Digital Intake Packet | Altamonte Medical Associates

1. Patient Information Form

.

Date

Form Type

Full Name

Date of Birth

Address

Address Line 2

Social Security Number

Home Phone

Cell Phone

Email

Gender

Employer Name

Employer Phone

Employer Address

Insurance Name

Primary Claims Address

Primary Claims City / State / ZIP

Primary Claims Telephone

Primary Policy Number

Primary Group Number

Secondary Claims Address

Secondary Claims City / State / ZIP

Secondary Claims Telephone

Secondary Policy Number

Secondary Group Number

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

2. Patient Data Sheet & Medical History

.

Name

Date of Birth

Sex

Race

Marital Status

Number of Children

Number of Persons in Household

Education / Grade

Last Medical Exam

Last Eye Exam

Present Medical Conditions

Past Illnesses / Hospitalizations / Surgeries

Immunizations / Dates

Drug / Food Allergies + Reaction

Current Medications / Vitamins / OTC / Strength / Frequency

3. Family History & Current Lifestyle

.

Father Medical History

Mother Medical History

Brother(s) Medical History

Sister(s) Medical History

Children Medical History

Current Occupation

Chemical or Other Hazards on the Job

Do you drink alcohol? If yes, how much?

Do you feel you have been exposed to AIDS?

Do you smoke or chew tobacco? If yes, how much?

Do you ever use illicit drugs? If yes, how much?

Do you have any sexual concerns?

Hobbies / Recreational Activities

Patient Name

Patient Signature

Date

4. Notice of Privacy Practices Acknowledgment

.

By completing this section, the patient acknowledges the Notice of Privacy Practices and understands that protected health information may be used and disclosed for treatment, payment, and health care operations as described by the practice.

Notice of Privacy Practices

Altamonte Medical Associates, P.A.

This Notice of Privacy Practices describes how your medical information may be used and disclosed and how you can access this information. At Altamonte Medical Associates, P.A., we are committed to delivering personalized, physician-led care with the highest standards of privacy and discretion.

Uses and Disclosures of Your Information

Treatment: We use your health information to provide comprehensive medical care. This includes coordination between providers, specialists, laboratories, and imaging facilities. In our concierge-style model, this may also include enhanced communication such as direct physician access, extended visits, and personalized care planning.

Payment: We may use your information to obtain payment for services rendered. This includes billing insurance carriers when applicable, as well as processing direct patient payments for fee-for-service or concierge care arrangements.

Healthcare Operations: We use your information to operate and improve our practice. This includes quality assessment, care coordination, staff training, compliance, and administrative activities designed to enhance your experience and outcomes.

Telehealth Services

We may provide care via telehealth platforms, including video visits, secure messaging, and remote monitoring. These services are conducted using secure, HIPAA-compliant technologies whenever possible. By participating in telehealth, you acknowledge that there are inherent privacy risks despite reasonable safeguards, and you consent to these services as part of your care.

Other Permitted Uses

We may disclose your information when required by law, for public health reporting, to prevent serious threats to health or safety, or for healthcare oversight activities.

Your Rights

Access and obtain a copy of your medical records
Request corrections or amendments to your information
Request restrictions on certain uses or disclosures
Request confidential communication methods
Receive a list of disclosures of your information
Obtain a paper or electronic copy of this notice

Concierge Care and Communication

As part of our enhanced care model, you may communicate with your physician via phone, text, email, or other electronic methods. While we take reasonable steps to protect your privacy, you acknowledge that certain communication methods may carry additional risks.

Our Responsibilities

Maintain the privacy and security of your protected health information
Provide you with this notice of our legal duties and privacy practices
Notify you following a breach of unsecured protected health information
Abide by the terms of this notice

We reserve the right to revise this notice at any time. Updated versions will be available upon request and on our website.

Contact Information

Altamonte Medical Associates, P.A.
If you have questions, concerns, or wish to file a complaint, please contact our office directly. You may also file a complaint with the U.S. Department of Health and Human Services without fear of retaliation.

Effective Date: April 18, 2026

I acknowledge that I have read and understand the Notice of Privacy Practices.

Patient Name

Patient Signature

Date

5. Authorization to Discuss / Disclose Information

.

Date

Name

SS#

Person 1 Name

Person 1 Relationship

Person 2 Name

Person 2 Relationship

Person 3 Name

Person 3 Relationship

Patient Name

Patient Signature

Date

6. Authorization for Release of Medical Information

.

Date of Birth

Social Security Number

Patient Name

Authorization Type

Release to Obtain from Discuss with

Parent/Guardian/POA Name

Address

City

State

ZIP

Release to / Obtain from / Discuss with

Name:

Address:

Telephone:

Exceptions / Notes

Patient Signature

Parent/Guardian/POA Signature

Parent / Guardian / POA Name

Relationship

Guardian / POA Date

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