Lumpectomy
Cataract Surgery
Colon Surgery
Gall Bladder
Heart Surgery
Hemorrhoids
Hernia
Hysterectomy
Laparoscopy
Mastectomy-type which side in Details column
Myomectomy
Oophorectomy
Tonsil/Adenoidectomy
Tubal Ligation
Endometrial Ablation

Other Surgical History not listed above

Family History

Family History

	Check all that apply	Details
Adopted
Unknown Paternal History
Unknown Maternal History
Alcoholism
Anemia
Anxiety
Asthma
Birth Defects
CAD
Cardiovascular Disease
CHF
Cancer: State Type in Details Column
Congenital Anomaly
COPD
Crohn’s Disease
Depression
Epilepsy
GERD
High Cholesterol
Hyperlipidemia
Hypertension
Hypothyroidism
Kidney Disease
Liver Disease
Multiple Births

Medications

Are you currently taking any medications?

Yes and I would like to list them here

Yes and I would like to provide a list to the front desk when I come for my appointment

I do not take any current medications

Please list all current medications

	Name of Medication	Dose	Frequency	Why are you taking this?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

I attest that the above information is true to the best of my knowledge and belief.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or Guardian *

Allergies

Do you have any known allergies?

Yes

No known allergies

*List all allergies and the reactions you experience*

	Allergy	Reaction
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

I attest that the above information is true to the best of my knowledge and belief.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or Guardian *

Preventative Care

Current smoking status

Never smoked

Current smoker

Former smoker

Length of smoking

# of packs per day

Date quit smoking

Second hand smoke exposure?

Yes

Do you vape?

Yes

Alcohol use

Yes

What type? (Beer, wine, liquor)

How often?

Caffeine use

Yes

What type? (Coffee, tea, soda)

How often?

Do you use recreational drugs?

Yes

Do you use sun protection?

Yes

Do you have tattoos?

Yes

Are you sexually active?

Yes

Have you been physically abused?

Yes

History of Domestic Violence?

Yes

Do you wear your seatbelt?

Yes

Do you have piercings?

Yes

If the following questions do not apply to you for any reason, please leave them blank.

THE FOLLOWING QUESTIONS REQUIRE DATES FOR THE ANSWERS. If you do not know the EXACT date, please use and estimate of the 1st of the month for your answer. (Example: you're not sure what day EXACTLY you received your flu shot, but you know it was in November, so your answer would be November 1st)

Date

Flu Shot

Pneumonia Vaccine

Pneumonia Vaccine Rcvd (Type YES or NO in date column)

Date of last HIV test

Mammogram

Pap Smear

COVID Vaccine

Advanced Care Planning

Please answer the following questions:

Do you have a Healthcare Power of Attorney?

Yes

Refuse to Answer

Do you have a Surrogate Decision Maker?

Yes

Refuse to Answer

Whom is your named Surrogate Decision Maker?

First Name

Last Name

Emergency Contact

In case of an Emergency, please list a person, which we may contact

	Name (First & Last)	Phone #	Relationship
1.
2.

I attest that the above information is true to the best of my knowledge and belief.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or Guardian *

IV Antibiotic & Home Health Care

Are you currently receiving IV antibiotics?

Yes

Do you have Home Health Care Services?

Yes

What is the name of the Home Health Company?

If you are doing IV antibiotics at home with home health care services, are you receiving the IV antibiotics via an Infusion Pharmacy?

Yes

What is the name of the Infusion Pharmacy? (If you don’t know the name of the Infusion Pharmacy, any information about the be greatly helpful!)

Financial Policy

Thank you for choosing Infectious Diseases Associates of North Central Florida, Dr. Ivan Soosaipillai, as your healthcare provider. We are committed to providing you with the best medical care and building a successful relationship between the provider & patient. Your understanding of our Practice Financial Policy and payment for services are an important part of this relationship. For your convenience, this document discusses a few of the commonly asked financial questions. If you need further information, please ask to speak to our Practice Manager.

When are payments due?
All copay, deductibles and past due balances are due at the time of check in unless previous arrangements have been made.

How may I pay?
We accept payment by cash, check, VISA, Mastercard, Discover and AMEX. Returned checks will incur a $45.00 service charge. It is then required to bring cash or money order to cover the amount of the check plus the fee to pay the balance. Your account balance, must be ZERO, prior to being seen by the provider.

Will you bill my insurance?
Yes. Insurance is a contract between you and your insurance company, we will bill your primary insurance carrier on your behalf. To properly bill your insurance company, it is imperative that you disclose all insurance information, including primary and secondary insurance, as well as any change of insurance information.

Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits.

What is my financial responsibility for services?
Our office staff will notify you of your financial responsibility. This amount is provided to us by your insurance company.

I have read and understand the above financial policy.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Appointment Policy

Here at Dr. Ivan's office, we believe that everyone's time is valuable. Our goal is to provide quality individualized medical care in a timely manner. "No shows" and late cancellations inconvenience those individuals who need access to medical in a timely manner. We would like to inform you of our office policy regarding missed appointment. This policy enables us to better utilize available appointments for our patients in need of medical care.

As a courtesy to our patients we call the patient minimum of 48 hours prior to the scheduled appointment as a reminder.

Cancellation/No show policy
In order to be respectful of the medical needs of other patients, please be courteous and call us promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel your scheduled appointment, we ask that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely medical care.

If an appointment is not cancelled with proper notice, you may be charged a fee of $25. Your insurance company will not cover this charge. Insurance companies only consider covering costs for services that were actually rendered.

What is a "no-show"?
The term "no-show" is for patients who miss an appointment without calling to notify the office in advance.

How do I cancel my appointment?
Our practice firmly believes that a good physician/patient relationship is based upon understanding, and good communication. To cancel appointments, please call 352-622-2020. If you do not reach one of our team members, you may leave a message. You can also email us at idaocala@gmail.com to notify us.

If you would like to reschedule your appointment, please leave your phone number. We will return your call, and give you the next available appointment time.

Acknowledgment
I understand the above appointment policy. Any cancellations not made with appropriate notice would be charged to me personally.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Authorization for the Release of Protected Health Information

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

📅

Date

Social Security Number

1. I, the above named patient or Legal Representative, hereby Authorize

2. Name of Provider/Office

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

3. To release and/or discuss the following information

Complete Record/No Restrictions

Outpatient care

Inpatient Care

Radiology Results

Lab Results

Office Visit Notes/Progress Notes Treatment Plan/Office Visit Notes/Progress Notes

Other

4. If my record contains the following information, it is also to be release if CHECKED below

Substance Abuse

Mental Health Treatment

Testing or Treatment HIV/STD Testing or Treatment

5. Release my records to:
Infectious Disease Associates of North Central Florida
Dr. Ivan Soosaipillai
3306 SW 26th Ave Ocala, FL 34471
P: 352-622-2020 F: 352-622-2025

6. Signature

I have carefully read and understand the above information, and do herein consent to its disclosure. I am aware that information regarding my medical condition will be release to the office named above. I understand that, if the person or organizations that I authorize to receive my protected health information are not subject to federal and state health information privacy laws, subsequent disclosure by such person or organization may not be protected by those laws. I understand that this consent is subject to revocation, in writing, at any time, unless action based on it has already begun.

This authorization expires

6 months

1 year from today's date or upon the following specified date

No Expiration

Authorization to expire on

📅

Date

I authorize the use of a copy of this form for the disclosure of the information described above:

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Relationship

Don't forget to bring your list of medications to your appointment.
Pelase include the name of the medication, dose, frequency
and why you are taking the medication.

We look forward to seeing you!

Please complete the required fields

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