HealthyHearts | Patient Information Form

Office & Patient

Preferred Office * Date of Birth * First Name * Last Name * Email Address Account Number (if known)

Sex

Male Female Other

Marital Status

Single Married Widowed Divorced Separated

If married, name of spouse Spouse's date of birth Patient's Employer Occupation

How did you hear about us?

Phone Numbers

At least one phone number is required.

Home Phone Work Phone Cell Phone

Preferred contact number

Home Work Cell

Home Address

Address Line 1 * Address Line 2 City * State * ZIP Code *

Are you a resident of a skilled nursing or board and care facility?

Yes No

Emergency Contact

Emergency Contact Name Emergency Contact Phone

Physicians

Referred By Primary Care Physician

Primary care physician status

Named above Unknown None

Demographics

Preferred Pharmacy

Preferred Pharmacy Name Preferred Pharmacy Phone Number

Preferred Pharmacy Address

Authorization to Disclose Medical Information

I authorize Cardiovascular Consultants Medical Group physicians and staff to disclose to and discuss my protected health information with the following (e.g. family member, friend) person or persons in addition to my other health care providers.

Name 1 Name 2

I prefer no one have access to my health information without my written consent except where allowed by law.

Yes No

Signature of patient (type your full name) * Date

Consent for Treatment

The undersigned hereby authorizes and consents to any cardiac examination, laboratory procedure, and all treatments rendered to me by Cardiovascular Consultants Medical Group.

Signature of authorized person (type your full name) * Date

Financial Agreement and Information Release

I hereby authorize payment directly to Cardiovascular Consultants Medical Group otherwise payable to me for the services rendered. I understand that I am financially responsible for all copays, deductibles, and noncovered services. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment, obtain authorization for medical services and communicate with other treating physicians.

Signature of insured/authorized person (type your full name) * Date

Required Acknowledgements

I confirm this patient information is accurate. I consent to being contacted regarding registration and appointment scheduling.