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Patient Info

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Medical History

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Acknowledgments & Disclosures

CONSENT FOR RELEASE OF MEDICAL INFORMATION

I respectfully authorize and request that you release copies of my medical records to: Aysev LLC.
I authorize release of information of my medical record: I understand that this information shall be
in effect for 180 days following the date of signature. However, I understand that this authorization
may be revoked at any time by giving oral or written notice to the medical office. A photocopy of
this authorization shall constitute a valid authorization. Should my case require review by a
governing agency or another medical profession actively involved in my care to make a final
determination, it is with my consent that a copy of these records will be submitted to the agency
or medical profession for this review. 

Scheduling: 

We will do our best to be on time, we can only ask the same of you. We generally wont charge a fee for changing appointment, we get it, things happen, however - if we see a pattern where appointments are constantly being changed and/or missed we may need to institute individual patient fees. We will not charge someone with out letting them know before. 

We attempt to contact you/your designated other to remind you of your up-coming appointment; however, it is the responsibility of the patient to arrive for their appointment on time. 
Fees: 

Just like you can't go into a supermarket and ask to purchase food and ask them to pay them another time. Fees, Co-pays and forward balances are due on the day of service. 

- If an account is not paid in full within 90 days, a 25% collection processing fee will be added to the outstanding balance and will be turned over to a collection company for further processing.

- No additional appointments will be made for delinquent accounts until they are brought current. Checks returned for any reason will be assessed a $40.00 service fee in addition to the amount of the check. NSF checks must be redeemed with certified funds and checks will no longer be permitted as payment.
Medical Marijuana Consent Form 

A qualified physician may not delegate the responsibility of obtaining written informed consent to another person. The qualified patient or the patient’s parent or legal guardian if the patient is a minor must initial each section of this consent form to indicate that the physician explained the information and, along with the qualified physician, must sign and date the informed consent form.
b. The approval and oversight status of marijuana by the Food and Drug Administration
c. The potential for addiction
d. The potential effect that marijuana may have on a patient’s coordination, motor skills, and cognition, including a warning against operating heavy machinery, operating a motor vehicle, or engaging in activities that require a person to be alert or respond quickly. 
64B8-9.018, F.A.C. 4B15-14.013, F.A.C. DH-MQA-5026 Rev. 02/18
e. The potential side effects of medical marijuana use. 
g. The risks, benefits, and drug interactions of marijuana
64B8-9.018, F.A.C. 4B15-14.013, F.A.C. DH-MQA-5026 Rev. 02/18 
h. The current state of research on the efficacy of marijuana to treat the qualifying conditions set forth in this section.
There does not appear to be good-quality primary literature that reported on cannabis or cannabinoids as effective treatments for AIDS wasting syndrome. 
64B8-9.018, F.A.C. 4B15-14.013, F.A.C. DH-MQA-5026 Rev. 02/18 
64B8-9.018, F.A.C. 4B15-14.013, F.A.C.
64B8-9.018, F.A.C. 4B15-14.013, F.A.C. DH-MQA-5026 Rev. 02/18