New Patient Packet

Cardiovascular Institute of the South - New Patient Packet

Name:

DOB: Chart: Age: Date:

PATIENT INFORMATION

If MINOR, 17 years old or younger, please fill out the Guarantor Information below.

I decline to answer the questions listed below that are requested by the U.S. Government.

Preferred Language:

English

Spanish

French

Other

Physical Address:

Street City State Zip Code

Mailing Address:

Street City State Zip Code

Employer Occupation Work Phone Number

Emergency Contact Name Emergency Contact Phone Number Relationship to Patient

***Is this visit related to a Worker's Compensation Claim? Yes No

Guarantor Information (Person Legally Responsible for minor's finances.) Same as above

Patient's Relationship to Guarantor:

Son Daughter Grandson Granddaughter Other:

Mailing address City State Zip Code

Sex: Male Female

Guarantor Date of Birth Social Security Number

Status: Divorced Married Single

Home Phone Number Cell Phone Number Employer Name and Phone Number

Please indicate how you heard about us.

Hospital Follow-up Health Fair/Screening Newspaper Television

Radio Yellow Pages Other Patient Internet

Physician Other:

Did a physician refer you to our clinic? No Yes Name:

Name of your family physician: Name and Address of Referring Physician

Home Telephone Number Cell Phone Number Alternate Phone Number Email Address

BILLING POLICIES

I understand that I am responsible for the payment of this account. I agree to present my current insurance card(s) or Worker's Compensation coverage information at each visit to Cardiovascular Institute of the South (CIS) in order for verification of my healthcare benefits and accurate filing of my medical claims. I authorize my current and future insurance plan(s) or worker's compensation carrier(s) to pay my medical benefits to CIS.

Primary Insurance:

Secondary Insurance:

Tertiary Insurance:

I also agree to the following:

To pay all deductibles and co-payments at the time of service.

To pay all allowable amounts not paid by my insurance plan(s) or other designated agency(s) within 30 days receipt of a statement.

If there are no medical benefits or other such coverage for the charges of this account, to pay the full balance of all charges at the time of service.

To allow CIS to verify my Worker’s Compensation coverage, if applicable, with my employer or employer's insurance carrier.

If this account becomes delinquent, to pay all collection and court fees incurred with the collection of this account.

To allow CIS to furnish my medical information and/or copies of my medical records to my insurance plan(s) or Worker’s Compensation carrier as reasonably requested for the processing of my medical claim(s).

To pay a $25 Medical Form/Letter Completion charge per requesting entity for medical forms or letters requiring medical record and/or provider review.

Furthermore, I agree to notify CIS immediately if I have knowledge that my medical claims are being filed to an incorrect insurance plan(s) or Worker's Compensation carrier.

E-Prescribing Information and Patient Consent

E-Prescriptions, or Electronic Prescriptions, are computer generated prescriptions created by your provider and sent directly to your pharmacy. CIS participates in E-Prescribing because we care about your health and wellbeing and E-prescribing has multiple safety benefits.

Instead of writing out your prescriptions on a piece of paper, your prescription is entered directly into the computer. Your prescription travels from your CIS' computer to the pharmacy's computer. E-prescriptions are sent electronically through a private, secure, and closed network, so your prescription information is not sent over the open internet or as email. If you do not want your prescription sent electronically, or your pharmacy does not accept e-prescriptions, your prescriptions can be printed for you.

The privacy of your personal health information contained in all your prescriptions, whether written or electronic, is protected by federal and state laws. The federal law is the Health Insurance Portability and Accountability Act (HIPAA).

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices and understand it may be changed at any time.

I give permission for CIS and its agents, employees and representatives to use my contact information, including cell phone numbers, for appointment reminders, patient satisfaction surveys, treatment, or other healthcare purposes.

Patient Consent for E-Prescribing

I agree that Cardiovascular Institute of the South may e-prescribe my prescriptions and may request and use my prescription medication history from other healthcare providers or third party pharmacy benefits payers for treatment purposes.

PATIENT CARE STATEMENT

It is the policy of the Cardiovascular Institute of the South (CIS) and its physicians to inform each patient that we strive to deliver excellence in health care. However, we feel that it is critical that our patients fully understand that cardiovascular disorders are by their very nature serious and capable of causing immediate death or disability.

As cardiovascular disorders often involve multiple organ systems and may require different methods of treatment, I understand that there are risks associated with care and that second opinions are encouraged.

PATIENT CARE STATEMENT cont.

I understand that I am in large measure responsible for my health.

As a representative of the above individual, I acknowledge the above on their behalf.

In signing this document, I acknowledge that I have provided the most accurate and complete information to the best of my knowledge; I have read and understand the policies and statements.