Current Clients

Welcome,

When the time comes for another consultation, call us or email us so we can give you an appropriate appointment. You must tell us of any changes in your condition and whether you have , in the interim, seen another doctor for the condition you complained of with us. We will also call you to schedule your next consultation.

New Clients

For 1st Class Care to schedule a consultation with a physician you need to fill out and submit the following
“Introductory Medical Form” (IMI). Along with this form we will need your most recent medical records including any imaging studies and a copy of your photo I.D.

These items should be faxed or emailed to 1-866-385-0980 or service@1stclasscare.net.

  • Your medical records must:
     1) Support your complaint indicating that it is chronic or continuing.
    2) Include entries no less than one year old.
    3) Outline suggested medications and treatment prescribed.

    *If any imaging study reports such as MRI’s or CT Scans are included they should have practitioner’s comments on them. As part of our continuing effort to prevent diversion of controlled substances, we confirm the authenticity of records by contacting the office of the health provider indicated on the records.

    • *The doctor and our associates will assess your records within 24 business hours for legitimacy and make certain they meet the above criteria. We will then immediately contact with you.
    *Payment will be due at the time of scheduling via credit card or Western Union.

     

Introductory Medical Information Form (IMI)
   
 
 

What “Medical Condition” are you seeking this consultation for?

(Please Explain)

 
The Complaint is pain in the:

Feet    
 

Have you had any surgeries in the last 5 years?

If yes, the type of surgery(s) and the date(s):
 

List your prescription or over-the-counter medications that you are currently taking:
Name of Medication
Dosage
Times per Day
 
On a scale of 0 (no pain) to 10 (crippling pain) without medication requested below or listed above
the pain is rated:
With the pain medication,the pain is rated:
 

Allergies to medications:

Name of Medication
Reaction you had
     

Height:

 

Diet: are you on a diet?

If so, are you under the care of a PHYSICIAN? 

Was medication prescribed? 

 

Caffeine:

Do you drink alcohol?

Tobacco: Do you use tobacco?

Cigarettes–pks per day:

Drugs: Do you currently use recreation/street drugs?

 

Have you been positively diagnosed within two (2) years by a qualified “MEDICAL PRACTITIONER” with any of the following?
Diagnostic Studies were:
Revealing:
I have tried other medications and modalities with poor results:
 

What medication are you requesting?
 

 

*Immediately upon our receipt of this IMI Form a Customer Service Representative from 1CC will phone or email you and advise you about all further steps.

– IMPORTANT –

FOR US TO WORK WITH YOU, YOU MUST READ AND AGREE TO THE FOLLOWING PARAGRAPHS.
YOU DO THIS IN THREE STEPS:

  1. CLICK ON THE "I AGREE" CHECKBOX, BELOW AND CLICK SUBMIT.
  2. PRINT OUT THIS IMI AND SIGN AND DATE IT MANUALLY ON THE SIGNATURE/DATE LINE
  3. SEND THE SIGNED IMI FORM TO US BY SCAN/EMAIL OR BY FAX (866-394-6513) ALONG WITH YOUR MEDICAL RECORDS.

1. I have been informed of the risk of addiction. I affirm that the requested medication would be for my own personal use, and that said medication is not being requested for any other purpose nor is it being requested from any other source. Also, I state that said medication has helped me lead a normal and productive life. I deny any kidney or liver damage. I authorize the transmission of any information obtained through electronic means.

2. I have received, reviewed, and agreed to “Notice of Privacy Practice,” and the “Terms and Conditions”  (T/C) of use of 1CC and I authorize 1CC to use, access and disclose all of my health information and to gather any such information from others as reasonably necessary for 1CC to perform their services – always within the rules of the T/C and Privacy Policy and that I understand that the medical practitioner who consults me may not be licensed in the state of my residence.

3. I hereby execute this authorization in compliance with the Health Insurance Portability and Accountability Act, HIPPA, 45 CFR 164.104, and request that any health care provider (including its agents, employees and associates) to whom I am referred by 1st Class Care, LLC release his or her records to 1st Class Care, LLC, 907 6th St. NW, Winter Haven, FL., 33881. Records may be faxed to 863-595-0196 or emailed to "service@1stclasscare.net". The Protected Health Information (PHI) released herein may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV), drug/alcohol records, and psychiatric/psychological information records. There are no exclusions of records to be released.

  1. The purpose of this disclosure is personal record maintenance.
  2. This authorization may be revoked at any time by a signed and properly dated written revocation to said referred health care provider who is provided with this request, but this release cannot be revoked as to PHI that had been previously released in reliance on this document.
  3. I understand that I am under no obligation to sign this document.
  4. I understand that once the PHI is disclosed, it may be redisclosed to individuals or organizations that are not subject to the federal privacy regulations. 1st Class Care cannot guarantee that the recipient of the information will not redisclose this information.
  5. A photocopy of this authorization shall be considered as effective and valid as the original and this authorization will expire one year after the date executed unless earlier revoked.