PatientDemographics(Confidential)
Today’sDate: _
Patient NameBirthdate: _
First NameLast NameMiddle Initial
Street Address_
CityStateZip Code
Home Phone:Cell Phone:Work Phone:
E-Mail Address:
Sex: M FMaritalStatus: M S D W OtherSocial Security #_
Patient EmployedBy
Thissectionmustbecompletedifyouarenotthesubscriberoftheinsurance.
ResponsibleParty:
Birth date:
RelationshiptoPatient:
ResponsiblePartySocialSecurity#
PrimaryInsuranceCompanyInsurance Phone#_
ID#Group#_
Secondary InsuranceCompanyInsurancePhone#
ID#Group#_
WhoReferredYoutoThis Practice_
Primary Care Physician (1stand lastname)Phone#_
…………………………………………………………………………………………………………………………………
Assignment & Release:
I,theundersigned,havecoveragewithandassigndirectlytoPinnacle CardiovascularAssociates.All medicalbenefits,ifany,otherwisepayabletomeforservicesrendered.IunderstandthatIamfinanciallyresponsibleforall chargeswhetherornotpaidbyinsurance.Iunderstandmysignaturerequeststhatpaymentbemadeandauthorizereleaseof medical information necessary to pay the claim. I authorize the use to this signature on all insurance submissions.
Patient/Guardian Signature
Date
IunderstandandagreethatIampersonallyresponsibleforallchargesincurredregardlessofmyinsurancecoverage.Inthe eventthatmy accountisreferredtoan attorneyforcollection, I agreethatinadditiontothe balance owed,Iwillbe responsiblefor collectionandattorneyfeesinadditiontothebalanceowed,Paymentfortheservicesrenderedortoberenderedinthefuture,is irrevocablyandunconditionallyguaranteedbyGuarantorwhosesignatureappearsbelow,togetherwithinterestthereonandall late charges,attorney’s feescost andexpenses of collection incurredinenforcing anyof such liabilities.
I agree thatall above information iscorrect tothebestofmy knowledge.
Patient/Responsible Party Signature
Date
I,theundersigned,authorizePinnacle CardiovascularAssociates.Tospeakwiththeperson(s)and/orProvider(s)listedbelowregarding mymedicalcare.IunderstandthatwithmysignatureIamauthorizingthereleaseofwrittenororalcommunicationbyPinnacle CardiovascularAssociates.Tothelistedperson(s)/Provider(s)andtherebyreleasePinnacle CardiovascularAssociates,andtheirstafffromall legal responsibility that mayarisefrom theact herebyauthorized:
Authorized Person/Emergency ContactRelationshipto PatientPhone number
AuthorizedPersonRelationship toPatientPhone number
Providers(otherdoctors):
NamePhone number
NamePhone number
SignatureofPatient/GuardianDate
I,theundersigned,authorizePinnacle CardiovascularAssociates.Toleaveavoicemailmessageatthefollowingphonenumber(s):
Messagesmayattimesincludesomeprotectedhealthinformation,includingappointmentreminders,testresultsandinstructions. IunderstandthatwithmysignatureIamauthorizingthereleaseoforalcommunicationbyPinnacle CardiovascularAssociates.tothis voicemailnumber(s)andtherebyreleasePinnacle CardiovascularAssociates.Andtheirstafffromalllegalresponsibilitythatmayarise from theact herebyauthorized.
SignatureofInsured/GuardianDate
PCA Account#
PATIENTHISTORYQUESTIONNAIRE
Today’s Date:
Name:Date of Birth:
Do you have any medication allergies: Do you have any food allergies:
List other Physicians treatingyouatthistime:
Name (1stand last)Specialty
Name (1stand last)Specialty
Pharmacy Name: Address: Phone #:
YourPastMedicalHistoryCheck box and circlechoicewhereappropriate / Date of Onset
0ChestPainorAngina
0HeartValveDisorders
0Arrhythmia/Palpitations
0CongenitalHeartDisease
0COPD/Emphysema/Bronchitis/Asthma
0CongestiveHeartFailure
0Diabetes: Type 1 or2
0Highcholesterol
0 Hypertension
0HeartAttack/CoronaryArteryDisease
0RheumaticHeartDisease
0Syncope/Dizziness
0Stroke/TIA
0HeartMurmurs
0AbnormalEKG
SocialHistory:
MaritalStatus:0Single 0Married 0Widowed 0Divorced0OtherNumberofChildren: YourOccupation Doyouexerciseroutinely/type/amount HistoryofTobaccoUse:0Yes0No HistoryofAlcoholUse:0Yes0No
HistoryofCaffeineUse: 0Yes0NoHistoryofIllicitDrugUse:0Yes0NoWhatbringsyoutotheofficetoday?
NoticeandAcknowledgement
I acknowledge I have been informed that the Notice of Privacy Practices fromPinnacle CardiovascularAssociates.Isavailabletome toreviewonthecompanywebsite or in the patient waiting room. Additionally, a copy is Availabletome uponrequestintheoffice.
Patient or Personal Representative Date Signature
IfPersonalRepresentative’ssignatureappears above, please describe Personal Representative’s Relationship to patient.
Credit and Payment Policy
Itisourgoal toprovide youthebestcardiaccare wepossiblycan.Part of yourcareincludesthebillingofyourinsuranceprovidedwe’vereceivedthecorrectandcompleteinformationfromyou. Ifcompleteinformationisnot provided atthetimeofyourvisit, you willbebilled. Pleasereadthefollowinginformationasit will answermanyof yourquestionsregardingourbillingpolicies.
AllPatients:Areexpectedtohavetheircurrentinsurancecard,validpictureID,Co-pay,co-insuranceand any balancethatisdueatthetimeof service.
HMO/ManagedCarePlans/Tricare:Itisyourresponsibilitytomakesureacurrentreferralhasbeen obtainedpriortoappointmentwithouroffice.Ifnoreferralhasbeenobtained,yourappointmentwillberescheduled. Itis thepatient’s responsibilitytomake surethecorrectreferral isinplaceif youarehavingtesting performed.
Co-pays: Primaryand secondaryinsurancesco-pays mustbe paidattimeofcheckin.Patientswillbeasked tore-scheduleiftheydon’thavetheirco-pay.Iftheco-payisnotpaidattimeofservice,therewillbea$25.00 billing feeadded.
Collections:PatientsthathaveanunresolvedbalancewillbesenttoCollections,patientswillthenaccruean additionalcollectionsfeeof35%.Patientsareexpectedtoresolveallbalancesand/orCollectionissuesbeforesetting uptheirnextappointment;Pinnacle CardiovascularAssociatesdoesnotpermitpatientstocarrybalances.Ifpatientbalancesare not addressedpatientsarerunning theriskof being discharged fromPinnacle CardiovascularAssociates.
NoShows:Failuretocancelanappointmentwithin48hourswillresultina$25.00noshowfee.Any diagnosticstudy(Echo,NuclearStresstest,AbdominalUltrasound,ABIs,Stresstest,StressEcho’s)not canceledwithin48hourswillresultina$50.00noshowfee.IfyouhaveaNuclearStresstestanadditional feeof $50.00will be accrued with a possibleadditional$75.00ifyouarescheduled fora lexascan.
Pleaserememberaconfirmationcallisacourtesydonebythisofficeandnotanobligation, therefore willnot bea reason towaive a no-show fee.
Ihaveread,understand,andagreetotheaboveFinancialPolicy.I understandthatchargesnot coveredbymyinsurancecompany,aswellasapplicableco-paymentsanddeductibles,aremyresponsibility.Iunderstandthatitismyresponsibilitytocontactmyinsurancecarrier(s)iftheydonotrespondtopaymentrequestsmadeonmybehalf.
Signature(guarantor if patientis a minor)
Office use only
AccountNumber
Date:
Carlos Leche MD, F.A.C.C
1601 West Reynolds Street Suite 102
Plant City Florida 33653
Phone # (813) 413-1455 Fax # (813) 413-1454
LOWEREXTREMITYSTUDYQUESTIONNAIRE
Patient Name:DOB:Date:
PCA Account #
For office tocomplete
Pleasetakeamomentandcompletethefollowingtodiscussat yourvisit.
Check if you have or are currentlyexperiencingthefollowing:
[] History of Peripheral arterial disease
(Peripheral vascular disease)
[] Pain in one or both legs
[] Cramps in your calves or thighs []Exertionalpaininyourlegs
[] History of stents or bypass surgeryinvolving your legs [] History of leg ulcer
[]Swellinginoneorbothlegs
[] History of Deep vein thrombosis (DVT) [] History of Pulmonary embolism (PE)
Wewillprovideyouthechoicetooptoutofthoseactivities.Youmayalsochoosetooptbackin.Wemayuseordiscloseyourprotectedhealthinformationinthefollowingsituationswithoutyourauthorization. Thesesituationsinclude:asrequiredbylaw,publichealthissuesasrequiredbylaw,communicablediseases,healthoversight,abuseorneglect,foodanddrugadministrationrequirements,legalproceedings,lawenforcement,coroners,funeraldirectors,organdonation,research,criminalactivity,militaryactivityandnationalsecurity,workers’compensation,inmates,andotherrequiredusesanddisclosures.Underthelaw,wemustmakedisclosurestoyouuponyourrequest.Underthelaw,wemustalsodiscloseyourprotectedhealthinformationwhenrequiredbytheSecretaryoftheDepartmentofHealthandHumanServicesto investigateordetermineourcompliancewiththerequirementsunderSection164.500.
USESANDDISCLOSURESTHATREQUIREYOURAUTHORIZATION
OtherPermittedandRequiredUsesandDisclosureswillbemadeonlywithyourconsent,authorizationoropportunitytoobjectunlessrequiredbylaw.Withoutyourauthorization,weareexpresslyprohibitedtouseordiscloseyourprotectedhealthinformationformarketingpurposes.
Wemaynotsellyourprotectedhealthinformationwithoutyourauthorization.Wemaynotuseordisclosemostpsychotherapynotescontainedinyourprotectedhealthinformation.Wewillnotuseordiscloseanyofyourprotectedhealthinformationthatcontainsgeneticinformationthatwillbeusedforunderwritingpurposes.
Youmayrevoketheauthorization,atanytime,inwriting,excepttotheextentthatyourphysicianorthephysician’spracticehastakenanactioninrelianceontheuseordisclosureindicatedintheauthorization.
YOURRIGHTS
Thefollowingarestatementsofyourrightswithrespecttoyourprotectedhealthinformation.
Youhavetherighttoinspectandcopyyourprotectedhealthinformation(feesmay apply)–Pursuanttoyourwrittenrequest,youhavetherighttoinspectorcopyyourprotectedhealthinformationwhetherinpaperorelectronicformat.Underfederallaw,however,youmaynotinspectorcopythefollowingrecords:Psychotherapynotes,informationcompiledinreasonableanticipationof,orusedin,acivil,criminal,oradministrativeactionorproceeding,protectedhealthinformationrestrictedbylaw,informationthatisrelatedtomedicalresearchinwhichyouhaveagreedto participate,informationwhosedisclosuremayresultinharmorinjurytoyouortoanotherperson,orinformationthatwasobtainedunderapromiseofconfidentiality.
Youhavetherighttorequestarestrictionofyourprotectedhealthinformation–Thismeansyoumayaskusnotto useordiscloseanypartofyourprotectedhealthinformationforthepurposesoftreatment,paymentorhealthcareoperations.YoumayalsorequestthatanypartofyourprotectedhealthinformationnotbedisclosedtofamilymembersorfriendswhomaybeinvolvedinyourcareorfornotificationpurposesasdescribedinthisNoticeofPrivacyPractices.Yourrequestmuststatethespecificrestrictionrequestedandtowhomyouwanttherestrictiontoapply.Yourphysicianisnotrequiredtoagreetoyourrequestedrestrictionexceptifyourequestthatthephysiciannotdiscloseprotectedhealthinformationtoyourhealthplanwithrespecttohealthcareforwhichyouhavepaidinfulloutofpocket.
Youhavetherighttorequestconfidentialcommunications–Youhavetherighttorequestconfidentialcommunicationfromusbyalternativemeansoratanalternativelocation.Youhavetherighttoobtainapapercopyofthisnoticefromus,uponrequest,evenifyouhaveagreedtoacceptthisnoticealternativelyi.e.electronically. (Continuedonbackpage…)
Youhavetherighttorequest anamendmenttoyourprotectedhealthinformation– Ifwe denyyourrequestforamendment,youhavetherighttofileastatementofdisagreementwithusandwemaypreparearebuttaltoyourstatementandwillprovideyouwithacopyofanysuchrebuttal.
Youhavetherighttoreceiveanaccountingofcertaindisclosures–Youhavetherighttoreceiveanaccountingofdisclosures,paperorelectronic,exceptfordisclosures:pursuanttoanauthorization,forpurposesoftreatment,payment,healthcareoperations;requiredbylaw,thatoccurredpriortoApril14,2003,orsixyearspriortothedateoftherequest.
Youhavetherighttoreceivenoticeofabreach–Wewillnotifyyouifyourunsecuredprotectedhealthinformationhasbeenbreached.
Youhavetherighttoobtainapapercopyofthisnoticefromusevenifyouhaveagreedtoreceivethenoticeelectronically.Wereservetherighttochangethetermsofthisnoticeandwewillnotifyyouofsuchchangesonthefollowingappointment.Wewillalsomakeavailablecopiesofournewnoticeifyouwishtoobtainone.
COMPLAINTS
YoumaycomplaintousortotheSecretaryofHealthandHumanServicesifyoubelieveyourprivacyrightshavebeenviolatedbyus.YoumayfileacomplaintwithusbynotifyingourHIPAAComplianceOfficerofyourcomplaint.Wewillnotretaliateagainstyouforfilingacomplaint.
HIPAA COMPLIANCE OFFICER: Juana Gordillo Office Manager.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person orbyphoneatourmainphonenumber.
Pleasesignbelow.PleasenotethatbysigningthisformyouareonlyacknowledgingthatyouhavereceivedorbeengiventheopportunitytoreceiveacopyofourNoticeofPrivacyPractices.
PatientNamePatientSignatureDate
Carlos A Leche, MD, F.A.C.C
1601 West Reynolds Street Suite 102
Plant City Florida 33563
Phone # 813-413-1455 Fax # 813-413-1454
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I, ______DOB: ______SS: ______
Authorize to release my confidential information regarding my medical records to:
Pinnacle Cardiovascular Associates
Carlos A Leche, MD, F.A.C.C
1601 West Reynolds Street Suite 102
Plant City Florida 33563
Phone # 813-413-1455 Fax # 813-413-1454
Please send ALL records on patient to include: Cardiac Cath, EKG tracing, H&P, Discharge notes, Previous Cardiology consult note, Labs, ECHO, Nuclear Stress Test, Operative Reports, CTA’s, Arterial Doppler, Carotid Doppler, Office notes, and ER reports.
______
Patient Signature Date