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Orthopedic Miami Hand Surgeon, Shoulder, Wrist, Elbow

Badia Hand to Shoulder Center at Doral


BADIA HAND TO SHOULDER CENTER
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Meet our team »
Home » Patient Forms

Patient Forms


New Patient Packet

Step 1 of 10

10%
  • Date Format: MM slash DD slash YYYY
  • Workers Comp or Auto Insurance

  • Primary Insurance

  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance

  • Date Format: MM slash DD slash YYYY
  • Primary Care Physician

  • Emergency Contact

  • I do hearby consent to any medical care which is deemed advisable or necessary by my healthcare provider and grant authority to Badia Hand to Shoulder Center, to administer and perform all examinations, treatments, diagnostic procedures and surgeries needed now or in the future. I guarantee payment for all services rendered. All medical benefits including major medical benefits, private insurance, and any other health plan, are assigned to Badia Hand to Shoulder Center. The signature below confirms all of the information provided herein is true and accurate. Photocopy of this consent is to be considered as valid as the original.
  • Financial Policy

    This is an agreement between Badia Hand to Shoulder Center, as creditor, and the Patient/Debtor named on this form.

    By executing this agreement, you are agreeing to pay for all services that are received. Payment is expected at the time services are rendered. We accept cash, personal check, money order, cashier’s check, Visa and Master Card. We collect copay, coinsurance and any deductible at the time services are rendered.

    Insurance: Insurance is a contract between you and your insurance company. We will file insurance claims only for plans with whom we have a contract with. We participate in some managed care plans. In order to file your claims, we require a legible copy of the front & back of the insurance card, photo ID, social security number and verification of benefits by your insurance company prior to visits. It is the responsibility of the insured/patient to supply current and accurate information for claims submissions. All copay, coinsurance and deductibles are due at the time services are rendered.

    If you are covered by a plan that we are not participating providers for, payment is expected when services are rendered. We will provide you with an itemized receipt for you to file with your insurance. Your insurance company will be responsible for reimbursing you for any coverage you may have.

    Collection fee: A fee totaling 30% of the balance due will be added to your account if we have to send your account to a collection agency. You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account to any credit reporting agency such as a credit bureau.

    Waiver of confidentiality: You understand that if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

    Returned checks: There is a fee currently of $25.00 for any checks returned by the bank. Payment made on a returned check must be made in cash or by a money order.

    Copying of records: You will need to request in writing, and pay a reasonable copying fee ($1/page for the first 25 pages and 25 cents for every page thereafter) if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history. Copies of images (x-ray, MRI) are available in CD and are subject to a $10.00 fee per disc.

    Consent to photograph: I authorize Badia Hand to Shoulder, LLC and its affiliates to take pictures of my (or my child’s) medical or surgical procedure(s) and condition(s) and to the use of such pictures for treatment, scientific, educational or research purposes.

    Effective date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

    My signature below certifies that I have read (or the form has been read to me) and I understand the contents on this form.

  • Acknowledgement of Privacy Practices

    I hereby acknowledge that I have received a copy of Badia Hand to Shoulder Center Notice of Privacy Practices as required by federal law.
  • Patient Consent for use and disclosure of Protected Health Information

    I authorize the office Badia Hand to Shoulder Center to disclose protected health information to the following:
  • Telephone Messages

    Please choose one:
  • Consent to photograph

    I authorize Badia Hand to Shoulder, LLC and its affiliates to take pictures of my (or my child’s) medical or surgical procedure(s) and condition(s) and to the use of such pictures for treatment, scientific, educational or research purposes.

  • Mutual Agreement

    Dr. Alejandro Badia, M.C., and Badia Hand to Shoulder Center (collectively labeled “physician”) agree to provide treatment to:
  • (“patient”). The Physician takes pride in being able to extend a greater degree of privacy than is required by law.
  • Federal and State privacy laws are complex. Unfortunately, some medical offices try to find loopholes around these laws. For example, physicians are forbidden by law from receiving money for selling lists of patients or medical information to companies to market their products or services directly to patients without authorization. Some medical practices, though, can lawfully circumvent this limitation by having a third party perform the marketing. While personal data is never technically in the possession of the company selling its products or services, the patient can still be targeted with unwanted marketing information. Physician believes this is improper and may not be in the patient’s best interest. Accordingly, Physician agrees not to provide medical information for the purposes of marketing directly to Patient. Regardless of legal privacy loopholes, Physician will never attempt to leverage its relationship with Patient by seeking Patient’s consent for marketing products for others.

    We want your feedback. If our office gets it right, tell us. If we could do something better, tell us. We take quality improvement seriously. While there are scores of “rating sites” in cyberspace, many fail to provide useful information. Let’s get it done right. We can make recommendations as to which sites follow minimum standards for fairness and balance. Just ask us.

    Physician has invested significant financial and marketing resources in developing the practice. Nothing in this Agreement prevents a patient from posting commentary about the Physician – his practice, expertise, and/or treatment – on web pages, blogs, and/or mass correspondence. In consideration for treatment and the above noted patient protection, if patient prepares such commentary for publication on web pages, blogs, and/or mass correspondence about Physician, the Patient exclusively assigns all Intellectual Property rights, including copyrights, to Physician for any written, pictorial, and/or electronic commentary. This assignment shall be operative and effective at the time of creation (prior to publication) of the commentary.

    This agreement shall be in force and enforceable for a period of five years from Physician’s last date of service to Patient. As a matter of office policy, Physician is requiring all patients sign the Mutual Agreement so as to establish that any anonymous or pseudonymous publishing or airing of commentary will be covered by this agreement for all Physician’s patients. Further, this agreement will survive for a minimum of three years beyond any termination of the Physician-Patient relationship.

    Patient and Physician acknowledge that breach of this Agreement may result in serious, irreparable harm. Patient and Physician agree to the right of equitable relief (including but not limited to injunctive relief). Should a breach of this Agreement result in litigation, the prevailing party in the litigation shall be entitled to reasonable costs, expenses, and attorney fees associated with the litigation.

    Patient has been given the opportunity to ask questions and receive satisfactory and adequate explanations.


  • Agreement as to Resolution of Concerns


    “I”, “Patient/Guardian” shall be understood to mean
  • "Physician" shall be understood to mean Alejandro Badia, M.D. / Badia Hand to Shoulder Center.

    Further, I understand that I am entering into a contractual relationship with Physician for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availability of medical care, and may result in irreparable harm to a medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative agrees not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician.

    Furthermore, should a meritorious medical malpractice cause or cause of action be initiated or pursued, I and/or my representative agree to use American Board of Medical Specialties (“ABMS”) board-certified expert medical witness(es) in the same specialty as Physician. Furthermore, I agree that these witnesses will be members in good standing of, and adhere to the guidelines and/or code of conduct, defined for expert witnesses by the ASSH and AAOS.

    In further consideration for this, Physician agrees to the same stipulations.

    Patient/guardian and Physician acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to Physician’s reputation and business. Patient/guardian and Physician agree in the event of a breach to allow specific performance and/or injunctive relief.


  • Credit Card Authorization

    Successful treatment depends not only on the skill of your physician, but on the commitment, attendance and efforts of you, the patient, as well. At Badia Hand to Shoulder Center we pride ourselves on working with our patients in a timely manner so that the treatment process has the most minimal impact on our patients’ precious time. In addition, your timely attendance is important to facilitating short wait times and optimal patient flow.

    The staff at Badia Hand to Shoulder Center is committed to accommodating your scheduling needs. In return, Badia Hand to Shoulder Center expects 24 hours’ notice prior to rescheduling or canceling an appointment. Any appointments cancelled or rescheduled without 24 hour notice will be assessed a $50.00 fee. This fee also applies to appointments in which a patient fails to attend or call. Our office has set this time aside to accommodate the schedule, and without proper notice, we are unable to provide the opportunity to another patient who may have requested the same time.

    For workers compensation patients, should your workers compensation insurance refuse to pay this fee due to your negligence, you will be responsible for this fee.

    I have read the cancellation policy and understand that I will be responsible to pay a cancellation/no show fee of $50.00 as indicated above. I authorize Badia Hand to Shoulder Center to charge a one-time fee of $50.00 to the credit card on file for each appointment missed. I understand that I will not be informed prior to this fee being charged to my account. I understand that if I give at least 24 hours advanced notice of cancelling an appointment, this fee will not be charged from my account. I understand that if I do not provide my credit card information to Badia Hand to Shoulder Center, I will still be responsible for this fee, and will be billed for this fee.

  • NEW PATIENT MEDICAL HISTORY FORM

  • Chief Complaint

  • Body part affected
  • History of Present Illness

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Prior Testing/Treatment

  • Type of treatment - Status of symptoms after treatment - Date(s) of treatment
  • Orthopedic surgeries

  • Medical Questions

  • Review of Symptoms

  • Family History

  • Social History

  • Date Format: MM slash DD slash YYYY
  • Allergies

  • If yes, please list below
  • Medication

  • Medical History

  • Date Format: MM slash DD slash YYYY

Directions

Orthopedic Miami Hand Surgeon, Shoulder, Wrist, Elbow Location

Badia Hand to Shoulder Center (Miami)

3650 NW 82nd Ave. Suite 103
Miami/Doral, FL 33166
United States (US)
Phone: (305) 227-4263

Monday8:30AM - 5:00PM
Tuesday8:30AM - 5:00PM
Wednesday8:30AM - 5:00PM
Thursday8:30AM - 5:00PM
Friday8:30AM - 5:00PM
SaturdayClosed
SundayClosed

Have a Question? Ask Dr. Badia »

Dr. Badia
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News & Events

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Orthopedic, Sports Medicine & Musculoskeletal Imaging Conference & Antarctica Expedition ‘Breaking the Ice’ Life is not measured by the number... Read More

 

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Badia Hand to Shoulder Center
Badia Hand to Shoulder Center
4.8
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Leonard Wolfson
Leonard Wolfson
19:42 04 Nov 19
Excellent visit. I injured my finger yesterday and was seen today by Dr. Badia. The staff was friendly and very efficient and the doctor spent more than enough time explaining what was going on and explaining my options. Truly a great experience.read more
Luisa Alfonso
Luisa Alfonso
16:25 06 Sep 19
The Dr and staff are professional and friendly. I’m happy I came here and I received the attention and answers I needed. I had injured my hand and I left the office feeling better. Thank you all for everything!!!read more
Robledo Aybar
Robledo Aybar
16:30 09 Aug 19
Due to a fall, I fractured my wrist in late Nov. 2018. Dr Badia and his team helped me overcome this issue and today I’m working, and back on my bike and running. The best service and experience!read more
Ellen Westbrook
Ellen Westbrook
23:08 29 Jul 19
Staff displayed professionalism and caring. Dr. Badia was as enthusiastic as I was about this surgery to improve the function of my hand. The surgical day process was smooth; I was kept informed every step of the way. I felt comfortable and safe.read more
victor mendelsohn
victor mendelsohn
02:37 30 May 19
From the first call I made to Dr. Badia‘s office I was impressed by the professionalism of the person who answered the phone. When I arrived at the office for my appointment I was once again greeted in a professional manner. This professionalism radiated through all of the team. I hadn’t seen Dr. Badia for over 10 years and he greeted me as if we’ve been in contact with each other for years.read more
Alexander Aguiar
Alexander Aguiar
18:19 24 Apr 19
From my first visit the staff as well as the Dr. Badia have been exceptionally professional and caring. I had an injury to my pinky finger, the required a placement of a rod in order to align. The surgery went well and was scheduled right away. The office staff has been amazing with scheduling and confirming appointments. Overall I am very happy with the care i received as well as the results. My finger healed and my range of motion has also gotten much better. Thank you Dr. Badiaread more
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Badia Hand to Shoulder Center

Complete Care of the Hand, Wrist, Elbow and Shoulder
in one Medical Facility
Dr. Alejandro Badia, M.D, F.A.C.S.
Past President ISSPORTH (2011-2013)

Our Office Hours:
Mondays to Fridays
Saturdays
Sundays
8:30 AM - 5:00 PM
Closed
Closed
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305 227-HAND (4263)
3650 NW 82nd Ave. Suite 103
Doral, Florida 33166
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