Patient Registration Forms

At NoVa Cardiovascular Care, we strive to provide culturally-sensitive patient care. Per our policy, we support our patient’s right to utilize chaperones when requested or necessary during examinations or procedures.

Patient Name:

Patient DOB:

I wish to have a chaperone in the room during my test. I do not wish to have a chaperone in the room during my test.

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

Patient's Signature

Date

Full Name

Soc. Sec #

Date of Birth

Full Time Part Time Student

INSURANCE INFORMATION

Phone

Policy ID Number

Group ID Number

Address

City

State

Zip

Occupation

Work Phone

Cell Phone

Home Phone

Emergency Contact Name

Phone Number

Employer

Company Name

Street Address

City

State

Zip

Does your insurance required a Referral

Yes No

Name of Primary Insurance Agency

Mailing Address

City

State

Zip

If the patient is not the insurance policyholder or if there is a secondary insurance company, Please complete below

Policy Holder's Name

Home Address

City

State

Zip

Employer / Company

City

State

Zip

Name of Secondary Insurance Company

Mailing Address

City

State

Zip

Your Relationship to Policy Holder

Spouse

Child

Other

Other, Please Specify

Policy Holder's Info

Male

Female

Date of Birth

Phone

Home

Office

Insurance Phone

Policy ID #

Group #

Name of Referring Physician

Please Read and Sign the following:
Direct payment of surgical/medical benefits to NOVA Cardiovascular Care, Inc (NVCC). NVCC is authorized by me for services rendered by any of its employees/him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance.
NOVA Cardiovascular Care, Inc. is hereby authorized to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.
All information given by me in applying for payment is certified to be correct. Release of all records on request and payment of authorized benefits made on my behalf is authorized.
A photocopy of these assignments shall be deemed as valid as the original

Patient's Name

Date

Patient History Questionnaire

Name

Date of Birth

Age

Referring Provider

Today's Date

Reason for today’s visit

If you HAVE HAD or CURRENTLY HAVE any of the following,
please indicate with a check next to the condition:

RESPIRATORY

Asthma

COPD/Bronchitis

Pneumonia

Persistent cough

Shortness of breath

Sleep Apnea

CPAP?

HEMATOLOGICAL/ONCOLOGICAL

Anemia

Bleeding disorder

Thrombophilia/Clotting disorder

Blood clots in legs or lungs

Cancer, What type?

RHEUMATOLOGY

Gout

Arthritis/Joint Swelling

Muscle Aches

Connective Tissue Disease

INFECTIOUS DISEASE

Hepatitis

HIV/AIDS

ENDOCRINE

Diabetes

Thyroid Disease

Weight Gain/Loss

Night Sweats

GASTROINTESTINAL

Gastrointestinal Bleeding

Blood in Stool

Gall Stone

Hiatal Hernia

Acid Reflux/Heartburn

Stomach Ulcers

Liver Disease

Nausea or Vomiting

RENAL/UROLOGICAL

Kidney Disease

Dialysis

Blood in Urine

Kidney Stones

Painful urination

Enlarged Prostate

NEUROLOGICAL

Neuropathy

Vision change / Loss of vision

Stroke / TIA

Seizures

PSYCHOLOGICAL

Anxiety / Panic attacks

Depression

Insomnia

Other psychiatric concern

If Other, please specify

Social History

Occupation

If so, how long?

Packs per day:

If you quit, when?

If so, how much?

If so, what kind?

If so, how much?

If so, how often?

Type of exercise

Family History

Please indicate any family health problems such as Hypertension, Diabetes, Coronary Artery Disease, Stents, CABG, Valve replacement/repair, Hyperlipidemia, AAA, CHF, Cardiomyopathy, Arrhythmias, Congenital Heart Disease, Sudden/unexplained death. Include age and alive/deceased.

Father

Mother

Siblings

Other

Surgical History

Please indicate any surgical operations you have had, including date if known

Allergies

If so, please list

Current Medications

Please list current medications and doses (if known)

Signature

Date

Patient History Form

Today's Date

Patient's Name

Date of Birth

Signature

Date

Acknowledgement of Receipt of Privacy Practices

NOVA Cardiovascular Care, Inc. will use and disclose your personal health information to treat you, to receive payment for care we provide and for other health care operations. Health Care operations generally include activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you better understand our policies regarding protected health information. The terms of the notice may change. Updates will be posted and available in our office. I acknowledge I have received, read and understand the NOTICE OF PRIVACY PRACTICES.

have received a copy of the “Notice of Privacy Practices” for NOVA Cardiovascular Care, Inc. As provided in the notice, terms of the notice may change. If we change our privacy practices, you may receive a revised copy. This notice is available in our office for review.

I understand that I may access my medical records at any time and that I may copy or inspect my PHI to be used or disclosed in accordance with NOVA Cardiovascular Care, Inc.’s policy.

I understand that NOVA Cardiovascular Care, Inc. may charge me for copies of my medical records or completion of medical forms (including FMLA, Worker’s Comp, etc.) and that a fee schedule will be provided to me. Electronic copies of my records can be emailed to me directly or faxed to other providers for free.

I understand that a request for a copy of my records must be submitted to NOVA Cardiovascular Care in writing and may take up to 7 business days to process.

I understand that NOVA Cardiovascular Care, Inc. has the right to deny me access to my records in certain circumstances that are in accordance with the law; however, in such an instance I will be provided with a denial in writing.

Authorization For Use & Disclosure of Personal Health Information

Our Notice of Privacy Practices provides information about we may use and disclose protected health information (PHI) about you. It has been explained to the patient that disclosures may be made to family and friends related to the patient’s health with permission provided by the patient. It has also been explained that we will only disclose information relevant to current treatment. Our patient has agreed to only disclose PHI to the following:

Spouse

In Person By Phone

Parent(s)

In Person By Phone

Sibling(s)

In Person By Phone

Other

In Person By Phone

Expiration date of authorization

OR Until otherwise specified

authorize the use or disclosure of my PHI as specified in the Notice of Privacy Practices for NOVA Cardiovascular Care, Inc. I understand the purpose of the authorized use and disclosure of PHI is for use within NOVA Cardiovascular Care, Inc. or for authorized disclosure to another entity subject to the privacy rules of NOVA Cardiovascular Care, Inc. for treatment, payment, or healthcare operation purposes. I also understand that if the organization authorized to receive my PHI is not a health place or health care providers, that organization may disclose my PHI and it may no longer be protected under federal privacy rules and regulations. I understand that this authorization is voluntary and may be revoked at any time. I understand that I may ask questions of NOVA Cardiovascular Care, Inc. if I do not understand any information contained in the Notice of Privacy Practices.

Patient's Name / Signature

Relationship to Patient

Date

Financial Policy

NOVA Cardiovascular Care, Inc. would like you to understand our financial policies.

1. Payment is due at the time of service unless arrangements have been made in advance by your carrier. We accept Visa and Mastercard.

2. Your insurance policy is a contract between you and your insurance company. As a service to you, we will file your insurance claim if you assign the benefits to the doctor (if you agree to have your insurance company pay the doctor directly). If your insurance company does not pay the practice within a reasonable period, we will expect you to complete payment. If we later receive a check from your insurer, we will refund any overpayment to you.

3. We have made prior arrangements with many insurance companies and other health plans to accept an assignment of benefits. We will bill them and you are required to pay a copayment at the time of your visit.

4. If you are insured by a plan that we do not have a prior arrangement with, we will prepare and send the claim for you on an unassigned basis. This means the insurer will send the payment directly to you. This means our charges for your care are due at the time of service.

5. Not all insurance plans cover all services. If your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.

6. We will bill your insurance company for all services provided in the hospital. You are responsible for any balance due.

I have read and understand the practice’s financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice at any time.

Signature of patient (or responsible party, if minor)

Date

VA Exchange Policies Waiver

NOVA Cardiovascular Care, Inc. accepts all patients regardless of their insurance status. It is, however, the patient’s responsibility to check with their insurance about network coverage. NOVA Cardiovascular Care may not be in the preferred network of certain insurance policies, including some VA Exchange Plans. These new plans have developed due to healthcare changes connected to the Federally Funded Healthcare Policies.

Due to the possibility of healthcare changes, I,

understand that it is my responsibility as the insured part to have verified that my visit with any physician at NOVA Cardiovascular Care, Inc. will be covered by my current insurance plan as either an in-network or out-of-network service.

NOVA Cardiovascular Care, Inc. will do its best to submit and collect charges to/from my insurance company according to standard practices, but as the patient I am ultimately responsible for any charges that are incurred if my insurance company does not participate with NOVA Cardiovascular Care.

I have read the above, understand, and agree to these terms and conditions as they pertain to this and all future services with NOVA Cardiovascular Care, Inc.

Signature

Date

Patient’s Rights and Responsibilities

Awareness of patient’s rights has been heightened with the rise in healthcare consumerism. Patients have active participation in decisions about their healthcare. The conventional model where the doctor “always knows best” no longer goes unchallenged. Relinquishing power to patients includes acknowledging a patient’s rights.

Patient Rights

A patient and/or his/her legal representative has the right to:

Receive informed consent regarding procedures, risks, and alternatives, and receive answers to questions with respect to treatments.
Refuse treatment and accept the potential consequences of that choice after a thorough explanation.
Have another person present during exams and/or treatments.
Expect all communications and records will be treated as confidential.
Receive complete, current information concerning diagnosis, treatment, and prognosis in terms reasonably understood.
Know the identity and professional status of the individual providing the service to them.
Expect reasonable continuity of care.
Be fully advised of and accept or refuse to participate in any research project.
Receive an explanation of charges for services rendered
Receive considerate and respectful care.
Expect to not be denied treatment solely on the basis of race, color, religion, or sexual preference

Patient Responsibilities

A patient and/or his/her legal representative has the responsibility to:

Be honest and forthright with the doctor and office staff by providing accurate and complete information about present complaints, past illnesses, accidents, hospitalizations, medications, and any other information related to his/her health.
Report to the doctor in a timely manner any new incident, trauma, or changes in health
Acknowledge and consider instructions provided by the doctor/staff
Request clarification, about any aspect of care not fully comprehended
Keep scheduled appointments or give adequate notice of delay or cancelations
Treat doctors and staff with respect and courtesy
Seek results of any and all tests ordered in a timely manner, understanding their significance and that failure to do so may have a negative impact on health.

Considering the above items, lack of cooperation may cause endangerment to the patient’s health and/or impaired results of care. It is permissible for the doctor to discontinue treatment of a patient who fails to cooperate in an agreed upon plan of management.

I understand and accept these terms and conditions

Patient's Signature

Date

Authorization for Release of Medical Records

Patient's Name

Date of Birth

Address

Phone Number

Physicians

If other, please specify

I hereby authorize NOVA Cardiovascular Care, Inc. to release any and all medical records requested by the above-named Physician(s).

Signature

Date

Patient Insurance Information

Patient Name

Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Email address

SS #

Date of Birth

Referring Provider

** This information above is required, regardless of insurance status **

Add new row

Emergency Contact / Next of Kin

Emergency Contact Phone Number

Relationship

I, the undersigned, have insurance coverage with the above-named insurance provider and assign directly to NOVA Cardiovascular Care all medical benefits for services rendered. I understand that I am financially responsible for all charges unpaid by insurance. I hereby authorize NOVA Cardiovascular to release all information necessary to secure payment of benefits. I authorize the use of this signature on all of my insurance submissions. I understand that any charges incurred are ultimately my responsibility. If my account becomes delinquent, any fees required to collect the debt will be added to my account balance. I understand that there will be a $35 charge for any returned checks or insufficient funds. I have read and agree to the above terms and conditions.

Patient Signature

Date

Your information will be encrypted.

Patient Registration Forms

At NoVa Cardiovascular Care, we strive to provide culturally-sensitive patient care. Per our policy, we support our patient’s right to utilize chaperones when requested or necessary during examinations or procedures.

If the patient is not the insurance policyholder or if there is a secondary insurance company, Please complete below

Patient History Questionnaire

If you HAVE HAD or CURRENTLY HAVE any of the following,please indicate with a check next to the condition:

Social History

Family History

Surgical History

Allergies

Current Medications

Patient History Form

Acknowledgement of Receipt of Privacy Practices

Authorization For Use & Disclosure of Personal Health Information

Financial Policy

VA Exchange Policies Waiver

Patient’s Rights and Responsibilities

Authorization for Release of Medical Records

Patient Insurance Information

If you HAVE HAD or CURRENTLY HAVE any of the following,
please indicate with a check next to the condition: