Faa Flight Physical Patient Form printable pdf download

Carolina Medical Consultants, P.A.

FAA Flight Physical Patient Form

Welcome to our office!

Date: ___________________

Patient Name: ___________________________________________________________

Address:

___________________________________________________________

Home Phone: ________________________

Work Phone: __________________

Marital Status: _______________________

Sex:

Male

Female

Date of birth: ________________________

SSN: ________________________

Place of Employment: _____________________________________________________

REASON FOR VISIT TODAY: FLIGHT PHYSICAL

Please read the following:

•

We do not file any insurance for flight physicals

•

The cost of a flight physical is $108.00

•

For Class I physicals that require an EKG, there is an additional $40 charge

•

We accept cash, check, VISA, Discover, or Mastercard

•

Payment is expected at the time of service

•

If you have insurance and Dr. Jenkins requests we schedule you for additional testing or a referral

to another physician, we will need your insurance information.

Consent to Treatment:

I consent to treatment necessary for the care of myself. I authorize the release of medical information

necessary to pay a claim or any other agents. I understand that payment of charges incurred is due at the

time of service. In the event a physician or medical facility requests your PHI for the purpose of

continuation of care, I authorize Carolina Medical Consultants to release all medical records including

information relating to drug, alcohol, psychiatric, and/or sexually transmitted disease, including HIV/AIDS

information. I agree to allow CMC to leave medical information on my answering machine when needed.

I have access to and understand the Notice of Privacy Practices which provides a more complete

description of the information uses and disclosures. I understand that the organization reserves the right to

change their notice and practices. I understand that I have the right to request restrictions as to how my

health information may be used or disclosed to carry out treatment, payment, or healthcare operations and

that the organization is not required to agree to the restrictions requested. I have read and fully understand

the above consent for treatment, financial responsibility, release of medical information and insurance

authorization. I understand that I may revoke this consent in writing, except to the extent that the

organization has already taken action in reliance thereon.

Patient Signature: ________________________________________ Date: _________

Faa Flight Physical Patient Form

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