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www.SmartChoiceNow.com 4235 Sunbeam Road • Jacksonville, Florida 32257 (904) 322-8555 • Fax: (904) 322-8578 Wissam M. Shaya, M.D. * U.S. government required stascal data necessary for all healthcare enes to aain “Meaningful Use” of Electronic Health Records. Please return this document to the SCPUC recepon desk upon compleon www.SmartChoiceNow.com 4235 Sunbeam Road • Jacksonville, Florida 32257 (904) 322-8555 • Fax: (904) 322-8578 Wissam M. Shaya, M.D. Your Smart Choice Primary and Urgent Care Doctor (SCPUC): ����������������������������

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Page 1: Your Smart Choice Primary and Urgent Care Doctor (SCPUC): · Wissam M. Shaya, M.D. hX^XP}À vu v µ] o v Ç(} ooZ o Z v }©]v^D v]vP(µoh _}( o }v] , o ZZ } X Wo µ v Z] } µu v }

www.SmartChoiceNow.com 4235 Sunbeam Road • Jacksonville, Florida 32257

(904) 322-8555 • Fax: (904) 322-8578

Wissam M. Shaya, M.D.

* U.S. government required statistical data necessary for all healthcare entities to attain “Meaningful Use” of Electronic Health Records.Please return this document to the SCPUC reception desk upon completion

4235 Sunbeam RoadJacksonville, FL 32257

Wissam M. Shaya, M.D.www.SmartChoiceNow.com 4235 Sunbeam Road • Jacksonville, Florida 32257

(904) 322-8555 • Fax: (904) 322-8578

Wissam M. Shaya, M.D.

Your Smart Choice Primary and Urgent Care Doctor (SCPUC): ����������������������������

Page 2: Your Smart Choice Primary and Urgent Care Doctor (SCPUC): · Wissam M. Shaya, M.D. hX^XP}À vu v µ] o v Ç(} ooZ o Z v }©]v^D v]vP(µoh _}( o }v] , o ZZ } X Wo µ v Z] } µu v }

www.SmartChoiceNow.com 4235 Sunbeam Road • Jacksonville, Florida 32257

(904) 322-8555 • Fax: (904) 322-8578

Wissam M. Shaya, M.D.

* U.S. government required statistical data necessary for all healthcare entities to attain “Meaningful Use” of Electronic Health Records.Please return this document to the SCPUC reception desk upon completion

We at SCPUC appreciate you greatly as our patient and strive to accomplish wonderful results and the optimum of health for you as well as the other members of our patient community. We believe we provide our patients with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something everyone in our office takes quite seriously. Furthermore, we embrace that commitment equally for all of our patients.

Similarly, your commitment to the healthcare process is required. We require your commitment to maintain the highest standards of healthcare on your behalf and on behalf of all of SCPUC’s patients. Appointments with our doctors are our primary means to provide our patients healthcare. An appointment that is not utilized because it is not cancelled or rescheduled is a missed opportunity to provide care for another patient. For optimal care for all of our patients, it is imperative that appointments are kept when scheduled or cancelled in a timely manner. Therefore, in order to reinforce a practice of appointment cancellation and/or rescheduling, our practice has instituted a Missed Appointment Policy in which we must enlist your participation. We hope that this policy is understood by our patients as a means to ensure that every appointment is treated as important and valuable.

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We expect you to keep all your appointments. Write down the time of your visits. With the exception of seriousemergencies it is expected that you keep all your appointments.If you need to re-schedule an appointment we require a minimum 24 hours notice. In such a case, please call our office at(904) 322-8555 and arrange for a make-up appointment with one of our Front Desk Receptionists. The appointment shouldbe rescheduled for the same week, preferably the very next day if possible.In an instance of a cancellation without 24 hours notice or no-show to a scheduled appointment, we reserve the right tocharge you a fee.

• In the case of a 15 minute scheduled appointment time or Pre-Phyisical, the fee will be $50.00.

• In the case of a Complete Physical or other 30 minute scheduled appointment, the fee will be $75.00.

In instances of repeated non-compliance with your scheduled visits, we also reserve the right to discontinue care due tonon-compliance with our treatment plans.

I understand and agree to adhere to the SCPUC appointment policy.

Page 3: Your Smart Choice Primary and Urgent Care Doctor (SCPUC): · Wissam M. Shaya, M.D. hX^XP}À vu v µ] o v Ç(} ooZ o Z v }©]v^D v]vP(µoh _}( o }v] , o ZZ } X Wo µ v Z] } µu v }

www.SmartChoiceNow.com 4235 Sunbeam Road • Jacksonville, Florida 32257

(904) 322-8555 • Fax: (904) 322-8578

Wissam M. Shaya, M.D.

* U.S. government required statistical data necessary for all healthcare entities to attain “Meaningful Use” of Electronic Health Records.Please return this document to the SCPUC reception desk upon completion

Made Between Smart Choice Primary Care and You (Our Patient) ...

We believe that to achieve this goal there must be a partnership between the patient and your medicalprovider (physician or nurse practitioner). Below are just a few of the highlights of what you can expectfrom your relationship with SCPUC. We hope that you will take the opportunity to ensure your health and well-being as vigorously as we will.

SCPUC Patient-Provider Partnership Agreement

You agree to work together to ...

• You agree to keep us involved in your care and inform us of all outside medical visits including intended ER visits • Be open and honest in providing your doctor with your health-related information • Agreetokeepscheduledappointmentsatourofficeaswellaswithanyspecialists • Followthemedicalcareplanthatisagreeduponatyourofficevisitasbestyoucan • Participate in developing an action plan to self-manage a chronic condition (such as diabetes, asthma, etc.) if applicable • Take steps to achieve a healthy lifestyle and get preventive services • Agree to ask questions if you do not understand any portion of your health care • Notifyusifyourinsurance,prescriptioncoverageorfinancialsituationchanges

X _____________________________________________________________ Date _____________________________________


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