IRMC Endocrinology
880 37th Place, Suite 105
Vero Beach, FL 32960
772.562.9707 PHONE
772.562.9794 FAX
www.irmcphysicians.com
Welcome
Thank you for choosing Indian River Medical Center Physician Practices where we provide the right care right
here. Whether you need an annual check-up, surgery, or have an injury that needs urgent care, you will find
caring and compassionate primary care providers, specialists and staff members who will take the time to
meet your needs.
Office Policies
Initial Visit: Please complete the enclosed paperwork and bring with you, along with all the bottles of
medications you are currently taking. We require your health insurance cards and a photo identification card.
Past medical records are helpful at an initial visit, so you should request them from your doctors. We also
require that you come in AT LEAST 20 MINUTES prior to your appointment to allow adequate time for our
staff to prepare your patient record.
Follow-up Visit: To ensure your safety and the accuracy of your medical record, it is important to provide an
up-to-date list of all medications, vitamins and herbal supplements at each visit. Please list the amount of the
medication you are taking (the dosage) and how often you are taking it.
Refills: Please call your pharmacy to see if the prescription has been filled prior to calling the office. Patients
should request prescriptions at least 24 hours in advance from the pharmacy. The pharmacy will fax the
request to our office and we will in turn reply to their request. Prescriptions will not be filled on weekends or
after 5:00pm Monday – Friday. After 12 months, a medical history update and exam are necessary for any
refills. Antibiotics, steroids, and all addictive medications cannot be refilled without an office visit.
Referrals: If a referral has been made to another physician and you do not hear from that physician’s office
within 2-3 days, please contact our office so that we can assist you in getting your appointment scheduled.
Laboratory Testing: Many times your physician will ask that you have “fasting” blood work .The definition of
fasting is: nothing after midnight except water or medications. When the doctor orders blood work, please
have it done no less than 1 week prior to your next appointment so that your lab results can be discussed
with you when you come in.
Hospitalist Services: Our physicians work with the hospitalist service at IRMC when their patients require
hospitalization. A hospitalist is a physician specialist in inpatient care who provides 24/7 care while you are
in the hospital. We advise that you call our office when admitted so that we may follow on your progress
during your hospitalization. Our collaboration with the hospitalists allows for a continuity of care and
availability during office hours.
After hours: Bringing your concerns to our attention during office hours will ensure the problem is dealt
with sooner and a prompt follow-up is scheduled. For urgent matters, you should go to the Emergency
Department for any medical emergencies.
The Right Care Right Here
IRMC-Physician Practices
Patient Registration Form
Name (Last, First, MI)
How did you hear about us?
□ TV
□ Friend/Family
Mailing Address
Today’s Date
□ Internet
□ Newspaper
Second Address (if applicable)
Emergency
Contact
Financially
Responsible Party
Patient Information
Social Security Number
Current Home Phone
City
Date of Birth
□ Preferred
State
Zip
State
Zip
Gender
Marital Status
□ Male
□ Single □ Married □ Divorced
□ Female
□ Widowed □ Separated □ Partner □ Other
□ Preferred Work/Other Phone
□ Preferred Email Address
Cell Phone
(
)
(
)
(
)
Employment Status
Employer Name
□ Full Time □ Part Time □ Not Employed
□ Retired
□ Student
Race
□ Asian □ Black/African American □ Caucasian □ Hispanic □ Native American/Alaskan Native
□ Native Hawaiian/Pacific Islander □ Multi-Racial □ Unknown/Refused
Employer Address & Phone
Referring Physician’s Name
Ethnicity
Preferred Language
□ Latino/Hispanic
□ English
□ Non-Latino/Non-Hispanic □ Spanish
□ Unknown/Refused
□ Other ____________________
Primary Care Physician’s Name (Check if same as Referring Physician □)
Local Pharmacy Name and Specific Location:
Mail Order Pharmacy:
Is patient responsible party/guarantor? □Yes □No (If you are over the age of 18 and not in the care of an institution you are the guarantor as you are the
person financially responsible for any charges you may incur during your visit)
Name
Address
City/State/Zip
Relationship to Patient
Home Phone
(
□ Preferred
)
Cell Phone
(
□ Preferred
Social Security Number
)
Name
Home Phone
□ Preferred
Address
(
)
City/State/Zip
Cell Phone
□ Preferred
(
)
Relationship to Patient
Primary Insurance Company
Policy #
Patient’s Relationship to Insured
Insurance
Information
City
□ Radio
□ Other
□ Physician Referral
Group#
Subscriber’s Full Name (If other than patient)
Subscriber’s Date of Birth
□ Self □ Spouse □ Child □ Other_______________________________________
Subscriber’s Social Security #
Gender
Subscriber’s Employer name (if self-employed, company name)
□ Male □ Female
Secondary Insurance Company
Policy #
Patient’s Relationship to Insured
Group#
Subscriber’s Full Name (If other than patient)
Subscriber’s Date of Birth
□ Self □ Spouse □ Child □ Other_______________________________________
Subscriber’s Social Security #
Gender
Subscriber’s Employer Name (if self-employed, company name)
□ Male □ Female
Workers’ Comp/
Auto Information
Is this visit the result of an accident?
□ Employment
□ Automobile
□ Other
□ Yes
□ No
Claim Adjuster / Contact Name
Insurance Address
City
State
Date of Accident: (mm/dd/yyyy)
Claim No.
Phone No.
Insurance Name
(
Zip
)
Phone No.
(
)
By signing below, I acknowledge that the information I provided is correct to the best of my knowledge.
Patient Signature: ___________________________________________________________________________
Date: ______/______/______
Guarantor Signature: ________________________________________________________________________
Date: ______/______/______
RELEASE OF INFORMATION
I hereby authorize IRMC-Physician Practices to use and disclose my health information for all purposes necessary for treatment, payment and health
care operations, including but not limited to release of my information requested by my insurance company (or carrier) and any information necessary
for treatment purposes.
Patient Signature: ______________________________________________________________________
Date: ______/______/______
ASSIGNMENT OF INSURANCE
I hereby authorize my insurance benefits to be paid directly to Indian River Health Services; I understand I am financially responsible for non-covered
services. I authorize the release of any medical or other information necessary to process insurance claims on my behalf.
Patient Signature: _______________________________________________________________________
Date: ______/______/______
FINANCIAL LIABILITY
I have been provided a copy of the IRMC-Physician Practices financial policies and agree to the specified terms. I hereby agree to pay all charges due
(or become due) to IRMC-Physician Practices for care and treatment, including co-payments and deductibles provided under my plan. Benefits, if any,
paid by a third party will be credited on account. I understand that I will be responsible for charges if any of the following apply:
My health plan requires prior authorization or referral by a Primary Care Physician (PCP) before receiving services at IRMC Physician Network
and I have not obtained such an authorization or referral or I receive services in excess of such authorization or referral, and/or
My health plan determines that the services I received at IRMC-Physician Practices are not medically necessary and/ or not covered by my
insurance plan, and/or
My health plan coverage has lapsed or expired at the time I receive services at IRMC Physician Practices, and/or
I have chosen not to use my health plan coverage
Patient Signature: _______________________________________________________________________
Date: _____/______/______
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
We keep a record of the health care services we provide you. We will not disclose your record to others unless you direct us or unless the law
authorized or compels us to do so. You may see your records or get more information about them by contacting IRMC Medical Records Department.
Our Notice of Privacy Practices describes in greater detail how your health information may be used and disclosed, and how you can access your
information.
By my signature below I acknowledge receipt of the Notice of Privacy Practices.
Patient Signature: _______________________________________________________________________
Date: ______/______/______
MEDICARE PATIENTS ONLY
PLEASE ANSWER QUESTIONS BELOW
Dear Medicare Patient:
As a direct result of mandated Medicare Secondary Payer (MSP) regulations, we are required to gather the following information to determine if
Medicare is your primary insurance.
1. Is the Illness/injury due to an automobile accident, liability accident, or Workers’ Compensation?
2. Is the illness covered by the Black Lung Program or Veterans Administration?
3. If under 65, are you a renal dialysis patient in your first 30 months of Medicare entitlement?
4a. If under age 65, is your Medicare coverage due to disability?
4b. Is patient covered by a large group health plan through patient’s employer or Spouse’s current employer?
5. If 65 and over is patient covered by Employer Group Health Plan through patient’s or Spouse’s current employer?
Patient Signature: _______________________________________________________________________
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ No
□ No
□ No
□ No
□ No
□ No
Date: ______/______/______
IRMC-PHYSCIAN PRACTICES
VERBAL AUTHORIZATION
TO DISCUSS HEALTH AND MEDICAL INFORMATION
PATIENT NAME: ______________________________________ DATE OF BIRTH: __________________
PARENT OR LEGAL GUARDIAN: __________________________________________________________
If I am not present, I authorize IRMC Physician Practices and staff to disclose my
relevant health information with the family and/or friends named below.
I decline to name family members and/or friends who my providers and staff may
discuss my health information with at this time. However, I understand that I can
always verbally authorize providers and staff to discuss health information with
family members and/or friends or I may complete form at a later date.
Name: _________________________________ Relationship: _____________ Phone#:_____________
Name: _________________________________ Relationship: _____________ Phone#:_____________
Name: _________________________________ Relationship: _____________ Phone#:_____________
Name: _________________________________ Relationship: _____________ Phone#:_____________
I understand that this authorization is valid and in effect until such time as I withdraw it in writing
or in person, or one year following date of signature.
I understand that I can revoke, update, or change this verbal authorization at any time in writing. The
termination to verbally release health and medical information is effective on the date the physician
office receives it. It does not apply to any information released prior to the date of receipt of the
written termination.
________________________________
________________________________
________________
Signature of patient or legal representative/guardian
(Attach copy of documentation of authority)
Authority or relationship of representative
Date
Provider Based Billing Information
What does “Provider Based designation mean?
This is a Medicare status for hospitals and clinics that comply with specific Medicare regulations.
Medicare has determined that IRMC has met these regulations and has now been designated as
such. This status requires that IRMC bill Medicare in two (2) parts.
What does “Hospital Services” mean on my bill? I didn’t go to the hospital for my
care.
Medicare allows hospitals to bill for both the physician and hospital outpatient services, in two
separate charges, when a patient is seen in a physician office owned by a hospital. Most hospitals
have opted to utilize this approach to billing.
Your billing statement includes two separate charges for each visit – one for the physician’s
services (Part B) and another for the hospital outpatient facility and technical services (Part A).
The hospital outpatient facility and technical services charge will be clearly defined on your bill
under the description “Hospital Services.” We understand this may seem complicated and
apologize in advance for any confusion this may cause.
Will Medicare cover this?
Most Medicare patients will be covered by their supplemental insurance and will not have to pay
more out-of-pocket. Medicare patients without supplemental insurance will pay a small amount.
Patients with health insurance will need to check with their insurance provider to determine what
will be covered by their insurance plan. Cost will vary based on the type of benefit plan you have.
Most patients will not have to pay any additional dollars out-of-pocket.
Estimate of your financial responsibility
Medicare requires that we provide you with an estimate of your Part A and Part B coinsurance
amounts. These amounts will vary based on the type and number of services received.
Estimate of Coinsurance Charges
Part A
Part B
$10 to $34
$2 to $37
Office Visit
$8 to $16
NA
Radiology
$10 to $170
$10 to $35
Cardiovascular Diagnostics
$8 to $43
$2 to $6
Pulmonary Test
*Certain tests and procedures have higher coinsurance amounts due to their complexity.
Why does the Medicare Secondary Payor (MSP) Questionnaire need to be
completed?
As a participating Medicare provider IRMC is required to screen Medicare patients according to the
Medicare Secondary Payor (MSP) rules. At each visit, business services representatives will ask
you the MSP questions. These questions will help to confirm if Medicare or another payer should
process the claim as primary.
What type of questions should I ask my health insurance company?
Ask your health insurance company whether it covers facility charges or provider-based billing. If it
does, ask what percentage of the charge is covered.
Please contact our Patient Financial Services office at 772-794-5611 with any questions you
may have.
_____________________________
Patient Signature
_________________
Date
MEDICARE SECONDARY PAYOR (MSP) QUESTIONNAIRE
Patient Name:____________________________________
Date of Birth_______________________
Physician: _______________________________________
Medical Record #:__________________
I AM ENTITLED TO MEDICARE BENEFITS:
[ ] NO - RETURN FORM TO THE FRONT DESK
[ ] YES - PROCEED TO SECTION I.
SECTION I
Select the ONE statement that is true for you:
[ ] I a o er a d arried… Proceed to section II
[ ] I a o er a d ot arried i ludes ido ed … Proceed to section III
[ ] I a u der , Disa led a d urre tly e ployed… Proceed to section IV
[ ] I a u der , Disa led a d u e ployed…
Disability Date: _____________________ IV Proceed to section
SECTION II
Select the one statement that is true for you:
[ ] My spouse and I are both fully retired
The date of my retirement: _________________________
The date of y spouse’s retire e t: __________________ …Proceed to section V
[ ] I work full or part-time (my spouse is retired) for a company with:
[ ] LESS tha 20 e ployees… Proceed to section V
[ ] MORE tha 20 e ployees… Proceed to section IV
[ ] My spouse works full or part-time (I am retired) for a company with:
[ ] LESS tha 20 e ployees… Proceed to section V
[ ] MORE tha 20 e ployees… Proceed to section IV
SECTION III
Select the one statement that is true for you:
[ ] I a fully retired…
The date of y retire e t: _____________________ ….Proceed to section V
[ ] I work full or part-time for a company with:
[ ] LESS tha 20 e ployees… Proceed to section V
[ ] MORE tha 20 e ployees… Proceed to section IV
SECTION IV
Select the one statement that is true for you: (This does not apply to supplemental plans or employer
plans offered during retirement.)
[ ] YES
I have health care coverage through my employer. [ ] NO
I have health care coverage through someone else. [ ] NO
[ ] YES
IF YES, list name of guardian and relationship:__________________________________________
Proceed to Section V
Patient Name: ___________________________ Date of Birth_____________________
SECTION V
Is this visit related to an injury due to a fall?
[ ] YES - Did the a ide t o ur i … [ ] your ho e [ ] pu li lo atio
Date of Accident:___________________
OR
[ ] other
Is this visit related to an illness/injury due to an automobile accident?
[ ] YES - Date of Accident:_____________________________
RETURN TO FRONT DESK AND PRESENT YOUR AUTOMOBILE INSURANCE CARD.
[ ] NO Proceed to Section VI
SECTION VI
Indicate which statements apply to you.
[ ] I a e titled to Worker’s Co pe satio for this ser i e.
[ ] I am entitled to Black Lung benefits.
[ ] I am entitled VA benefits.
[ ] I am entitled ESRD benefits.
[ ] I am entitled COBRA benefits.
[ ] I a e titled to other Federal e efits. UMWA, Go ’t resear h progra s, Hospi e Please
Explain: _____________________________________________________________________
__________________________________________________________________
Patient Signature ________________________________
Date ________________
Staff Signature ________________________________
Date ________________
Arturo R. Castro, MD, F.A.C.E
Board Certified Endocrinology
Name: ___________________________Date: ___________________________
Review of Systems:
Although many of the following symptoms may not pertain to you, please address each symptom and provide
any “other”.
General/Constitutional:
Chills: O No O Yes
Change in ring or shoe size: O No O Yes
Fever: O No O Yes
Cold intolerance: O No O Yes
Weight gain: O No O Yes
Excessive sweating: O No O Yes
Weight loss: O No O Yes
Excessive thirst: O No O Yes
Change in appetite: O No O Yes
Excessive urination: O No O Yes
Heat intolerance: O No O Yes
Ophthalmologic:
Respiratory:
Double vision: O No O Yes
Shortness of breath: O No O Yes
Glaucoma: O No O Yes
Snoring: O No O Yes
Cataracts: O No O Yes
Coughing: O No O Yes
Pain: O No O Yes
Cardiovascular:
Bulging eyes: O No O Yes
Chest pain: O No O Yes
Blurred vision: O No O Yes
Carotid artery blockage: O No O Yes
ENT:
Calf pain when walking: O No O Yes
Hoarseness: O No O Yes
Swelling of extremities: O No O Yes
Anterior neck pain: O No O Yes
Irregular heartbeats: O No O Yes
Neck mass: O No O Yes
Palpitations: O No O Yes
Enlarged Thyroid (goiter): O No O Yes
Gastrointestinal:
Decreased hearing: O No O Yes
Nausea: O No O Yes
Decreased sense of smell: O No O Yes
Vomiting: O No O Yes
Sort throat: O No O Yes
Indigestion: O No O Yes
Endocrine:
Abdominal pain: O No O Yes
Thyroid disease: O No O Yes
Constipation: O No O Yes
Excessive hair growth: O No O Yes
Musculoskeletal:
Diarrhea: O No O Yes
Cramps: O No O Yes
Difficulty swallowing: O No O Yes
Muscle aches: O No O Yes
Hematology:
Skin:
Enlarged glands: O No O Yes
Change in skin color: O No O Yes
Anemia: O No O Yes
Hair loss: O No O Yes
Bruise easily: O No O Yes
Acne: O No O Yes
Women only:
Dry skin: O No O Yes
LMP___________.
Itching: O No O Yes
Menopause: O No O Yes
Rash/Sores: O No O Yes
Decreased sex drive: O No O Yes
Neurologist:
Kidney stones: O No O Yes
Weakness: O No O Yes
Hot flashes: O No O Yes
Head injury (present or past): O No O Yes
Irregular menses: O No O Yes
Burning or pain in feet: O No O Yes
Missed period: O No O Yes
Headaches: O No O Yes
Men only:
Tingling/Numbness: O No O Yes
Erectile Dysfunction: O No O Yes
Tremor: O No O Yes
Prostate trouble: O No O Yes
Psychiatric:
Slow Urination: O No O Yes
Anxiety: O No O Yes
Decreased sex drive: O No O Yes
Depressed mood: O No O Yes
Infertility: O No O Yes
Difficulty sleeping: O No O Yes
Kidney stone: O No O Yes
Other:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
□ No Known Past Medical History
Past Medical History:
Please checkmark or circle ailments listed below. In case, you don't find any ailment listed then
please enter the details in the area provided for 'Other'.
□ Diabetes
□ Respiratory diseases
□ Eye Diseases such as:
__ retinopathy
__glaucoma
__cataracts
__legally blind
□ Neuropathy
□ Sleep Apnea
□ Gastrointestinal
problems such as:
__stomach problems
__ intestinal problems
__ liver disease
□ Feet ulcers
□ Thyroid disease
□ Heart or Vascular
Diseases such as:
__coronary artery disease
or previous heart attack
__congestive heart failure
__arrhythmias
__peripheral vascular
disease or claudication
__carotid artery stenosis
□ Cholesterol problems
□ Hypertension
□ Genitourinary problems
such as:
__kidney failure
__kidney stones
__erectile dysfunction
__prostate enlargement
□ Neurological problems,
including Stroke
□ Adrenal Gland problems
such as:
__adrenal insufficiency
__adrenal mass
□ Osteoporosis
□ Fractures
□ Other Endocrine
Diseases such as:
__hyperparathyroidism
__hypercalcemia
__hypoparathyroidism
__hypocalcemia
__pituitary disorders
__polycystic ovary
syndrome
__hirsutism (abnormal
hair growth)
□ Cancer
□ Head trauma (ever)
□ Psychiatric problems
such as:
__depression
__psychosis
□ Infertility
Other:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Surgical History:
□ No Known Surgical History
Please list any operations (and dates) you have ever had:
Name of Surgery/ Date
1.________________________________6. _________________________________
2. _______________________________ 7.__________________________________
3. _______________________________ 8.__________________________________
4. _______________________________ 9.__________________________________
5. _______________________________10._________________________________
Current Medications:
□ No Known Current Medication
Please list any Current Medications, Vitamins, Supplements (amounts, times per day):
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________
4. _________________________________________________
5. _________________________________________________
6. _________________________________________________
7. _________________________________________________
8. _________________________________________________
9. _________________________________________________
10. _________________________________________________
(if you need more space please write on the back of this paper)
Family History:
□ No known family history
Please check each ailment in your immediate family and include relationship:
□ Diabetes _________________________
□ Osteoporosis _______________________
□ Thyroid Disease ___________________
□ Hip Fracture _______________________
□ Cholesterol problems _______________
□ Parathyroid/Calcium problems_________
□ Hypertension _____________________
□ Pituitary tumors ____________________
□ Heart Problems ___________________
□ Infertility __________________________
□ Respiratory problems ______________
□ Abnormal hair growth _______________
□ Stomach/Intestinal _________________
□ Cancer ____________________________
□ Kidney diseases ___________________
□ Other: ___________________________
□ Stroke ___________________________
AUTHORIZATION FOR RELEASE OF
PROTECTED HEALTH INFORMATION
Patient Information
Patient Name__________________________________ Date of Birth________ Social Security Number______________
Address_________________________________ City_________________________ State _____ Zip______________
Phone_______________________ Medical Record Number (if known)______________________________
Disclosure From/To
I hereby authorize  IRMC  Other Healthcare Provider ____________________________________ To disclose to:
Recipient Information
Recipient Name___________________________________________
Recipient Address_________________________________City___________________State_____Zip______________
Phone___________________ Special Instructions: ______________________________________________________
Authorization Time Frame and Purpose of Disclosure
This authorization expires in 6 months unless otherwise specified.
Enter expiration date _________________________ or event date______________________________.
The purpose of the disclosure is:
 Continued Care/Dr.____________________________
 Personal Records
 Legal Purpose
 Other (Describe):
 Reimbursement
 Disability
 School
Description of Information to be Disclosed
Is this request for psychotherapy notes?  Yes, then this is the only item you may request on this authorization. You
must submit another authorization for other items below.  No, then you may check as many items below as you need:
 All PHI in medical
record
 History and Physical
 Physician orders
 Intake/output
 Discharge summary
Date(s):
 Operative report
 Cath Lab
 Physician progress
notes
 Rhythm strips
Date(s):
 ED records
 Labor and Delivery
records
 OB nursing
assessment
 Postpartum flowsheet
 Medication sheets
 Nursing
admission/notes
 Immunization records
 Cardiology reports
 Transfer forms
 Therapy notes
(PT/OT/Speech)
 Pathology reports
 Lab specimen
 Other:
 Other:
Indian River Medical Center, Vero Beach FL 32960
 Billing records
Authorization for Release of Information
Date(s):
AUTHORIZATION FOR RELEASE OF
PROTECTED HEALTH INFORMATION
Lab reports (specify dates)
 Xray/imaging reports (specify dates)
Consultation reports by
I acknowledge and hereby consent to such that the released information may contain sexually transmitted diseases,
alcohol and drug abuse, psychiatric or mental health services, HIV testing, HIV results or AIDS information. ____(Initials)
I understand that:
I may refuse to sign this authorization and that it is strictly voluntary.
If I do not sign this form, my health care and the payment for my health care will not be affected unless stated
otherwise (see Signature section).
I may revoke this authorization at any time in writing, but if I do, it will not have any effect on any actions taken
prior to receiving the revocation or when the law provides for my insurer to have the right to contest a claim under
my policy. Further details can be found in the Notice of Privacy Practices.
If the requestor or receiver is not a health plan or health care provider, the released information may no longer be
protected by federal privacy regulations and may be redisclosed.
I may see and obtain a copy of the information described on this form for a copy fee if I ask for it.
I get a copy of this form after I sign it if requested.
----------------------------------------------------------------------------------------------------------------------------- ------------------------------------Is the requestor of this PHI another health plan or health care provider?  Yes
 No
If yes, the health plan or health care provider must complete the following:
Will the requestor receive financial or in-kind compensation in exchange for using or disclosing this information?
 No
 Yes
If yes, describe: _____________________________________________________________
What is the purpose or use of this disclosure? ____________________________________________________
------------------------------------------------------------------------------------------------------------------------------------------------------- ---------SIGNATURE
By signing below, I have read the information on this form and authorize the disclosure of the protected health
information as stated.
_____________________________________________________________ (Patient/Guardian/Patient Representative)
(Signature/Date)
_____________________________________________________________ (Patient/Guardian/Patient Representative)
(Print Name/Date)
______________________________________________________________ (Guardian/Patient Representative)
(Relationship to Patient)
------------------------------------------------------------------------------------------------------------------------ --------Note: The identity of the requestor has been validated either with a government issued picture ID, such as a driver’s
license or a passport, or comparison of signatures documented in the PHI records.  Yes
 No (If no, describe Type
of ID________________________________________________
Indian River Medical Center, Vero Beach FL 32960
Authorization for Release of Information
page 1 of 4
INDIAN RIVER MEDICAL CENTER
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 REVIEW IT CAREFULLY.
THIS NOTICE APPLIES TO SERVICES FURNISHED TO YOU BY INDIAN RIVER MEDICAL CENTER AND ITS SUBSIDIARIES
(COLLECTIVELY “INDIAN RIVER MEDICAL CENTER”), ITS EMPLOYED AND NON-EMPLOYED STAFF, VOLUNTEERS AND
TRAINEES, AS WELL AS THE PHYSICIANS AND OTHER HEALTHCARE PRACTITIONERS WHO PROVIDE SERVICES AS AN
INPATIENT OR OUTPATIENT OR ANY OTHER SERVICES PROVIDED TO YOU IN A HOSPITAL-AFFILIATED PROGRAM
INVOLVING THE USE OR DISCLOSURE OF YOUR HEALTH INFORMATION. THIS NOTICE ALSO DESCRIBES HOW
AUTHORIZED HEALTH CARE PROVIDERS MAY USE AND DISCLOSE YOUR HEALTH INFORMATION ELECTRONICALLY
THROUGH THE “IRMC-HEALTHY ME” HEALTH INFORMATION EXCHANGE (HIE). YOU CAN GET ADDITIONAL INFORMATION ABOUT THE HIE FROM YOUR PARTICIPATING PROVIDER’S REGISTRAR OR RECEPTIONIST, OR BY VISITING
WWW.IRMC-HEALTHYME.COM OR WWW.IRMCHEALTHYME.COM.
Understanding Your Health Record/Information
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record
contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related
information. This information, often referred to as your health or medical record, may serve as:
• A basis for planning your care/treatment;
• A means of communication among the health professionals who contribute to your care;
• A legal document describing the care you received;
• A means by which you or a third party payer can verify that services billed were actually provided;
• A tool in educating health professionals;
• A source of data for medical research;
• A source of information for public health officials charged with improving the health of the nation;
• A source of data for facility planning and marketing; and
• A tool with which we can assess and improve the care we render and the outcomes we achieve.
Our Responsibilities
We are required by law to maintain the privacy of your health information, to provide you with this notice of our legal duties and
privacy practices with respect to your health information, and to notify you if there is a breach of your unsecured health information.
We will abide by the terms of this notice.
Permissible Uses and Disclosures Without Your Written Authorization
By law, we are allowed to use and disclose your health information for most purposes related to your medical treatment
(“treatment”), the payment for your medical treatment (‘payment”), and our healthcare operations (“operations”). The following
categories describe examples of the way we use and disclose health information:
For Treatment: We may use health information about you to provide you treatment or services. We may disclose health information
about you to doctors, nurses, technicians, medical students, or other facility personnel who are involved in taking care of you at the
facility. For example: a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow
the healing process. Different departments of the facility also may share health information about you in order to coordinate the
different things you may need, such as prescriptions, lab work, meals, and x-rays. We may also provide your physician or a subsequent
healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from this facility.
For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you,
your insurance company or a third party payer. For example, we may need to give your insurance company information about your
surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to
receive to determine whether your plan will cover it.
For Health Care Operations: Members of the medical staff and/or quality improvement team may use information in your health
record to assess the care and outcomes in your case and others like it and for conducting training programs or reviewing competence of health care professionals. The results will then be used to continually improve the quality of care for all patients we serve.
For example, we may combine health information about many patients to evaluate the need for new services or treatment. We may
disclose information to doctors, nurses, and other students for educational purposes. And we may combine health information we
have with that of other facilities to see where we can make improvements. We will remove information that identifies you from this
set of health information to protect your privacy.
page 2 of 4
Business Associates: There are some services provided in our organization through contracts with business associates. Examples
include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when
making copies of your health record. When these services are contracted, we may disclose your health information to our business
associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered.
To protect your health information, however, business associates are required by federal law to appropriately safeguard your
information.
Facility Directory: Unless you notify us that you object, we may include certain limited information about you in the facility
directory while you are a patient at the facility. The information may include your name, location in the facility, your general
condition (e.g., good, fair) and your religious affiliation. This information may be provided to members of the clergy and, except for
religious affiliation, to other people who ask for you by name. If you would like to opt out of being in the facility directory please
request the Opt-Out Form from the admission staff or Facility Privacy Official. Even if you ask us to keep your information out of
the directory, we may share your information for disaster-relief efforts or in a declared emergency situation.
Individuals Involved in Your Care or Payment for Your Care: Health professionals, using their professional judgment, may
disclose to a family member, other relative, close personal friend or any other person you identify, your health information that is
relevant to that person’s involvement in your care or payment related to your care. In addition, we may disclose information about
you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research: We may disclose information to researchers when an institutional review board that has reviewed the research proposal
and established protocols to ensure the privacy of your health information has approved their research and granted a waiver of the
authorization requirement.
Organized Health Care Arrangement: This facility and its medical staff members have organized and are presenting you this
document as a joint notice. Information will be shared as necessary to carry out treatment, payment and health care operations.
Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it
may affect treatment at the time.
As required by law, we may also use and disclose health information for the following types of entities including, but not limited to:
Funeral Directors: We may disclose health information to funeral directors, coroners and medical examiners consistent with
applicable law to assist them in carrying out their duties.
Organ Procurement Organizations: Consistent with applicable law, we may disclose your health information to organ
procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose
of tissue donation and transplant.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to
food, supplements, product and product defects or post-marketing surveillance information to enable product recalls, repairs or
replacement.
Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply
with laws relating to workers compensation or other similar programs established by law.
Specialized Government Functions: If you are in the military or a veteran, we will disclose your health information as required by
military command authorities or as required by law. We may disclose health information to authorized federal official for national
security purposes and intelligence activities.
Correctional Institution: Should you be an inmate of a correctional institution, we may disclose your health information to the
institution or agents thereof, as necessary for your health, and the health and safety of other individuals.
Public Health: We may disclose health information about you for public health activities. These activities generally include the
following:
• To prevent or control disease, injury, or disability.
• To report births and deaths.
• To notify a person who may have been exposed to a communicable disease or may otherwise be at risk for contracting or
spreading a disease or condition.
• For population based activities relating to improving health or reducing health care costs.
Victims of Abuse, Neglect or Domestic Violence: Your health information may be disclosed as authorized by law if there is a
reasonable belief that you are a victim of abuse, neglect, exploitation, or domestic violence. We'll only make this disclosure if you
agree or when required or authorized by law.
Health oversight activities: We may disclose medical information to a health oversight agency for activities authorized by law.
These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the
government to monitor the healthcare system, government programs, and compliance with civil rights laws.
page 3 of 4
Patient Safety Organization: Indian River Memorial Hospital d/b/a Indian River Medical Center (IRMC) contracts with PSOFlorida.
IRMC will submit to and receive patient safety work product from PSOFlorida. PSOFlorida has been formed as a component
organization of the Florida Hospital Association (FHA) under the authority of the Patient Safety and Quality Improvement Act, which
was passed by Congress in 2005. PSOFlorida’s mission is to improve the safety and quality of healthcare delivery thorough the
application of science and implementation of best-practice evidence with the objective of preventing patient injury or death.
Law Enforcement/Legal Proceedings: We may disclose health information for law enforcement purposes or legal proceedings as
required by law or in response to a valid subpoena or court order.
Health Information Exchange (HIE): We and other healthcare providers participate in a Health Information Exchange to facilitate
the secure exchange of your electronic health information between and among several health care providers or other health care
entities for your treatment, payment, or other healthcare operations purposes. This means we may share information we obtain or
create about you with outside entities (such as hospitals, doctors offices, pharmacies, or insurance companies) or we may receive
information they create or obtain about you (such as medication history, medical history, or insurance information) so each of us can
provide better treatment and coordination of your healthcare services.
Fundraising: We may contact you as part of a fundraising effort unless you elect not to receive any such communications. We may
use certain information (name, address, phone number, email, date of birth, gender, health insurance, service dates, department of
service, and outcome information) to contact you for the purpose of fundraising. You have the right to“opt out”of receiving such communication and your decision to opt out will have no impact on your treatment or payment rights. To opt out, please call 772.226.4978
to leave your name, address, phone number, and date of birth so we may ensure you are removed from our communications.
A School: We may disclose information if you are a student or prospective student if the information is limited to proof of immunizations, the school is required by State or other law to have such proof prior to admitting you, and the Hospital obtains and
documents the agreement to the disclosure from either a parent, guardian, or other person acting in loco parentis of the individual
(if an unemancipated minor) or from you (if an adult or emancipated minor).
Other Permitted Disclosures: When contacting you, primarily regarding appointment reminders and billing/collection efforts, we
may leave messages on your answering machine/voice mail.
In the event that one or more of Indian River Medical Center entities is sold or merged with another organization, your health
information will become the property of the new owner.
We may disclose your health information as required or permitted by the privacy regulations promulgated pursuant to the Health
Insurance Portability and Accountability Act, as amended and interpreted from time to time.
State-Specific Requirements: Many states have requirements for reporting including population-based activities relating
to improving health or reducing health care costs. Some states have separate privacy laws that may apply additional legal
requirements. If the state privacy laws are more stringent than federal privacy laws, the state law preempts the federal law.
Uses and Disclosures That Require Your Written Authorization
Other uses and disclosures not described in this notice will be made only with your written authorization. Your written authorization
is required for any disclosure of psychotherapy notes, except to carry out the treatment, payment, or health care operations allowed
by law. Your written authorization is required for any use or disclosure of your health information for marketing, except if the
communication is a face-to-face communication made by the Hospital to you, or is a promotional gift of a nominal value provided by
the Hospital. If the marketing involves financial remuneration to the Hospital from a third party, the authorization will state that
remuneration is involved. The Hospital will obtain your written authorization for any disclosure of your health information which is
a sale of your health information. This authorization will state that the disclosure will result in remuneration to the Hospital. You may
revoke your authorization at any time, provided the revocation is in writing.
Your Health Information Rights
Although your health record is the physical property of the healthcare practitioner or facility that compiled it, you have the
Right to:
Inspect and Copy Your Health Information:You have the right to inspect and obtain a copy of the health information that may be
used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health
information, you may request that the denial be reviewed. Another licensed health care professional chosen by the facility will review
your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with
the outcome of the review. If you request a copy of your information for your own personal use, we may charge a fee for the costs
of copying, mailing, or other supplies associated with your request. You may request to receive an electronic copy of your health
information. If it is readily producible in such form, you will receive it as requested; otherwise, the Hospital will provide the readable
electronic form and format that is producible and you agree to receipt in this format. If you direct us to send a copy of your health
information directly to another person, you will be asked to request this in writing, signed by you, and clearly identify the designated
person and where to send the copy of your health information
page 4 of 4
Amend Your Health Information Records: If you feel that health information we have about you is incorrect or incomplete, you
may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for
the facility. Any request for an amendment must be sent in writing to the Facility Privacy Official. We may deny your request for an
amendment and if this occurs, you will be notified of the reason for the denial.
Receive An Accounting of Disclosures: You have the right to request an accounting of disclosures. This is a list of certain
disclosures we make of your health information for purposes other than treatment, payment or health care operations where an
authorization was not required.
Receive Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about
you for treatment, payment or health care operations. You also have the right to request a limit on the health information we
disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For
example, you could ask that we not use or disclose information about a surgery you had. Any request for a restriction must be sent
in writing to the Facility Privacy Official. We are required to agree to your request only if 1) except as otherwise required by law, the
disclosure is to your health plan and the purpose is related to payment or health care operations (and not treatment purposes), and
2) your information pertains solely to health care services for which you have paid in full. For other requests, we are not required
to agree. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Health Information Exchange: With regard to the IRMC-Healthy Me HIE only, if you do not wish to allow independent doctors,
nurses, and other clinicians involved in your care to electronically share your health information through the IRMC-Healthy Me HIE,
you may do the following: do not sign in to the IRMC-Healthy Me HIE; if you have already signed in and wish to “opt out,” please
notify us in writing of your opt out preference. You may send your opt out written request via mail to Mindy Serafin, Privacy Official,
Indian River Medical Center, 1000 36th Street, Vero Beach FL 32960, or fax your written request to 772.562.5628 Attention Privacy
Official Mindy Serafin. Opting out of the HIE will not impact how your information is accessed and released in accordance with this
Notice and the law
Request Confidential Communications:You have the right to request that we communicate with you about medical matters in a
certain way or at a certain location. For example, you may ask that we contact you at work instead of your home. The facility will
grant reasonable requests for confidential communications at alternative locations and/or via alternative means only if the request
is submitted in writing and the written request includes a mailing address where the individual will receive bills for services rendered
by the facility and related correspondence regarding payment for services. Please realize, we reserve the right to contact you by other
means and at other locations if you fail to respond to any communication from us that requires a response. We will notify you in
accordance with your original request prior to attempting to contact you by other means or at another location.
Receive A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this
notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To exercise any of your rights, please obtain the required forms from the Privacy Official and submit your request in writing.
Other Uses of Your Health Information
Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with
your written permission/authorization. If you provide us authorization to use or disclose health information about you, you may
revoke that authorization, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information
about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we
have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Changes to this Notice
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about
you as well as any information we receive in the future. The current notice will be posted in the facility and on our website and
includes the effective date. If this notice is changed, the new notice will be posted in the facility and on our website and will include
its effective date, and you will be provided with a copy of the Notice when it changes.
For More Information or to Report a Problem
If you have questions regarding our privacy practice or would like additional information, you may contact the Privacy Official at
772.567.4311, ext. 1124. If you believe your privacy rights have been violated, you may file a complaint with the Privacy Official at
Indian River Medical Center. You may also file a complaint with the Secretary of the Department of Health and Human Services at
http://www.hhs.gov/ocr/office/index.html. There will be no retaliation against you for filing a complaint.
Facility Privacy Official
Indian River Medical Center, Mindy Serafin
Telephone: (772) 567-4311 ext. 1124
31-1811-4 4/03
Effective Date of Notice 04/14/03
Revised 01/09, 05/12, 09/12, 09/13
Refunds
IRMC-Physician Practices
Financial Policies
A refund is issued when an overpayment has
been identified. If you feel a refund is due,
please contact our billing office at772.794.5611.
Thank you for choosing IRMC-Physician
Practices for your medical care. We
appreciate that you have entrusted us with
your healthcare needs. We are committed to
providing you with the best patient care
available.
Failure to Pay
If you do not pay your bill, your account may be
sent to an outside collection agency. If your
account is sent to a collection agency, you will
need to contact them directly to settle your
balances.
Because healthcare benefits and coverage
options have become increasingly complex,
we have developed this financial policy to
help you understand your responsibilities as
a patient. We will do our best to assist you
with understanding your proposed
treatment and in answering questions
related to submitting your insurance claim
forreimbursement.
Policy and Fee Changes
These policies and fees are subject to change. We
will keep you informed of any modifications.
We realize medical care isan unexpected expense.
If you have concerns about your ability to pay, you
can contact us for help in managing your account.
If you have questions about these policies, please
contact our billing office at 772.794.5611.
IRMC-Physician Practices
1000 36th Street
Vero Beach, FL 32960
Phone: 772.794.5611
Fax: 772.794.1450
Your health insurance policy is a contract
between you and your health insurance
company. Please note it is your responsibility
to know if your insurance requires referrals,
pre-certifications, pre-authorizations, limits
on outpatient charges, and any requirements
for specific physicians, labs and/or hospitals
to use. You should beknowledgeable of any
deductibles, copayments, and/or coinsurance
or other out-of-pocket expenses for your
care.
If you are uncertain about your current
health insurance policy benefits you should
contact your plan to learn the details about
your benefits.
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When
doubt,
doubt,
contact
contact
for
the
cost
of
the
care.
When
ininin
doubt,
contact
your
your
plan
plan
directly
directly
for
for
clarification.
clarification.
your
plan
directly
for
clarification.
Co-payments/Co-insurances/Deductibles
Co-payments/Co-insurances/Deductibles
Co-payments/Co-insurances/Deductibles
You
You
are
are
expected
expected
to
pay
pay
your
your
co-payment
co-payment
and
and
any
any
You
are
expected
toto
pay
your
co-payment
and
any
co-insurance
co-insurance
and/or
and/or
deductible
deductible
amounts,
amounts,
ififknown,
ifknown,
known,
co-insurance
and/or
deductible
amounts,
at
the
the
time
time
of
service.
service.
atat
the
time
ofof
service.
Payments
Payments
Payments
Payment
Payment
Payment
isisdue
isdue
due
at
atat
the
the
the
time
time
time
services
services
services
are
are
are
provided
provided
provided
or
oror
upon
upon
receipt
receipt
of
aastatement
astatement
statement
from
from
our
our
billing
billing
office.
office.
upon
receipt
ofof
from
our
billing
office.
We
We
accept
accept
payment
payment
ininin
the
the
form
form
of
cash,
cash,
check,
check,
We
accept
payment
the
form
ofof
cash,
check,
money
money
order
order
or
credit
credit
card
card
(American
(American
Express,
Express,
money
order
oror
credit
card
(American
Express,
MasterCard,
MasterCard,
Visa
Visa
and
and
Discover).
Discover).
Returned
Returned
checks
checks
MasterCard,
Visa
and
Discover).
Returned
checks
are
are
subject
subject
to
aafee
afee
fee
of
$25.
$25.
We
We
do
do
not
not
accept
accept
are
subject
toto
ofof
$25.
We
do
not
accept
traveler's
traveler's
checks.
checks.
traveler's
checks.
Non-Medical
Non-Medical
Fees
Fees
Non-Medical
Fees
Additional
Additional
fees
fees
may
may
apply
apply
to
the
the
following:
following:
Additional
fees
may
apply
toto
the
following:
••Returned
•Returned
Returned
checks
checks
checks
ofof
medical
records
••Copying
•Copying
Copying
of
medical
medical
records
records
••Completion
•Completion
Completion
of
disability
disability
or
other
other
forms
forms
ofof
disability
oror
other
forms
Non-Covered
Services
Non-Covered
Non-Covered
Services
Services
Medicare
Medicare
Patients
Patients
Medicare
Patients
Medicare
may
not
cover
some
services
your
Medicare
Medicare
may
may
not
not
cover
cover
some
some
services
services
your
your
doctor
recommends.
You
will
be
informed
doctor
doctor
recommends.
recommends.
You
You
will
will
bebe
informed
informed
ahead
of
time
and
given
an
Advanced
ahead
ahead
ofof
time
time
and
and
given
given
anan
Advanced
Advanced
Beneficiary
Notice
(ABN)
to
read
and
sign.
Beneficiary
Beneficiary
Notice
Notice
(ABN)
(ABN)
toto
read
read
and
and
sign.
sign.
The
ABN
will
help
you
decide
whether
you
The
The
ABN
ABN
will
will
help
help
you
you
decide
decide
whether
whether
you
you
want
to
receive
services,
knowing
you
are
want
want
toto
receive
receive
services,
services,
knowing
knowing
you
you
are
are
responsible
for
payment.
You
must
read
the
responsible
responsible
for
for
payment.
payment.
You
You
must
must
read
read
the
the
ABN
carefully
before
signing.
ABN
ABN
carefully
carefully
before
before
signing.
signing.
Missed
Missed
Appointments
Appointments
Missed
Appointments
As
AsAs
aacourtesy
acourtesy
courtesy
to
toto
other
other
other
patients
patients
patients
and
and
and
our
our
our
physicians,
physicians,
physicians,
please
please
provide
provide
24-hour
24-hour
advance
advance
notice
notice
ififyou
ifyou
you
are
are
please
provide
24-hour
advance
notice
are
unable
unable
to
keep
keep
yourappointment.
yourappointment.
Procedures
Procedures
and
and
unable
toto
keep
yourappointment.
Procedures
and
surgeries
surgeries
vary
vary
by
practice,
practice,
and
and
will
will
be
discussed
discussed
at
surgeries
vary
byby
practice,
and
will
bebe
discussed
atat
time
time
of
scheduling.
scheduling.
time
ofof
scheduling.
Commercial
Insurance
Commercial
Commercial
Insurance
Insurance
Services
not
covered
by
your
plan
are
your
Services
Services
not
not
covered
covered
byby
your
your
plan
plan
are
are
your
your
responsibility
and
must
be
paidin
full
at
the
responsibility
responsibility
and
and
must
must
bebe
paidin
paidin
full
full
atat
the
the
time
of
service
or
upon
receiving
aabill.
time
time
ofof
service
service
oror
upon
upon
receiving
receiving
abill.
bill.