confidential patient information sheet (please print) … · heart and vascular care, inc. 3970...

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CONFIDENTIAL PATIENT INFORMATION SHEET (Please Print)

Name: _________________________________________________________ Age: ______ D.O.B.: ___________ Sex: ___________ (Last) (First) (Mi)

Street Address: ___________________________________________ Apt: __________ SS#: ______________________________

City: ____________________________State: _______Zip: ________Email: ___________________________ Marital Status: ____

Home Phone: __________________________ Work Phone: _____________________ Cell #: _______________________________

MEDICAL CONSENT - ASSIGNMENT OF BENEFITS - RELEASE OF INFORMATION

I authorize Heart and Vascular Care, Inc. to release any information in my examination or treatment to any insurance company or government agency providing my benefits, enabling them to process precertification or claims on my behalf.

I authorize my insurance carrier(s) to make payment directly to Heart and Vascular Care, Inc. for all services rendered. I understand that I will be charged an additional fee of $35 for any check or draft dishonored by my financial institution. I understand that upon my written request, the office will copy my medical records, and that I will be charged a fee according to the Georgia state medical records statute. I understand that I may be charged a $25 fee when I request that my provider complete medical forms on my behalf.

I understand that I am ultimately responsible for copays, co-insurance amounts, deductibles and any amount not covered by my insurance carrier. Payment is expected at the time that services are rendered.

x ________________________________________________ Date: ________________ Patient Information Updated On: ________________ Signature of patient

Heart and Vascular Care, Inc. 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040 Phone: 678-513-CARE (2273) • Fax: 678-513-8869 • www.hvcmd.com

Clinical Cardiology • Cardiac Imaging • Diagnostic Catheterization • Interventional Cardiology • Peripheral Vascular • Pacemaker Services • Electrophysiology

How did you hear about us: Physician Referred: _____________________________________________ (name of physician)

Referred by family/friend/current patient Internet Insurance Seen in the hospital Other __________________________

PATIENT EVALUATION (PLEASE ANSWER ALL QUESTIONS)

List all Surgeries: ____________________________________________________________________________________________________

List all Allergies: ____________________________________________________________________________________________________

List all Medications and Dosage: (Including aspirin and over the counter medications.) __________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________


Clinical Cardiology • Cardiac Imaging • Diagnostic Catheterization • Interventional Cardiology • Peripheral Vascular • Pacemaker Services • Electrophysiology

Date: ________________

Name: _____________________________________ Referring Physician _________________________________

Reason for Visit ________________________________________________________________________________

Past Medical History (check all that apply) Coronary Artery Disease High Cholesterol Thyroid Disorders Myocardial Infraction (Heart Attack) Stroke/TIA COPD/Lung Disease Sleep Apnea Asthma/Allergies Autoimmune Disorders Hypertension (High Blood Pressure) Anemia Diabetes Mellitus Heart Burn/Peptic Ulcers/Reflux Bleeding Disorders DVT Pulmonary Embolism PVD Kidney Disease Arthritis Lumbar Spine / Disk Degeneration Cancer HIV/AIDs Hepatitis Other _________________________________________

Pharmacy: ____________________________________________________________________________________________________________________

Adddress: ____________________________________________________________________________________________________________________

Phone: _______________________________________ Fax: ___________________________________


Clinical Cardiology • Cardiac Imaging • Diagnostic Catherization • Interventional Cardiology • Peripheral Vascular • Pacemaker Services

1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Heart and Vascular Care, Inc, 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040 and specifying the request method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request. 2. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment of your care, such as family members or friends. We are not required to agree with your requests; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use of disclosure of your IIHI, you must make your request in writing to: Heart and Vascular Care, Inc, 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040. Your request must be described in a clear and concise fashion: (a) the information you wish restricted; (b) whether you are requesting to limit our practice’s use, disclosure or both; and (c) to whom you want the limits to apply. 3. Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records, and billing records, but not including psychotherapy notes. You must submit your request in writing to: Heart and Vascular Care, Inc. 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040, in order to inspect and/or obtain a copy of your IIHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health professional chosen by us will conduct reviews. 4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to: Heart and Vascular Care, Inc. 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040. You must provide us with a reason that supports your request for an amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy: or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information. 5. Accounting of Disclosures. All if our patients have a right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part or the routine patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosure, you must submit your request in writing to: Heart and Vascular Care, Inc. 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists withinthe same12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. 6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at anytime. To obtain a copy of this notice, contact Heart and Vascular Care, Inc., 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040. 7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Heart and Vascular Care, Inc., 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health privacy policies, please contact: Heart and Vascular Care, Inc., 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040 or Call at 678-513-CARE (2273)

I acknowledge that I have received the Notice of Privacy Practices. __________________________________________________________ Signature Date

Patient Authorization for Practice to Release Protected Health Information to Third Parties

By signing this authorization, I authorize Heart and Vascular Care, Inc. to use and/or disclose certain protected health information (PHI) about me to or for the party or parties listed below.

• IgivemypermissiontoHeartandVascularCare,Inc.toleavedetailedmessagesonmyhomephone.

Patient Signature: ______________________________________________ Date: __________________

• IgivemypermissiontoHeartandVascularCare,Inc.toleavedetailedmessagesonmycellphone.


• IgivemypermissiontoHeartandVascularCare,Inc.toemailme.


• IgivemypermissiontoHeartandVascularCare,Inc.todiscussmymedicalinformationwithmy(ierelative/friend)

_______________________________________ whose name is _______________________________________


• IgivemypermissiontoHeartandVascularCare,Inc.todiscussmyfinancialinformationwithmy(ierelative/friend)

_______________________________________ whose name is _______________________________________


When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protectedbythefederalHIPPAPrivacyRule.IhavetherighttorevokethisauthorizationinwritingexcepttotheextentthatHeartandVascularCare,Inc. hasactedinrelianceuponthisauthorization.MywrittenrevocationmustbesubmittedtoHeart and Vascular Care, Inc.’s Privacy Officer at 3970 Deputy Bill Cantrell Memorial Road, Suite 100, Cumming, GA 30040.

Signed by:

Signature of Patient or Legal Guardian: _______________________________________ RelationshiptoPatient: _____________________________________

Patient’s Name: ______________________________________________________________________ Date: ________________________

Print Name of Patient or Legal Guardian: ____________________________________________________


Clinical Cardiology • Cardiac Imaging • Diagnostic Catherization • Interventional Cardiology • Peripheral Vascular • Pacemaker Services

Heart and Vascular Care, Inc. 3970 Deputy Bill Cantrell Memorial Rd, Suite 100, Cumming, GA 30040

Phone: 678-513-CARE (2273) Fax: 678-513-8869 www.hvcmd.com

Patient Consent for Email Communications

Email is a widely used form of communication. However, email transmissions are not inherently secure. Information sent via email is not encrypted and can be available for anyone to see. Therefore, sending information (especially sensitive or private information) via email is not a secure or confidential means of communicating. There are a number of risks associated with transmitting confidential information via standard email services. These risks include, but are not limited to:

● Emails can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. ● Senders can easily misaddress an email and send the information to an undesired recipient. ● Backup copies of emails may exist even after the sender and/or the recipient has deleted his or her copy. ● Employers and online services have a right to inspect emails and texts sent through their company systems. ● Emails can be intercepted, altered, forwarded or used without authorization or detection. ● Emails can be used as evidence in court. ● Email accounts may not be secured properly, and therefore it is possible that a third party may breach the confidentiality of such

communications. After considering the risks to unencrypted email communications, if you would like Heart and Vascular Care, Inc. to communicate via unencrypted email with you, that may contain your protected health information, please complete and sign this consent form below. You are not required to authorize the use of email as a communications method and a decision not to sign this authorization will not affect your health care services in any way. If you prefer not to authorize the use of email, we will continue to use our patient portal, U.S. Mail or telephone to communicate with you. I confirm that I wish to communicate with Heart and Vascular Care, Inc. and allow Heart and Vascular Care, Inc. to communicate with me via unencrypted email. Furthermore, I understand that:

● IN A MEDICAL EMERGENCY, I SHOULD NOT USE EMAIL. I SHOULD CALL 911. Furthermore, email is not appropriate for urgent problems during business hours. I should call Heart and Vascular Care, Inc. office at (678) 513-2273.

● Emails sent to Heart and Vascular Care, Inc. should not be time-sensitive. While we try to respond to email messages daily, we cannot guarantee that any particular email will be read and responded to within any particular period of time. If you have not heard back from us within three days, call our office to follow up if we have received your email.

● It is my request to allow Heart and Vascular Care, Inc. to communicate with me via email. ● Unencrypted email is not secure and the security and confidentiality of this communication cannot be guaranteed. ● All email communications will be documented in my clinical records at Heart and Vascular Care, Inc. ● Heart and Vascular Care, Inc. will not correspond via email with any email address except those listed on this consent form. Please refer

to our Notice of Privacy Practices for information as to permitted uses and disclosures of your health information and your rights regarding privacy matters.

● It is my responsibility to inform Heart and Vascular Care, Inc. of any changes in my email address from that listed below. ● It is my right to revoke this consent for email correspondence with Heart and Vascular Care, Inc. at any time via notification of the practice

contact listed below. My revocation of consent will not affect my ability to obtain future health care nor will it cause the loss of any benefits to which I am otherwise entitled. Any resumption of email communications thereafter will require completion of a new consent form.

Please initial each item below in which you authorize Heart and Vascular Care, Inc. to communicate with you via email. ____ Appointment reminders ____ Clinical / Medical Records ____ Breach notifications

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with unencrypted email as a form of communication and do hereby give permission to Heart and Vascular Care, Inc. to send personal health information via unencrypted email to the email address(es) listed below. Print Patient Name: _____________________________________ Date: ____________________________ Patient/Legal Guardian Signature: ___________________________________________________ Approved Email Address(es): _________________________________________________________________________________________

http://www.hvcmd.com/



General Consent for Care and Treatment Consent TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner or Physician Assistant), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. _____________________________________________ ____________________ Signature of Patient or Personal Representative Date _____________________________________________ ____________________ Printed Name of Patient or Personal Representative Relationship to Patient




Authorization to Release or Request Health Information

Last Name: __________________________First Name: _________________ ____________Middle: __________

Date of Birth: ______Home Phone: __Work Phone: _________________

Address: _______________City: _______________ State: ______

I hereby request access to the protected health information in my health record from (date)_______to (date) ____maintained or created by the provider named below to the recipient named below.

o Most recent Progress Notes

o Discharge Summaries o Billing Records

o Entire Health Record o Pathology/Lab Report

o Other_______________________________________________________________________________________ Purpose of Request: o Patient Request o Referral o Continuation of Care o Other: ________________________

o I will pick up copies of my records. o Fax my records to: __

o Mail copies of my records to the individual noted below

o Records to facility listed below o Records from facility listed below

Facility Name: ___________________________________________________________________________

Facility Address: __________________________________________________________________________

Facility Phone Number: ____________________________________________________________________

Facility Fax Number: ______________________________________________________________________

•I understand that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written authorization unless otherwise provided for in the regulations •I may revoke this Authorization at any time by providing my written revocation to the address at the top of this form. My revocation will not apply to information already retained, used, or disclosed in response to this Authorization. Unless sooner revoked, the automatic expiration date of this Authorization will be twelve (12) months from the date of signature. •Heart and Vascular Care, Inc. will charge an administrative fee per the Georgia state statute to cover the cost of labor, copying and postage. •Unless the purpose of this Authorization is to determine payment of a claim or benefits, Heart and Vascular Care, Inc. may not condition the provision of treatment or payment for my care on my signing this Authorization. •The information authorized for release may include drug/alcohol abuse information. If present has been disclosed from records whose confidentially is protected by federal law. Federal regulation (42CFR Part 2) prohibits recipients from making any further disclosure of this information except with specific written consent of the patient. HIV testing, ARC and/or SIDS related diagnosis is further prohibited from disclosure by State Regulations without the specific written consent of the patient. A general authorization for the release of information if held by another party is not sufficient for this purpose. •Notice is hereby given to the patient or legal representative signing this Authorization that Heart and Vascular Care, Inc. cannot guarantee that the Recipient receiving the requested health information will not re-disclose any of it to others. Notice is hereby given to the Recipient that law prohibits this re-disclosure of any health information regarding drug and/or alcohol abuse, HIV and mental health treatment

___________________________________________ ________________ ________________________________ Signature of Patient or Authorized Representative Date Relationship if Not Patient


confidential patient information sheet (please print) … · heart and vascular care, inc. 3970...

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