New Patient Forms

Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez M.D.

Please correct the errors described below.
  • The patient's name, address and patient number, if applicable,
  • The effective date of this authorization, and the recipients of the PHI according to this authorization,
  • The patient's desire to revoke this authorization, and
  • The date of the revocation, and the patient's signature.

Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D. will accept written revocations of this authorization via

All revocations must be sent to Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D. to the attention of the Privacy Officer, Kevin Marcantel, and are not effective until received by the Privacy Officer. This authorization shall not expire for life, unless patient informed. After this date, Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez M.D. tcan no longer use or disclose the patient's PHI without first obtaining a new authorization form.

I fully understand and accept the terms of this authorization.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

FOR OFFICE USE ONLY

On

Acknowledgement of Receipt of Privacy Notice

I have been presented with a copy of Cardiovascular Diagnostic Center, APMC's Notice of Privacy Practices, detailing how my information may be used and disclosed as permitted under federal and state law. I have understand the contents of the Notice. Further I permit a copy of this authorization to be used in place of the original, and requested payment of medical insurance benefits either to myself or to the party who accepts assignments. Regulations pertaining to medical assignment of benefits apply.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

If not signed by the patient, please indicate relationshop to patient (e.g., Spouse)

Internal Use Only

If patient or patient's representative refuses to sign acknowledgement of receipt of notice, please document the date and time the notice was presented to patient and sign below.

Patient Authorization to Use or Disclose Protected Health Information

, understand Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D. is authorized by me to use or disclose my protected health information (PHI) for a purpose other than treatment, payment or healthcare operations. I have read this authorization and understand what information will be used or discloses, who may use and disclose the information and the recipient(s) of that information. I specifically authorize any current employee or owner of Cardiovascular Diagnostic Center, APMC-Virginia Y. Gonzalez, M.D., or any other individual listed below to disclose my PHI as described on this form to the recipients listed below.

Name(s) or class of person(s) other than current employees or owner(s) authorized by this form to use and disclose the patient's PHI: Social Security. Disability Determination, Insurance Companies, Billing Companies, Referring Physician(s), Hospital(s). Names(s) or class of person(s) authorized by this form who may use and disclose the patient's PHI: Referring or consulting physician(s) and hospital(s). Purpose(s) of the information: Release of medical records and patients demographics for Disability Determination, referral, insurance and billing purpose.

Any other address or fax number is not permitted by this authorization.

The patient has a right to revoke this authorization in writing except to the extend that action has been take in reliance on this authorization of, if applicable, during a contestability period. In order for the revocation of this authorization to be effective Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D. must receive the revocation in writing. The revocation must include:

PLEASE PROVIDE A LIST OF CURRENT MEDICATIONS TO THE FRONT OFFICE

Have you ever had the following

Tell us about you risk of hearth disease

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If Yes, Please List your medication and the reaction you had

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If so, WHEN and WHERE

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If YES, Please list the Hospital Name and Date

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Health Habits

PATIENT INFORMATION

Please Provide Emergency Contact Information of a relative or friend not living with you

Policyholder Information (Please Complete if the patient is not the policyholder)

Financial Responsibility

All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payment; however, the patient is ultimately responsible for all fees charged for services rendered regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangement have been made in advance with our office. If hospitalization is indicated, the patient is responsible for furnishing insurance claims to be office prior to hospiralization.

Pre-certification or Pre-authorization for Care

Many insurance policies and managed care plans require pre-certification from the carrier or advance authorizations from the patient's Primary Care Physician. When such pre-certification or pre-authorization is not obtained when non-emergency care is sought, the insurance policy or managed care plan may provide no or dramatically reduced benefits. Our office staff will assist you to the extend possible to secure such pre-certification or pre-authorization. Ultimately, it is the patient's responsibility to secure such pre-certification or pre-authorization under the terms and conditions of their insurance policy or managed care plan.

Truth In Lending Agreement & Assignment of Benefits

This date, I have contracted with Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D., for the furnishing of medical or surgical procedures for illness or injury. I will be responsible for payment of the total bill incurred as a result of treatment received. Although I may choose to use insurance coverage to pay all or a portion of the bill incurred, I understand that the filing of insurance claims does not constitute payment of any portion of the bill and I understand that I am responsible for all charges billed to me for treatment. I accept full responsibility for payment of the total balance of my account. When the account becomes 90 days old, or after all insurance has been paid, a monthly finance charge of 1% will be applied to the remaining balance. I have this date assigned to Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D., the benefits due to me under my existing policy or policies of insurance. is accepted by Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D., as convenience to me and Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D., is hereby given my consent to file claims on said policy or policies and do such other actions as it deems necessary in connection therewith so as to obtain prompt payment under such policies. I authorize my insurance company to pay Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D., direct without payment to me.

Consent to Release of Medical & Insurance Information

I hereby authorize the physicians, employees and agent of Cardiovascular Diagnostic Center, APMC- Virginia Y. Gonzalez, M.D., to examine any and all of my insurance and/or medical records; to obtain at their expense, photo static copies of such records as they may desire ; to discuss my medical history, examination and treatment with physicians, nurses and other healthcare providers who have treated or examined me; and to release or discuss information relating to my care in order to expedite the processing of claims for reimbursement from insurers, managed care entities or other agencies responsible for claim processing. I further agree that this authorization shall be valid and effective unless and until it is revoked by me in writing. A photocopy of this authorization may serve as an original.

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