New Patient Paperwork

Please click here to download the New Patient Paperwork! If you are a new patient, completing these forms in advance will help ensure your appointment runs smoothly and on time. Please be sure to bring your driver’s license, insurance card(s), and a list of any medications you are currently taking. We also request you arrive 10 minutes prior to your appointment time to allow us to properly process your paperwork and insurance. Please note, we do not perform annual physicals or annual wellness examinations at your new patient visit. This appointment is to establish you with the practice.

Authorization to Release/Request Medical Records

Please click here to download the Authorization to Release/Request Medical Records Form. If you are requesting that Delta Internal Medicine Center to either release or obtain medical records on your behalf, we require this form to be completed and submitted to our office to process your request.  You are able to fax this to our office at 407-985-1947.

HIPAA & Communication Form

Please click here to download the HIPAA & Communication Form. We take your privacy extremely serious at Delta Internal Medicine Center, PA. If you wish to update your HIPAA & Communication Form, please forward this to our office. You may fax this directly to us at 407-985-1947.

Office Policies and Procedures:

  1. Appointments: When making an appointment, we will attempt to accommodate your schedule and your appointment time will be an approximate time. Emergencies do occur so we do appreciate your patience. Please note that if you arrive more than 10 minutes late for your appointment, you may be rescheduled.
  1. No Show/Late Cancellation/Reschedule Policy:  There will be a $25.00 fee applied to any “no show” or appointment not cancelled/rescheduled 24 hours in advance. If there are a total of 3 No Show/Late Cancellation/Reschedule occurrences, the patient may be dismissed from the practice.
  1. Prescription Refills: Please allow 48 hours for prescriptions to be filled. Based on the medication, there may be a restriction on the refill allowances between you visits with the provider.
  1. Completion of Forms: Our practice charges a fee for forms such as FMLA, disability, and others. The cost is dependent on the complexity of the form. The fee ranges from $25.00-$50.00. Payment must be made prior to the completion of the form and we ask that you allow 10 business days for completion.
  1. Payment: Patients are responsible for and expected to know their insurance benefits. We file your insurance as a courtesy and we are required to collect copayments, coinsurance, or deductibles at the time of service. If you are unable to pay, we will need to reschedule your appointment. Any unpaid balance on your account must be paid prior to any future appointments. If you are self-pay, payment is expected prior to your appointment. Personal checks are not accepted for the initial visit.
    1. Medication Prior Authorizations: Our practice does not process prior authorizations for medications. If we have prescribed a medication that is not covered by your insurance, we will prescribe an alternative for you. If you are notified that a medication is not covered, please do one of the following: (a) Contact your insurance company and request they let you know what a comparable alternative medication that is covered on your formulary; (b) Pay out of pocket for your medication that we have prescribed; (c) Request we submit the Prior Authorization for a $25.00 fee which is required to be paid in advance. Please note that prior authorization is not guaranteed and if there is a rejection or denial, there are no refunds on the fee.