(407) 351-9696

New Patient Forms

Insurance:

We accept nearly all major insurance plans including:

  • Cigna

  • United Healthcare

  • Aetna

  • Humana

  • Blue Cross Blue Shield**

**We are not in-network with some of the BCBS plans offered on the healtcare marketplace including Blue Select**

Self Pay Rates:

New Patient office visit: $130

Established Patient office visit: $90

The above rates do not include any procedures or labs done during your visit. Please call our office for discounted self pay rates for procedures such as Xrays, EKGs, Injections, and bloodwork.

Annual Physical Exam Special $275 includes:

  • Exam

  • EKG

  • Urinalysis

  • Preventative Bloodwork (chemistries, cholesterol, thyroid, blood count)

For the most up-to-date information on our accepted private health insurance plans, contact our office directly at 407-351-9696.

NEW PATIENT FORMS

Save time when visiting the office and fill out all your patient forms below

New Patient Forms

New Patient Registration Form
 

    Patient Information

  • Insurance Information

  • In Case of Emergency

  • The above information is true to the best of my knowledge. I authorize Harris Internal medicine or insurance company to release any information required to process my claims.
 

Verification

Health History Questionnaire
 

  • Personal Health History

  • Immunizations and dates

  • Health Habits and Personal Safety

  • All questions contained in this portion of the questionnaire are optional and will be kept strictly confidential.
  • Exercise

  • Diet

  • Caffeine

  • Alcohol

  • Tobacco

  • Drugs

  • Sex

  • Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse.
  • Personal Safety

  • Physical and/or mental abuse has also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse.
  • Family Health History

    Father

  • Mother

  • Siblings

  • Children

  • Maternal Grandmother

  • Maternal Grandfather

  • Paternal Grandmother

  • Paternal Grandfather

  • Mental Health

 

Verification

Controlled Substance Policy

Controlled Substance Policy

  • Controlled substance medications (i.e. narcotics, tranquilizers, and barbiturates) can be useful but have a high potential for misuse and are, therefore, closely controlled by local, state, and federal governments. They are intended to relieve pain, thus improving function and/or ability to work. Because Harris Internal Medicine takes the safety of our patients very seriously, the following terms will be strictly enforced.
 

Verification

Office Financial Policy

Harris Internal Medicine Financial Policy

  • We are committed to providing you with the best care possible. This goal is best achieved if everyone is aware of the financial policy, which is an agreement between the doctors of the practice and the patient. Your clear understanding of the financial policy agreement is important to our professional relationship.

    Insurance

    Payment for services is due at the time services are rendered, except as outlined as follows. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered. It is the responsibility of the patient to provide accurate and timely insurance information. Inaccurate or untimely information given to the staff that results in denial or non-coverage by your insurance company will result in the patient being responsible for payment.

    Non-Emergency Appointments

    Physicals, sick visits, and follow up appointments may be rescheduled if there are outstanding balances or if a co-payment is not made at time of service. If you are experiencing financial difficulty, please let us know. Health insurance is a contract between you, your employer, and your insurance company. It is important for you to be an informed consumer who understands the specifications of your insurance policy (eg, vaccine and doctor visit coverage, referral/authorization requirements for specialty care, radiographs, laboratory tests, and emergency hospital care) given made with the billing department. A $10 billing fee will be charged to you if your co-payment is not made at the time of service. Balances not paid in full within 10 days of the date on the final request letter will be forwarded to a collection agency. If your account is forwarded to a collection agency, we will continue to see you on an emergency basis only for the next 30 days, giving you time to find a new source of medical care.

    A $35 fee will be charged for all returned checks and your account will be placed on a “cash-only basis.” We will accept payments only by cash or credit card until the balance is cleared.

    We realize that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact our billing department promptly for payment arrangements and assistance in the management of your account.

    The Financial Agreement

    We must emphasize that as your healthcare providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are strictly your responsibility from THE DATE SERVICES ARE RENDERED. Therefore, it is necessary for you to know what benefits your insurance plan provides for you.

    I HAVE READ AND FULLY UNDERSTAND THE FINANCIAL POLICY SET FORTH BY HARRIS INTERNAL MEDICINE. I AGREE THAT IF IT BECOMES NECESSARY TO FORWARD MY ACCOUNT TO A COLLECTION AGENCY, I WILL ALSO BE RESPONSIBLE FOR THE FEE CHARGED BY THE AGENCY FOR THE COSTS OF COLLECTION IN ADDITION TO THE ORIGINAL AMOUNT DUE. I UNDERSTAND AND AGREE THAT THE TERMS OF THIS FINANCIAL POLICY MAY BE AMENDED BY THE PRACTICE AT ANY TIME WITHOUT PRIOR NOTIFICATION TO THE GUARANTOR.

 

Verification

Patient Self Determination Act Questionnaire

Patient Self Determination Act Questionnaire

  • If you have any further questions, you can contact your family attorney, local hospital, or medical association for additional information.
 

Verification

Notice of Privacy Practices

Notice of Privacy Practices

  • Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this acknowledgement. Our notice provides a description of our treatment, payment activities, and healthcare operations of the uses and disclosures we may make of your protected health information, and of important matters about your protected health information. A copy of our notice accompanies this acknowledgement. We encourage you to read it carefully before signing. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of privacy practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. By signing below I consent to Harris Internal Medicine’s Notice of Privacy Practices. I have had full opportunity to read and consider the contents of Harris Internal Medicine’s Notice of Privacy Practices. I understand that by signing this acknowledgement, I am giving my consent to the use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.
  • Right to revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Practice Manager. Please understand that revocation of this consent will not affect any action we took prior to the receipt of your revocation. We may decline to treat you or to continue to treat you if you revoke this consent.
 

Verification

Office Policy Downloads

Please make sure to download our office Financial Policy, Notice of Privacy Practices, and Controlled Substance Policy.