Patient Demographic & Consent Form

Patient Information

Emergency / Next of Kin / Parent / Guardian / Change Contact Information

Contact Information (if different from above)

Notices Acknowledgement

By signing below, I acknowledge the following documents * and have also been notified that they can be obtained on the website:

  1. Notice of Privacy (see below)
  2. Consent for Treatment (see below)
  3. Financial Responsibility (see below)
  4. HIPAA and Authorization (see below)
Please use your mouse (on a computer / laptop) or your finger (on a tablet or phone) to sign.


This Notice, outlines the ways in which the Prestige Medical Concierge (“Company”), may use and disclose medical information about you, which discloses your individual identity.

Company protects you with respect to disclosure of your Protected Health Information by:

  • limiting who may see, use and further disclose this information, and
  • informing you of our legal duties and your legal rights respecting this information.

This Notice and the referenced Privacy Policy and Use and Disclosure Procedures are required by a new federal regulation known as the “Privacy Rule,” applying to as a “provider” and, in some cases, as an “indirect provider” and/or “business associate”.

This Notice also outlines Company’s obligations and your rights regarding the use and disclosure of Protected Health Information. Company is required by law to maintain the privacy and security of your Protected Health Information and to notify you promptly following a breach of unsecured Protected Health Information, and to comply with the terms of the Notice that is currently in effect. Your information will not be used or shared other than as described in this Notice unless you provide written approval to do so. If you do provide written approval, you may change your mind at any time by written request.

This Notice summarizes the HIPAA privacy rights and obligations of all parties who have access to your Protected Health Information, including providers of health care services who have direct treatment relationships with you.

Administration of all your rights is placed with the Privacy and Security Officer designated herein, at the end of this Notice (“Privacy and Security Officer”).


For Treatment (as Provider). We may use Protected Health Information about you in your treatment. This may include uses and disclosures to provide, coordinate, manage or supplement your health care and related services.

For Payment (as Provider). We may use and disclose Protected Health Information about you to bill or collect for the treatment and services we provide.

For Healthcare Operations (As Provider). We may use and disclose Protected Health Information about you in performing business activities called “healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation certification, licensing or credentialing activities.

As Required by Law. We will disclose relevant Protected Health Information about you when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health Information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Law Enforcement. We may release Protected Health Information about you if asked to do so by a law enforcement official such as: in response to a court order, subpoena, warrant, summons or similar process.

Health Oversight Activities. We may disclose Protected Health Information about you to a health oversight agency for oversight activities authorized by law.

National Security and Intelligence Activities. We may release Protected Health Information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

To your family and friends. We must disclose your health information to a family member, friend or other person to the extend necessary to help with your healthcare or payment for your healthcare, but only if you agree that we may do so.


You have the following rights regarding Protected Health Information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and obtain a copy of Protected Health Information about you, with limited exceptions. You may request that we provide copies in a format other than photocopies unless we cannot practically do so. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

Right to Amend. You have the right to request an amendment of Protected Health Information about you for as long as the information is kept by or for the Company. To request an amendment, your request must be made in writing and submitted to the Privacy and Security Officer. In the written request, you must provide a reason that supports your request.

Right to an Accounting of Disclosures. You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities. You can ask for a list of the times we have shared your Protected Health Information for six (6) years prior to the date you ask, who we shared it with, and why.

Right to Request Restrictions. You have the right to request that we place additional restrictions or limitation on our use or disclosure of your Protected Health Information. We are not required to agree with these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Right to Request Confidential Communications. You have the right to request that we communicate with you about Protected Health Information about you by alternative means or at alternative locations. To request confidential communications, you must make your request in writing to the Privacy and Security Officer. Your request must specify how or where you wish to be contacted.

Right to Copies of This Notice. You have the right to paper and electronic copies of this Notice. You may ask us to give you a copy of this Notice at any time.


We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. All material changes or revisions to the Notice will be prominently posted on the website by the effective date of such changes. The new notice will be available upon request, in our office, and on our web site.


If you believe your privacy rights as described in this Notice have been violated, you may file a complaint with Company or with the Secretary of the U. S. Department of Health and Human Services. To file a complaint with Company, contact the Privacy and Security Officer who will provide you with a copy of the complaint procedure upon request. All complaints must be submitted in writing. You will not be penalized for filing a complaint.


If you have any questions about this Notice, please contact the Privacy and Security Officer.

The following individual is designated by Company for purposes of HIPAA Privacy compliance:

Privacy and Security Officer: Dalia Elizalde, T:772-241-7880


During the course of patient care, I may request and authorize the disclosure of my individually identifiable health information in writing as described below.

(a) To a Named entity

(b) Persons/organizations authorized to make requested disclosure of the information

(c) Providers/organizations to whom the disclosure may be made

(d) Specific description of information to be disclosed (including descriptive date(s))

(e) Specific purpose of the disclosure

(f) This authorization will expire (indicate date, or an event relating to you personally or to the purpose of the authorization)

Protected Health Information (“PHI”) may include information/documents regarding medical treatment of the patient including, but not limited to, diagnosis, procedures, treatment plans, appointments and test results; account and billing information including, but not limited to, account balances, payments and payment arrangements, insurance claims status, and third-party financing.

I understand that the Health Insurance Portability and Accountability Act of 1996, and its implementing regulations (“HIPAA”) govern the terms of this Authorization.

I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to the persons/organizations identified in item (b) below providing the information. This right is described in Company’s Notice of Privacy Practices.

I understand that I am not required to sign this Authorization and my execution of this Authorization is not condition for treatment.

I understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipient listed above and, in that case, will no longer be protected by HIPAA. However, sale of PHI or use of the information for marketing by a third party that renumerates the provider should be explicitly stated.

HIPAA regulations authorize the release of PHI to other providers for the purpose of treatment, obtaining payment from third party payers, and the day-to-day healthcare operations of Prestige Medical Concierge. Other than those releases authorized by HIPAA, PHI will only be released to persons/organizations listed on this authorization and stated purpose.

This authorization shall be effective for twelve (12) months from the date of authorized signature