New Patient Package

GENERAL INFORMATION

Today's Date:

Patient’s Name:

Address:

City:

State:

Zip:

Sex:

M F

Date of Birth:

Social Security Number:

Occupation:

Employer:

Employer Address:

Employer Phone:

Spouse's Name:

PATIENT CONTACT INFORMATION:

Home:

Cell:

Work:

Primary Care Physician (PCP) Name:

Address:

Phone:

Fax:

Emergency Contact Name:

Phone:

Relationship:

Nearest relative not living with you:

Phone:

Relationship:

PREFERRED CONTACT INFORMATION: I authorize Mobitz Heart and Rhythm and/or its affiliates to contact me to discuss my care (e.g., test results), provide appointment reminders, and to follow up with me regarding my condition or services I received from Mobitz Heart and Rhythm. My preferred method of contact is indicated below (check all that apply):

Home Phone

Cell Phone

Text

Work Phone

Email:

Please select the appropriate box below:

Mobitz may include detailed information in its message to me Mobitz may include a message with only its name/caller name and call-back number

Please note that you are responsible for any charges incurred in receiving our communications (e.g., any charges imposed by your cellular service provider for receiving calls or text messages).

ACCESS TO RECORDS: Mobitz Heart and Rhythm may provide the individuals named below with information related to my health including access to my medical records. I understand this may include information regarding testing, examination and treatment for HIV, AIDS related illness, mental health and drug, alcohol or chemical abuse to the extent such records are included in my medical record.

Name:

Relationship:

Name:

Relationship:

INSURANCE INFORMATION

Patient's Name:

Today's Date:

PRIMARY INSURANCE

Insurance Company Name:

Address for Claims:

Phone Number:

Group Number:

Policy Holder’s Name:

Policy Holder’s SSN

DOB:

SECONDARY INSURANCE

Insurance Company Name:

Address for Claims:

Phone Number:

Group Number:

Policy Holder’s Name:

Policy Holder’s SSN

DOB:

MEDICAL HISTORY

Patient’s Name:

Today's Date:

Date of Birth:

Age:

Sex:

M F

Weight:

Height:

Please list all medications you are presently taking. Please include both prescription and non-prescription medications and vitamins

Add new row

Please list all of your allergies:

Check if you have no known drug allergies

Check here if you have a latex allergy

Do you smoke cigarettes?

Yes No

Smoked in the past but quit?

Yes No

if yes, how many years have you smoked?

Packs per day?

If you have quit, when did you quit?

Do you drink alcohol?

Yes No

If yes, how much do you drink in an average week?

Very Rarely 1-2 Drinks per Week 1-2 Drinks per Day Other:

Other:

NOTE: 1 drink equals one ounce (oz) of liquor, 6 oz of wine, or 12 oz of beer

Please list all hospitalizations and the reasons:

Add new row

Please any other pertinent medical history; outpatient treatment or chronic illnesses.

POLICIES

BUSINESS HOURS. Our office business hours are Monday through Friday, 8:00 AM to 5:00 PM, excluding holidays.

OFFICE APPOINTMENTS.

New Patients: To make an appointment please call 713-909-3166 or send us a request through our websitewww.MOBITZHEART.com.
Established patients: To make an appointment please call 713-909-3166, send us a request through our websitewww.MOBITZHEART.com, or send us a request using the patient portal.
Telemedicine/Telehealth Appointments. Telehealth (virtual visits by phone and/or video) appointments may be scheduled during our business hours. Follow the above instructions to request a telemedicine visit.
For any urgent or emergent health issue please call 911 or visit a nearby emergency room.
Bring to Your Appointment:

Your insurance card(s),
A photo ID
Previous medical records or test results (if available or applicable)
A current list of your medications with pharmacy instructions or simply bring the medication bottles in with you
Any documentation regarding what treatments you do or don’t want if you are incapacitated and not able to inform us of your wishes and any documents that specify who you want to make medical decisions for you in such situations (e.g., a medical power of attorney)
Update us with any changes of address, phones, insurance or necessary contact information.

CANCELLATION AND MISSED APPOINTMENT POLICY. Please notify us at least 24 hours in advance, if possible, should you need to cancel or reschedule your appointment. This will allow us to accommodate another patient to that time slot.

LATE ARRIVAL. Please arrive at the office or prepare for your Telemedicine appointment at least 30 minutes before your appointment. Please notify us promptly if you will be late to your appointment as we may need to reschedule. Our goal is to timely serve all of our patients and your late arrival may impact our ability to do so.

COMPLETION OF FORMS AND LETTERS. Please allow up to 7 business days to complete any forms or letters you may request (e.g., inability to perform work duties, clearance to return to work, disability forms, etc.). The practice may charge fees as permitted by applicable laws and payor policies.

PREOPERATIVE CLEARANCE. As part of the practice’s preoperative clearance for surgical procedures, the practice may require patients to be seen in the office or via telehealth within 90 days before the planned surgery.

MEDICAL RECORDS. The patient must complete a medical records release form if they want the practice to send their medical records to his/her designated third party. The practice may charge fees as permitted by applicable laws. Please call us to obtain the form and pertinent instructions.

PRESCRIPTION REFILL POLICY. Please allow the practice a minimum of 5 business days to process your request to refill your medications at your local pharmacy and up to 3 weeks for mail order prescriptions. You can request refills by calling us at713-909-3166 or through the patient portal.

PATIENT INFORMATION. The practice kindly asks all of our patients to immediately notify us with any changes to their contact information, insurance(s), preferred pharmacies, allergies, medications, medical conditions and other pertinent information which could affect their medical care.

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

Signature of Patient, Parents or Legal Guardian:

Date

Print Name:

CONSENT TO TREATMENT

PURPOSE. This purpose of this disclosure and consent is to help you understand your options so that you may give or with hold your consent to the proposed treatment.

GENERAL CONSENT. I understand that I have the right to be informed about my condition, any recommended treatment and medical and diagnostic procedures, and to make decisions regarding my treatment. I voluntarily request Mobitz Heart andRhythm (and its physicians, nurses, employees and others as it deems necessary) to examine me, order necessary testing, and to diagnose and treat my condition. If I am unable or unwilling to undergo such testing or treatment my treatment plan may be revised and my condition or outcomes may be affected. I understand that it is my responsibility to actively participate in my care and that I need to keep my physicians informed of any changes in my medical condition. I understand that in connection with my treatment, photos or videos may be taken. I understand that at times, services may be rendered to me through the use of audio, video or other electronic communications (“Telehealth”). I understand that I may withhold or withdraw my consent to a telehealth consultation at any time before and/or during the consult.

RISKS & BENEFITS OF TREATMENT. The risks and benefits of the plan of care and treatment recommended to me, and to which I have agreed, have been fully explained to me. I further acknowledge that I have been informed of alternatives to the recommended treatment and the material risks of each, including the risks involved if I decide not to receive treatment. I understand that Telehealth, though has many benefits, it may not be appropriate for all situations. I understand that potential risk of Telehealth is that because of my specific medical condition, or due to technical problems, a face-to-face consultation still maybe necessary after the Telehealth appointment, and, in rare circumstances, security protocols could fail causing a breach of my privacy. The alternative to Telehealth consultation is a face-to-face visit with a physician.

COMMUNICABLE DISEASE TESTING. I acknowledge that Texas law provides if any health care worker is exposed to my blood or other bodily fluid, Mobitz Heart and Rhythm may perform tests, without my consent, on my blood or other bodily fluid to determine the presence of Hepatitis B and C, Human Immunodeficiency Virus (HIV) and Acquired Immune DeficiencySyndrome (AIDS). I understand that such testing is necessary to protect those who will be caring for me while I am a patient at Mobitz Heart and Rhythm. I understand that the results of tests taken under these circumstances are confidential and do not become a part of my patient record.

NO GUARANTEE. I acknowledge that no guarantees or warranties have been made to me with respect to treatment to be provided by Mobitz Heart and Rhythm. I understand that all supplies, medical devices and other goods sold or furnished to me by Mobitz Heart and Rhythm are sold or furnished on an “AS IS” basis, and Mobitz Heart and Rhythm disclaims any expressed or implied warranties with respect to them. With respect to specific supplies and devices, manufacturers’ warranties may apply, and I may request manufacturer’s warranty information concerning such supplies and/or devices.

USE AND DISCLOSURE OF INFORMATION/NOTICE OF PRIVACY PRACTICES. I understand that my medical records are confidential and cannot be disclosed without my written authorization except in limited circumstances when otherwise permitted or required by law. With my signature below, I acknowledge receipt of the Notice of Privacy Practices of Mobitz Heart andRhythm which further describes how Mobitz Heart and Rhythm may use/disclose my health information. I understand that my medical information may include communicable disease information including HIV, AIDS, records related to mental health treatment and alcohol and substance abuse diagnosis or treatment, and I authorize release of that information as part of my medical record. I understand that I have the right to restrict the release of this information at any time.

E-PRESCRIBING CONSENT. ePrescribing is defined as a physician’s ability to electronically send an accurate and understandable prescription directly to a pharmacy from the point of care. I understand that this is an important element in improving the quality of care as it can reduce medication errors and enhance patient safety. With my signature below, I consent to Mobitz Heart and Rhythm’s enrolling me in the ePrescribe program and its request for my prescription medication history from other healthcare providers and my pharmacy benefits provider for treatment purposes.

COMPLAINTS. If I have a complaint, I may submit my complaint to Mobitz Heart and Rhythm by mail or call the organization at any time at the below address and phone number. I may also file a complaint with the Texas Board of Medicine (TMB).The instructions for filing a complaint with the TMB are available on the TMB’s website (http://www.tmb.state.tx.us/page/complaints) and on the Mobitz Heart and Rhythm website.

MEDICAL RECORD RETENTION. I understand that Mobitz Heart and Rhythm must keep my medical records for a time required by law and I authorize Mobitz Heart and Rhythm and related providers to dispose of these records as permitted or required by law.

REVOCATION OF CONSENT. I understand that this Consent to Treatment will be valid as long as I am a patient at MobitzHeart and Rhythm unless I revoke it at an earlier date.I have had the opportunity to review the information contained in this Consent to Treatment, and to ask questions about mytreatment and the associated risks and benefits. I believe I have sufficient information and with my signature below, I consent totreatment.

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

Patient, Parents, Legal Guardian Signature:

Date

Print Name (Patient, Parent, Legal Guardian):

ASSIGNMENT OF BENEFITS & FINANCIAL RESPONSIBILITY

ASSIGNMENT OF BENEFITS. I hereby assign, grant, and convey directly to the organization listed below, all rights, benefits, insurance or other third-party benefits, including insurance reimbursements, if any, otherwise payable or entitled to, for any services provided by the organization, regardless of the organization’s managed care network participation status. I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to the organization for any services or supplies provided to me by the organization.

DESIGNATION OF AUTHORIZED REPRESENTATIVE. I designate the organization as my authorized representative in dealings with third-party pay ors related to services provided to me by the organization. This designation permits the organization to, among other things, request documents and to file complaints and appeals on my behalf.

AUTHORIZATION TO RELEASE INFORMATION. I authorize the release of any medical or other information to my insurance carrier or other medical entity as necessary to determine my benefits or the reimbursement payable to the organization for related services. A copy of this authorization may be sent to my insurance company/provider of health and/or other benefits as well as their contractors or other entity if requested.

FINANCIAL RESPONSIBILITY. I understand that I am financially responsible to the organization for any charges not covered by my health care benefits including, but not limited to co-payments/co-insurance, deductibles, and non-covered services. I understand that it is the policy of the organization to collect any patient responsibility for services (i.e., copayments, coinsurance and/or deductibles) at the time services are rendered. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for the payment for all services received.

By signing this document, I acknowledge that I have read and understand the above information, I understand my responsibilities, and I have access to a copy of this form.

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

Signature of Patient, Parents or Legal Guardian:

Date

Print Name:

NOTICE OF PRIVACY RIGHTS

THIS NOTICE DESCRIBES HOW MEDICAL/HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Mobitz Heart and Rhythm, PLLC (“we” or “us”) is required by law to maintain the privacy of your protected health information; to provide you this Notice of our legal duties and privacy practices relating to your protected health information; to provide you with notice following a breach of your protected health information; and to abide by the terms of the Notice that are currently in effect. Note, when permitted to use or disclose your information, we may use, disclose and transmit such information in an electronic format.

I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The following categories describe the different reasons that we typically use and disclose your health information. These categories are intended to be generic descriptions only, and not a list of every instance in which we may use or disclose your health information. Please understand that for these categories, the law generally does not require us to get your consent in order for us to release your health information.

For Treatment. We may use and disclose your protected health information to provide, coordinate, or manage your health care services. For example, we disclose your health information, as necessary, to your physicians or a hospital where you are being treated. For Payment. We may use and disclose your protected health information for billing and payment purposes. We may disclose your protected health information to your representative, or to an insurance or managed care company, Medicare or another party responsible for paying for services rendered to you. For example, we may send a claim for payment to your insurance company, or other party responsible for payment, and that claim may have a code on it that describes the services that were provided to you. We are required to restrict disclosure of your medical information to a health plan or third-party payor if the disclosure is for payment for a health care item or service that you paid for in full out-of-pocket.

For Health Care Operations. We may use and disclose your protected health information as necessary for health care operations, such as management of our practice, personnel evaluation, education and training and to monitor our quality of care. For example, we may use and disclose information to make sure the care you receive is of the highest quality.

Individuals Involved in Your Care or Payment for Your Care. We may release protected health information about you to a friend or family member who is involved in your medical care, as well as to someone who helps pay for your care, but we will do so only as allowed by state or federal law, or in accordance with your prior authorization.

Emergencies. We may use or disclose your protected health information as necessary in emergency treatment situations.

As Required By Law. We may use or disclose your protected health information when required by law to do so.

Business Associates. We may disclose your protected health information to a contractor (also called a “business associate”)who needs the information to perform services for us. Our business associates are committed to preserving the confidentiality of this information, and have signed an agreement with us that holds them to certain privacy standards.

Public Health Activities. We may disclose your protected health information for public health activities. These activities may include, for example, reporting to a public health authority for preventing or controlling disease, injury or disability, and births and deaths. As a general rule, we are required by law to disclose certain types of information to public health authorities, such as the Texas Department of State Health Services.

Reporting Victims of Abuse, Neglect or Domestic Violence. If we believe that you have been a victim of abuse, neglect or domestic violence, we may use and disclose your protected health information to notify a government authority, if authorized bylaw or if you agree to the report.

Health Oversight Activities. We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure actions or for activities involving government oversight of the healthcare system.

To Avert a Serious Threat to Health or Safety. When necessary to prevent a serious threat to your health or safety or the health or safety of the public or another person, we may use or disclose protected health information to someone able to intervene in or prevent the threatened harm.

Judcial and Administrative Proceedings. We may disclose your protected health information in response to a court or administrative order. We also may disclose information in response to a subpoena, discovery request, or other lawful process; efforts will be made to contact you about the request or to obtain an order or agreement protecting the information.

Law Enforcement. We may disclose your protected health information for certain law enforcement purposes, including, for example, to comply with reporting requirements or to answer certain requests for information concerning crimes.

Research. We may use or disclose your protected health information for research purposes if the privacy aspects of the research have been reviewed and approved, if the researcher is collecting information in preparing a research proposal, if the research occurs after your death, or if you authorize the use or disclosure.

Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organizations. We may release your protected health information to a coroner, medical examiner, funeral director or, if you are an organ donor, to an organization involved in the donation of organs and tissue.

Disaster Relief. We may disclose protected health information about you to a disaster relief organization.

Military, Veterans and other Specific Government Functions. If you are a member of the armed forces, we may disclose your protected health information as required by military command authorities. We may also disclose protected health information for national security purposes or as needed to protect the President of the United States or certain other officials or to conduct certain special investigations.

Workers’ Compensation. We may use or disclose your protected health information to comply with laws relating to workers’ compensation or similar programs.

Inmates/Law Enforcement Custody. If you are under the custody of a law enforcement official or a correctional institution, we may disclose your protected health information to the institution or official for certain purposes including the health and safety of you and others.

Treatment Alternatives and Health-Related Benefits and Services. We may use or disclose your protected health information to inform you about treatment alternatives and health-related benefits and services that may be of interest to you.

II. USES AND DISCLOSURES WITH YOUR AUTHORIZATION

Except as described in this Notice, we will use and disclose your protected health information only with your authorization.You may revoke an authorization in writing at any time. If you revoke an authorization, we will no longer use or disclose your protected health information for the purposes covered by that authorization, except where we have already relied on theAuthorization.

Except for limited situations, we must obtain your written authorization prior to disclosure of psychotherapy notes. An example of a situation where we may disclose without your authorization is when we are required to do so by law, such as for state mandated reporting of abuse.

III. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Listed below are your rights regarding your protected health information. Each of these rights is subject to certain requirements, limitations and exceptions. Exercise of these rights may require you to submit a written request to us. At your request, we will supply you with the appropriate form to complete. If you have questions about how to exercise your rights, please contact us using the information listed below. You have the right to:

Request Restrictions. You have the right to request restrictions on our use or disclosure of your protected health information.You also have the right to request restrictions on the protected health information we disclose about you to a family member, friend or other person who is involved in your care or the payment for your care. We are not required to agree to your requested restriction (except that if you are competent you may restrict disclosures to family members or friends), and in some situations we will not be able to agree to your request. If we do agree to accept your requested restriction, we will comply with your request except as needed to provide you emergency treatment or to comply with our legal obligations.

Access to Personal protected health information. You have the right to inspect and obtain a copy of your clinical or billing records or other written information that may be used to make decisions about your care, subject to some exceptions. Your request must be made in writing. In most cases we may charge a reasonable fee for our costs in copying and mailing your requested information. In certain limited circumstances allowed by law, we may deny your request to review or copy your medical information. If this occurs, you will be notified of the denial and you have the right to have your request and the denial reviewed by another licensed health care professional.

Request Amendment. You have the right to request amendments of your protected health information maintained by us if you believe it is incorrect or incomplete. Your request must be made in writing and must state the reason for the requested amendment. We may deny your request for amendment, but will inform you of the reasons for the denial and the right to submit a written statement disagreeing with the denial.

Request an Accounting of Disclosures. You have the right to request an “accounting” of certain disclosures of your protected health information. This is a listing of disclosures made by us or by others on our behalf, but does not include disclosures for treatment, payment and health care operations, disclosures made pursuant to your authorization, and certain other circumstances. To request an accounting of disclosures, you must submit a request in writing, stating a time period that is within six(6) years from the date of your request. The first accounting provided within a 12-month period will be free; for further requests, we may charge you our costs.

Request a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time.

Request Confidential Communications. You have the right to request that we communicate with you concerning your health matters in a certain manner. For example, you can ask that we contact you at home, not at work. We will accommodate your reasonable requests.Notification of a Breach. You have the right to be notified if your medical information is used or disclosed in a manner that is not permitted by law. In the event of a breach, we actively take steps to rectify the disclosure.

IV. FOR FURTHER INFORMATION OR TO FILE A COMPLAINT

If you have any questions about this Notice or would like further information concerning your privacy rights, please contact us using the information listed below. If you believe that your privacy rights have been violated, you may file a complaint in writing with us using the contact information listed below or with the Office for Civil Rights of the U.S. Department of Health and HumanServices. We will not retaliate against you if you file a complaint.

V. CHANGES TO THIS NOTICE We reserve the right to change this Notice and to make the revised or new Notice provisions effective for all protected health information already received and maintained by the us as well as for all protected health information we receive in the future.We will provide a copy of the revised Notice upon request.

Patient and/or Guardian’s Receipt of Notice of Privacy Practices

I, the undersigned, have received a copy of Mobitz Heart and Rhythm Medical Center PLLC Notice of Privacy Practices as part of my patient packet

Patient’s Name (Printed)

Parents/Legal Guardian’s Name (Printed) (if applicable)

Patient or Guardian’s Signature

Date

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