New Patient Packet

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Welcome to Our Practice

Thank you for choosing Cleveland Health Center for your healthcare needs. We are committed to providing you with the highest quality, compassionate care.

Before Your Appointment

Please complete this New Patient Packet prior to your appointment. These forms are fillable and signable electronically, or you may print and bring them with you.

Please Bring the Following:

Your current insurance card(s)
A valid photo identification (Driver's License, State ID, or Passport)
A list of your current medications

If you are unable to complete these forms in advance, please arrive 30 minutes early to complete them in our office.

1. Patient Registration

First Name(Required)

Middle Initial

Last Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Sex

Marital Status

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Social Security Number (Last 4)

Email Address(Required)

Home Phone

Cell Phone(Required)

Work Phone

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

If Patient Is A Minor

Father's Name (Last, First)

Father's Date of Birth

MM slash DD slash YYYY

Father's Address

Father's SSN (Last 4)

Father's Phone

Mother's Name (Last, First)

Mother's Date of Birth

MM slash DD slash YYYY

Mother's Address

Mother's SSN (Last 4)

Mother's Phone

Pharmacy & Referral

Preferred Pharmacy

Pharmacy Phone

Referred By

2. Advance Directive Information

An Advance Directive is a written statement of your wishes regarding medical treatment (e.g., Living Will or Durable Power of Attorney), made to ensure those wishes are carried out should you be unable to communicate them.

I have completed an ADVANCE DIRECTIVE for health care:

Yes

If yes, indicate which:

Living Will

Durable Power of Attorney

I am requesting information regarding ADVANCE DIRECTIVES:

Yes

Patient / Guardian Signature

Electronic signature: type your full legal name

Date

MM slash DD slash YYYY

3. Insurance Information

Primary Medical Insurance

Primary Insurance Carrier(Required)

Primary Carrier Phone Number

Primary Policy #(Required)

Primary Group #(Required)

Primary Subscriber Name(Required)

Primary Subscriber SSN (Last 4)

Primary Subscriber Relationship to Patient

Secondary Medical Insurance (if applicable)

Secondary Insurance Carrier

Secondary Carrier Phone Number

Secondary Policy #

Secondary Group #

Secondary Subscriber Name

Secondary Subscriber SSN (Last 4)

Secondary Subscriber Relationship to Patient

Tertiary Medical Insurance (if applicable)

Tertiary Insurance Carrier

Tertiary Carrier Phone Number

Tertiary Policy #

Tertiary Group #

Tertiary Subscriber Name

Tertiary Subscriber SSN (Last 4)

If You Are Currently Uninsured

Person Responsible for Payment (Last, First, M.I.)

Relationship to Patient

Address (Street, City, State, Zip)

4. Certification Statement

I certify that the information above is true and accurate to the best of my knowledge. I understand that I am financially responsible for all charges whether or not paid by insurance.

Name of Patient (Print)(Required)

Signature of Patient / Responsible Party(Required)

Electronic signature: type your full legal name

Name of Responsible Party (Print)

Responsible Party Driver's License #

5. Medical History Questionnaire

Name

First Last

Birth Date

MM slash DD slash YYYY

Sex

Height (inches)

Weight (lbs)

Prescription refill needed today?

Yes

Reason for seeing the doctor today:

Medical Providers Involved in Your Care

Providers

Provider Name

Specialty

Phone

Fax

Allergies

List allergies to prescription medications with side effect / allergic reaction:

Prescription Medication Allergies

Medication

Side Effect / Allergic Reaction

Allergies to OTC medications or supplements (if any):

Current Prescription Medications

Prescription Medications

Name of Medication

Dose / Frequency

# Refills Left

Prescriber Name

OTC medications and supplements

Surgical / Hospitalization History

Surgeries / Hospitalizations

Year

Hospital Name, City and State

Reason / Type of Surgery

6. Medical History – Conditions

Please check all conditions you have or have had. Use the 'Other' field in each category to note any conditions not listed.

General

High Blood Pressure

High Cholesterol

Prediabetes

Diabetes

Thyroid Disease

Other conditions in General category:

Eyes / Ears / Mouth / Throat

Cataracts

Macular Degeneration

Vision Loss

Hearing Loss

Vertigo

Tinnitus

Dysphagia (Swallowing Difficulty)

Other conditions in Eyes/Ears/Mouth/Throat category:

Heart & Vascular

Coronary Artery Disease

Heart Failure

Heart Valve Disease

Aneurysm of Aorta

Peripheral Artery Disease

Venous Insufficiency

Other conditions in Heart & Vascular category:

Genitourinary – Males

Enlarged Prostate

Erectile Dysfunction (ED)

Prostate Malignancy

Bladder Malignancy

Other conditions in Genitourinary (Males) category:

Genitourinary – Females

Overactive Bladder

Urinary Incontinence

Recurrent UTIs

History of Blood in Urine

History of GU Malignancies

Other conditions in Genitourinary (Females) category:

Renal

CKD (Chronic Kidney Disease)

History of Kidney Stones

Other conditions in Renal category:

Lung

Asthma

COPD

Emphysema

Chronic Bronchitis

Chronic Cough

Sleep Apnea

History of Lung Tumor

Other conditions in Lung category:

Neuropsychological

History of Stroke

TIA

Carotid Artery Disease

Headaches

Parkinson Disease

Essential Tremor

Seizure Disorder

Multiple Sclerosis

Reduced Memory

ADHD

Generalized Anxiety

Depression

Neuropathy

Other conditions in Neuropsychological category:

Immunology / Allergology

History of Sinus Infections

Chronic Allergies

Other conditions in Immunology/Allergology category:

Skin

History of Melanoma

Other Skin Malignancies

Other skin conditions:

Gastrointestinal

GERD (Reflux / Heartburn)

Barrett's Esophagus

IBS (Irritable Bowel Syndrome)

Colitis

History of Diverticulitis

History of Colon Malignancy

Other conditions in Gastrointestinal category:

Hematology / Oncology

Anemia

Low Platelets

CLL

Other conditions in Hematology/Oncology category:

Musculoskeletal

Polymyalgia Rheumatica

Rheumatoid Arthritis

Generalized Osteoarthritis

Chronic Back Pain

Spinal Stenosis

Fibromyalgia

Osteopenia

Osteoporosis

Muscle Weakness

Leg Cramps

Leg Muscle Pain with Exertion

Other conditions in Musculoskeletal category:

7. Medical Tests, Procedures & Hospitalizations

Medical Tests / Procedures: Check the box if you have had the test. Indicate the year and outcome (e.g., normal / abnormal):

Colonoscopy - Year & Outcome

Stool Cards - Year & Outcome

Mammogram - Year & Outcome

PSA - Year & Outcome

Heart Catheterization - Year & Outcome

Stress Test - Year & Outcome

EGD (Upper Endoscopy) - Year & Outcome

CT Scan of the Abdomen - Year & Outcome

Ultrasound of the Aorta - Year & Outcome

Kidney Ultrasound - Year & Outcome

CXR (Chest X-Ray) - Year & Outcome

DEXA - Year & Outcome

Foot Exam (if diabetic) - Year & Outcome

Eye Exam (if diabetic) - Year & Outcome

Other Test - Year & Outcome

8. Family & Social History

Family History

Check the box if a close family member has had any of the following conditions. Indicate the approximate age of diagnosis:

Heart Disease

Father

Mother

Sibling

Other member

Heart Disease - Age at Diagnosis

Stroke

Father

Mother

Sibling

Other member

Stroke - Age at Diagnosis

High Blood Pressure

Father

Mother

Sibling

Other member

High Blood Pressure - Age at Diagnosis

Diabetes

Father

Mother

Sibling

Other member

Diabetes - Age at Diagnosis

Colon malignancy

Father

Mother

Sibling

Other member

Colon malignancy - Age at Diagnosis

Breast Malignancy

Father

Mother

Sibling

Other member

Breast malignancy - Age at Diagnosis

Other Malignancies

Father

Mother

Sibling

Other member

Other Malignancies - Age at Diagnosis

Dementia/Alzheimer's

Father

Mother

Sibling

Other member

Dementia/Alzheimer's - Age at Diagnosis

Depression

Father

Mother

Sibling

Other member

Depression - Age at Diagnosis

Alcoholism

Father

Mother

Sibling

Other member

Alcoholism - Age at Diagnosis

Other family history conditions:

Social History

Occupation (if retired, list previous occupation/s):

Smoking history:

None

Current smoker

Former smoker

If current smoker: Packs/day and how long (years)?

If former smoker: When did you quit?

Alcohol use:

None

Yes

If yes, what kind and how often?

Illicit drug use?

Yes

Sexually active?

Yes

History of STDs?

Yes

9. Immunization History

Please indicate the date of vaccination:

Influenza (Flu shot) - Date Received

Prevnar 13 (newer pneumonia shot) - Date Received

Pneumovax (regular pneumonia shot) - Date Received

Shingrix 1st dose- Date Received

Shingrix 2nd dose- Date Received

Zostavax (older shingles shot)- Date Received

Td (tetanus vaccine) - Date Received

Tdap (Boostrix-tetanus &cough) - Date Received

Hepatitis A & B vaccine (Twinrix)- Date Received

RSV - Date Received

COVID 19 - Date Received

Other Immunizations

10. General Consent & Authorizations

Consent to Treatment

I voluntarily consent to medical evaluation and treatment provided by Cleveland Health Center and its healthcare professionals. This includes routine examinations, diagnostic testing, procedures, and medical care deemed necessary for my diagnosis and treatment. I understand that no guarantees are made as to treatment outcomes and that I may ask questions or decline treatment at any time.

Assignment of Insurance Benefits

I authorize my insurance company to pay medical benefits directly to Cleveland Health Center for services rendered. I understand that I am financially responsible for any charges not covered by insurance, including copayments, coinsurance, deductibles, or non-covered services. I authorize the release of medical or billing information as needed to process insurance claims.

Consent to Receive Communications

I consent to receive communications from Cleveland Health Center via phone calls, voicemail, text messages, and email regarding my care, appointments, billing, and administrative updates. I understand automated technology may be used and that standard messaging/data rates may apply. I may opt out at any time by notifying the office.

Telemedicine Informed Consent

I consent to receive medical services via telemedicine when appropriate. I understand that telemedicine may include remote communication and videoconferencing. I acknowledge the risks and limitations of telemedicine, including potential technical issues, and I understand that I may discontinue or request in-person care at any time. My rights to confidentiality and privacy apply equally to telemedicine services.

Non-Covered & Elective Services Acknowledgment

I understand that Cleveland Health Center may offer elective or non-covered services, including wellness and aesthetic treatments, which are not eligible for insurance reimbursement. I acknowledge that I am fully responsible for payment of such services and that these charges will not be billed to or reimbursed by my insurance provider.

Acknowledgment & Electronic Signature

I HAVE READ AND UNDERSTAND THE GENERAL CONSENT & AUTHORIZATIONS AND AGREE TO THE TERMS ABOVE.(Required)

I have read and agree to the General Consent & Authorizations.

Patient Name (print)(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Signature of Patient or Legal Guardian(Required)

Electronic signature: type your full legal name

Print Name of Patient or Legal Guardian

Relationship to Patient (if guardian)

11. Authorization to Disclose Health Information

1. Patient Information

Patient Name (First, Middle, Last)(Required)

CHC Medical Record # (if known)

Current Address

Same as previous

Street Address Address Line 2 City State ZIP Code

Last 4 Digits of SSN

Date of Birth(Required)

MM slash DD slash YYYY

Phone Number

2. Release Information From

Facility / Provider Name

Facility Address (Street, City/State, Zip)

Facility Phone Number

3. Release Information To: Cleveland Health Center
Address: 5463 Spencer Court, Wildwood, Florida 34785
Phone: (352) 353-0092 Fax: (352) 353-0416

Delivery Method:

Paper

Secure Electronic Delivery

Purpose of Disclosure:

Continuity of Care

Other

If Other, specify purpose:

Dates of Service to Release – FROM

MM slash DD slash YYYY

Dates of Service to Release – TO

MM slash DD slash YYYY

Records to Release:

Office Visits

History & Physical

Emergency Dept Reports

Discharge Summary

Operative Reports

Other records to release (specify):

I, the undersigned, authorize the above named sending Facility/Provider as described in Section 2 to release health information as indicated above. I understand and acknowledge that the requested health information may contain information regarding physical and mental illness, HIV test results or diagnosis, treatment of AIDS/AIDS-related conditions, and/or alcohol/drug abuse. This authorization does not include permission to release outpatient Psychotherapy Notes. Release of Psychotherapy Notes requires a separate authorization.

This authorization will expire one year from the date written below, unless revoked in writing. I understand that treatment, payment, enrollment, or eligibility for benefits will not be based on whether or not I sign this authorization. If Authorization is not complete, signed and dated, it may be returned and result in my information not being released until completed.

Signature of Patient / Patient's Personal Representative(Required)

Electronic signature: type your full legal name

Printed Name(Required)

Date Signed(Required)

MM slash DD slash YYYY

Relationship, if not Patient

12. Financial Policy

Effective Date: January 1, 2026 | Last Updated: February 21, 2026

I. Definitions
Patient: The individual receiving care. Responsible Party: The person financially responsible for charges. Proof of Insurance: A valid, current insurance card. Out-of-Network: Your insurance plan is not contracted with our practice. Self-Pay / Uninsured: No active health coverage.

II. Insurance Coverage & Proof of Insurance
Insurance information is required at each visit. Verification is not a guarantee of payment. Your plan rules apply; you are responsible for understanding your benefits, limitations, referral requirements, prior authorizations, network status, and coverage determinations. If insurance information is missing or incorrect, you may be responsible for the full cost of services.

III. Copayments, Deductibles & Coinsurance
Copayments are due prior to services. Deductibles and coinsurance are the Patient's responsibility and are due when billed.

IV. Out-of-Network Plans
If we are out-of-network with your plan, payment is due at the time of service unless other arrangements are made in advance in writing. Reimbursement from your insurer is not guaranteed.

V. Non-Covered / Elective Services
Some services may be non-covered, elective, or not medically necessary. You are responsible for full payment for such services at the time of service or in advance.

VI. Self-Pay, Deposits & Estimates
Self-pay patients may receive discounted rates. Full payment is due at the time of service. Deposits required: New patients: $300 minimum; Established patients: $150 minimum. You may request a Good Faith Estimate. A card on file may be required to cover remaining balances.

VII. Payment Methods & Convenience Fee
Accepted forms: cash, personal check, and credit/debit cards. Card payments may incur a $2.00 convenience fee where permitted by law.

VIII. Returned Payments
Returned checks are subject to a $25 fee. Future payments must then be made by cash, card, or money order.

IX. Billing, Statements & Collections
Remaining balances are due upon receipt of a statement. If payment is not received within 60 days, the account may be referred to a collection agency or attorney. Unpaid balances may result in scheduling restrictions or dismissal from the practice.

X. Third-Party Liability & Denials
We do not bill third-party liability carriers (auto, workers' comp, etc.). If a claim is denied or down-coded, you are responsible for the balance.

XI. Administrative Services & Records Fees
Medical records fees: $1.00/page (up to 50 pages), $0.50/page (over 50 pages), $15 for itemized bills, $20 for USB/CD.

XII. Missed Appointments & Cancellation Fees
We require at least 48 business hours' notice to cancel or reschedule. Fees: $100 for office visits, $200 for diagnostic/procedure appointments. These fees are not billable to insurance.

XIII. Financial Hardship & Minor Patients
Payment plans may be offered at the discretion of practice leadership. A parent or legal guardian must accompany minors at their first visit and is the Responsible Party.

Acknowledgment & Electronic Signature

I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY AND AGREE TO ABIDE BY ITS GUIDELINES.(Required)

I have read and agree to the Financial Policy.

Name of Insured / Subscriber (Primary)(Required)

Patient Date of Birth(Required)

MM slash DD slash YYYY

Signature of Patient or Legal Guardian(Required)

Electronic signature: type your full legal name

Print Name of Patient or Legal Guardian

Date

MM slash DD slash YYYY

Relationship to Patient (if guardian)

13. Notice of Privacy Practices (HIPAA)

Effective Date: January 1, 2026 | www.myclevelandhealthcenter.org | (352) 353-0092

This Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. At Cleveland Health Center, your privacy is a priority. We are committed to protecting the confidentiality of your health information in accordance with HIPAA and Florida law.

Uses and Disclosures Without Authorization
We may use or disclose your Protected Health Information (PHI) for: Treatment (to coordinate and provide medical care), Payment (to bill insurance and obtain payment), Healthcare Operations (for administrative and operational purposes), Persons Involved in Your Care (in emergencies or if you do not object), Business Associates (contractors bound by confidentiality agreements), Public Health & Safety (reporting diseases, preventing injury, etc.), Legal Purposes (court orders, subpoenas, law enforcement), Appointment Reminders (to contact you regarding services).

Uses Requiring Written Authorization
Psychotherapy Notes, Marketing communications, Sale of PHI, Genetic Information (for underwriting). You may revoke any authorization in writing at any time.

Your Rights Regarding Your PHI
Right to Access: Inspect and request copies of records. Right to Amend: Request amendments with justification. Right to an Accounting: List of disclosures outside of treatment/payment. Right to Request Restrictions: On how we use/disclose PHI. Right to Confidential Communications: Via specific methods. Right to a Paper Copy: Even if received electronically. Right to Notification of Breach: If unsecured PHI is breached.

Complaints
If you believe your rights have been violated, you may file a complaint with the Cleveland Health Center Privacy Officer at [email protected] or the U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint.

Acknowledgment of Notice of Privacy Practices

I acknowledge that I have been offered access to Cleveland Health Center's Notice of Privacy Practices, effective January 1, 2026, which explains how my health information may be used and disclosed and how I may access that information. A copy is available upon request and at www.myclevelandhealthcenter.org.

Patient Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Signature(Required)

Electronic signature: type your full legal name

Date

MM slash DD slash YYYY

If signed by Authorized Representative (if applicable):

Representative Name

Relationship to Patient

Representative Signature

Electronic signature: type your full legal name

Date

MM slash DD slash YYYY

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