FLORIDA MOBILE HEALTH

PATIENT INTAKE FORM · CONFIDENTIAL

This form is transmitted securely over HTTPS. Do not complete this form on a public or shared device. Michele Li Causi FNP-BC, RD, CDCES — info@floridamobilehealth.com
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Service selection & payment

Select the service you are booking. Payment is required in full before your visit is confirmed. All services are self-pay — no insurance billed directly.

Select one. Additional services may be added at your visit.

New Patient Visit · 60 minutes
Initial comprehensive evaluation. History, physical exam, lab review, medication reconciliation, care plan. Diabetes, GLP-1, hormones, or primary care.
$200
Follow-Up Visit · 30 minutes
Established patients only. Lab results review, medication adjustments, ongoing chronic disease management.
$120
Brief Visit · 15 minutes
Established patients. Single focused issue — prescription renewal, single question, minor medication change only.
$75
Diabetes / GLP-1 Consultation · 60 minutes
Comprehensive diabetes evaluation OR initial GLP-1 consultation (Ozempic, Mounjaro, Wegovy). Includes CGM recommendation, nutrition plan, prescriptions as appropriate.
$200
Hormone / Menopause Consultation · 60 minutes
HRT evaluation, perimenopause/menopause management, thyroid, hormonal imbalance. Lab review included.
$200
Initial Nutrition Consultation · 60 minutes · RD
First visit — Registered Dietitian full assessment. Personalized meal planning, GLP-1 side effect nutrition, metabolic health. HSA/FSA eligible.
$150
Nutrition Follow-Up · 45 minutes · RD
Established patients only. Progress review, plan adjustment, ongoing support. HSA/FSA eligible.
$75
Payment & financial policy acknowledgment
Payment is due in full before your visit is confirmed. Florida Mobile Health is a self-pay, direct-care practice. We do not bill insurance directly.

What this means for you: You pay us directly at the time of booking or before your visit. We will provide you with a detailed Superbill (itemized receipt with CPT codes and diagnosis codes) that you can submit to your insurance company for possible out-of-network reimbursement. We cannot guarantee reimbursement from your insurance.

HSA/FSA: All services are eligible for Health Savings Account (HSA) and Flexible Spending Account (FSA) payment.

Cancellation policy: Cancellations with less than 24 hours notice are subject to a $50 late cancellation fee. No-shows are charged the full visit fee. To cancel or reschedule, contact us at 352-399-8874 or info@floridamobilehealth.com.

Scope of practice: As a Florida-licensed FNP-BC, Michele Li Causi does NOT prescribe controlled substances (Schedule II–V), testosterone, or other controlled medications. If you require these medications, you must maintain a separate prescribing relationship with another provider.

Emergency care: Florida Mobile Health is not an emergency service. In a medical emergency, call 911 or go to your nearest emergency room. Response to messages is during business hours only.

State & telehealth consent

Select your state of residence. Your state determines the specific telehealth consent disclosures required by law. You must read and agree to all disclosures before proceeding.

Michele Li Causi FNP-BC is licensed in FL, AZ, NV, CO, NM, and UT only. If you are located in another state, we cannot provide care to you at this time.

HIPAA notice & practice policies

You must acknowledge the following before your visit.

HIPAA Notice of Privacy Practices
Your rights under HIPAA: You have the right to: (1) Get a copy of your health information; (2) Correct your health information; (3) Request confidential communications; (4) Ask us to limit what we use or share; (5) Get a list of those with whom we've shared your information; (6) Get a copy of this privacy notice; (7) Choose someone to act for you; (8) File a complaint if you believe your privacy rights have been violated.

How we use your information: Florida Mobile Health uses your health information for: treatment and care coordination; payment processing; healthcare operations; and as required by law. We will not sell your information or use it for marketing without your written authorization.

Business Associates: We may share your information with business associates (such as billing services, IT providers) who are bound by HIPAA-compliant business associate agreements.

Minimum Necessary: We use and disclose only the minimum necessary health information to accomplish the intended purpose.

Contact for Privacy Questions: Michele Li Causi FNP-BC · 352-399-8874 · info@floridamobilehealth.com
Scope of practice & prescription policy
Michele Li Causi FNP-BC DOES NOT and WILL NOT prescribe:
• Controlled substances (Schedule II–V), including but not limited to opioids, benzodiazepines, stimulants, and sleep medications
• Testosterone or anabolic steroids
• Any medication outside the scope of the following specialties: primary care, diabetes management, metabolic health, nutrition, and women's hormonal health

If you require controlled substances or medications outside this scope, you must maintain a separate prescribing relationship with another provider. Florida Mobile Health CANNOT replace this relationship.

GLP-1 medications (Ozempic, Mounjaro, Wegovy, etc.) ARE within scope and may be prescribed at the provider's clinical discretion, subject to appropriate evaluation and monitoring.
Superbill & insurance
Florida Mobile Health does not bill insurance directly. After your visit, you will receive a detailed Superbill containing: date of service, CPT (procedure) codes, ICD-10 (diagnosis) codes, provider NPI, and all information needed for you to submit a reimbursement claim to your insurance company. Florida Mobile Health makes no guarantees regarding insurance reimbursement. All costs are your responsibility regardless of your insurance coverage.

Patient information

Basic demographic information required for your medical record.

Chief complaint & care goals

Tell Michele why you are here and what you want to accomplish. Be as specific as possible — this shapes your entire visit.

Medical history

Check all conditions that apply to you. This is not exhaustive — you can add details in the notes fields.

Medications & allergies

List all current medications, supplements, and vitamins. Include dose and frequency if known.

Social & lifestyle history

This information helps Michele understand your lifestyle and design a realistic, personalized care plan.

OB/GYN history (female patients)

Electronic signature & submission

By signing below, you confirm that all information provided is accurate and complete to the best of your knowledge, and that you have read and agreed to all disclosures in this form.

Summary of agreements
By submitting this form, I confirm that I have read, understood, and agreed to all of the following:

✓ Payment and financial policy — payment required before visit; self-pay practice
✓ Universal telehealth informed consent
✓ State-specific telehealth consent for my state
✓ HIPAA Notice of Privacy Practices
✓ Scope of practice and prescription policy (no controlled substances)
✓ Superbill and insurance policy

I certify that I am the patient or the legal guardian/authorized representative of the patient named in this form. I certify that all information provided is accurate and complete to the best of my knowledge. I understand that providing false information may affect my care and may result in termination of the care relationship.

Typing your full legal name below constitutes your electronic signature and has the same legal effect as a handwritten signature.

Electronic Signature

What happens next: After you submit this form, Michele's team will review it and contact you within 1 business day to confirm your appointment and process payment. Payment must be received before your visit is confirmed. You will receive a confirmation email at the address you provided.