ENGLISH - Intake Form (New Patient / Annual

ROSABEL M BENCOMO M.D P.A

6840 SW 40th Street, Suite 209, Miami, FL 33155

Telemedicine: (786) 800-2430 | Office: (786) 222-8807 | Fax: (305) 763-8379

Visit Type *

Office Visit. Telemedicine. (By Computer or Phone)

Please select who is requesting Our Services? *

The Services are for me (I'm the Patient). I'm the Legal Guardian of the person needing Services.

Legal Guardian Information *

Patient Full Name *

Name Last Name

Patient Date of Birth *

month / day / year

Do you have MEDICARE as Primary Health Insurance? (65 or older or disability). *

Yes. No.

Advance Beneficiary Notice of Noncoverage (ABN)

G. OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the D. the Telemedicine Service listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D. the Telemedicine Service listed above, but do not bill Medicare. MDteleMe may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don’t want the D. the Telemedicine Service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

MDteleme Warning!

You have chosen Option 3. Meaning...

You DO NOT WANT to use the D. Telemedicine Service listed above.

Patient Phone Number *

Email

(An email Address is required if you would like to be registered for Virtual Consultation)

Address *

Street

City State

Zip Code

Gender *

Male Female Other Rather not say

Weight and Height *

Photo of your ID (please take it readable)

Photo of your Insurance Card (if any)

RELEASE OF HEALTH INFORMATION

In case you cannot reach me, I authorize an RMB / MDteleMe representative to try to contact me, using my Emergency Contact and provide strictly necessary information related to the immediate care of my medical condition.

Do you have an Emergency Contact? (in case we cannot reach at you) *

Yes No

Please note that providing Emergency Contact information would facilitate faster communication with you.

Emergency Contact Information *

Pharmacy (medications will be electronically sent to the pharmacy)

Pharmacy Name/Type

Address

City State

Zip Code

Marital Status

Single Married Divorced Legally Separated Widowed

Ethnicity

Hispanic/Latino Black/African American White Asian Native American Other Rather not say

Do you use any of the following? Check all that applies.

Alcohol Tobacco Caffeine Recreational Drugs

Medication Allergies? *

No Yes

Which medication are you allergic to?

Antibiotic Pain Medication Seizure Medications Sulfa Local Anesthetics Others (Discuss with Provider)

Specify which Medication, you are allergic to:

Allergies to Other Substances, Medications or Food

No Yes

Specify which other Medication, Substances or Food you are allergic to:

Type of Allergic Reaction

Rash Shortness of Breath Swelling Anaphyilaxis Other (Discuss with Provider)

Which other reactions you've had? Please Describe...

Medical Condition (Do you have any Chronic Medical Condition?) *

No Yes

Select which Medical Condition

Diabetes High Blood Pressure Thyroid Heart Asthma Mental illness (anxiety, depresion, bipolar, ...) Anemia Seizures Other(s) (discuss with provider)

Describe which other Medical Condition...

Medications, are you taking any? *

No Yes

Which Medication(s)?

Any Surgeries? *

No Yes

Which Surgeries?

Describe which other Surgeries you've had.

Have you had a Colonoscopy done? Please answer if you are 50 years or older. A Colonoscopy is a procedure performed by a gastroenteorologist for an early colorectal cancer screening.

No Yes

When did you have the Colonoscopy done? Check all that applies.

Less than 10 years ago. More than 10 years ago. I was told it was Normal, I need to repeat in 10 years. I was told I need to repeat the procedure in 3 to 5 years. (This is a recommendation doctors do if polyps are found)

When did you have a Pap Smear done? (Recommended for 21 years and older)

Less than 12 Months. More than 12 Months. I'm older than 21 years and I have never had a Pap Smear.

Was the Pap Smear Result Normal?

Yes No

Have you had any Mammography? (Recommended for 40 years or older)

Less than a Year. More than a Year. I'm 40 years or older and I have never had a Mammogram.

Was the Mammography Result Normal?

Yes No

Mother, Alive? *

No Yes

Mother, Any Medical Condition?

No Medical Condition High Blood Pressure Diabetes Heart Thyroid Cancer Respiratory Chronic Condition Other

Any other Medical Condition not listed before?

Father, Alive? *

No Yes

Father, Any Medical Condition?

No Medical Condition High Blood Pressure Diabetes Heart Thyroid Cancer Respiratory Chronic Condition Other

Any other Medical Condition not listed before?

Any Family History of Cancer? *

No Yes

Explain which type of Cancer and family member...

Terms and Conditions (you need to read and accept to receive services)

Signature (Please Sign if you agree to Our Terms and Conditions) *