New Patient Intake Form

Do not wait until your last pill to call for a refill — a 72-hour turnaround is required. If you have not seen the physician in six months, your refill may be denied.

The Health Insurance Portability and Accountability Act (HIPAA) provides patients with fundamental rights to privacy regarding their protected health information (PHI). Elite Sports Medicine is committed to protecting your medical information and complying with HIPAA regulations.

Consent to Use and Disclose Health Information

By signing this form, I consent to the use and disclosure of my protected health information by Elite Sports Medicine for the purposes of treatment, payment, and healthcare operations, including coordination and management of healthcare, communication with other providers, billing and payment, and routine healthcare operations.

Right to Revoke

I understand that I have the right to revoke this consent in writing at any time, except to the extent that Elite Sports Medicine has already taken action based on my prior consent.

Notice of Privacy Practices

I acknowledge that I have received and had an opportunity to review Elite Sports Medicine's Notice of Privacy Practices (below), and have read and agree to the HIPAA Consent and Privacy Practices above.

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.

1. Uses and Disclosures of Health Information

We may use and disclose your health information for treatment, payment, and healthcare operations — for example, sharing information with other healthcare providers involved in your care, or with your insurance company to obtain payment for services.

2. Your Rights

You have the right to request restrictions on certain uses and disclosures of your information, receive confidential communications, inspect and copy your medical record, request an amendment to your record, receive an accounting of disclosures, and obtain a paper copy of this notice.

3. Our Legal Duties

We are required by law to maintain the privacy of your health information, provide you with this notice of our legal duties and privacy practices, and abide by the terms of this notice.

4. Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office (Privacy Officer, Elite Sports Medicine, phone 561-202-8886) or with the Secretary of the U.S. Department of Health and Human Services — Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, phone 1-877-696-6775, hhs.gov/ocr.

Effective Date: June 4, 2025

1. Medical Consent

I hereby consent to medical evaluation and treatment by the providers and staff at Elite Sports Medicine, which may include diagnostic procedures, medical treatments, and other services deemed necessary for my care. I understand that I have the right to be informed about my treatment options and to ask questions regarding my care.

2. Financial Agreement

I understand and agree that all charges for services rendered are due at the time of service unless other arrangements have been made in advance, including copayments, deductibles, and coinsurance amounts required by my health insurance policy.

3. Insurance and Patient Responsibility

I understand that it is my responsibility to know the terms of my health insurance coverage. While Elite Sports Medicine may assist in verifying benefits, it is ultimately my responsibility to ensure services are covered, and I agree to pay any remaining balance not covered by my insurance.

4. No-Show Fee Agreement

If I fail to show up for a scheduled appointment without providing at least 24 hours' notice, I will be charged a $35.00 no-show fee. This fee is not covered by insurance and must be paid prior to scheduling any future appointments.

5. Late Arrival Policy

There is a 15-minute grace period for scheduled appointments. If I arrive more than 15 minutes past my appointment time, my appointment may be rescheduled at the discretion of the provider. Repeated late arrivals may also be subject to the no-show policy.

I voluntarily consent to receive medical care, treatment, and services by the providers and staff at Elite Sports Medicine, including physical examinations, diagnostic tests (e.g., X-rays, lab work), medical treatments, procedures or therapies, and administration of medications.

I understand I have the right to ask questions and be informed about the benefits, risks, and alternatives to any recommended treatment, and that I may refuse any treatment without jeopardizing my future care. I certify that I have read, understood, and agree to the above, and I authorize the medical staff of Elite Sports Medicine to provide evaluation and treatment as deemed necessary.