New Patient Paperwork

We will file insurance with your provider according to your individual plan. The patient wi]] be responsible for any outstanding deductible, their co-insurance % and/or co-pay. Referral numbers required by some insurance companies must be given at the time of service, otherwise the service becomes the patient's responsibility. For all private insurance companies, the patient will be responsible for payment at time of service. We wi]] provide the necessary information for the patient to file for reimbursement. I hereby authorize payment directly to SKG HEART CENTER, PLLC of the medical and/or surgical benefits, otherwise payable to me for services as described, realizing that I am responsible to pay for non-covered services.I, hereby authorize the physician to release any information required in the course of my treatment necessary to process insurance claims.

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.

Medical History

Social History

(Y- Yes N-No F-Former S-Social)

Surgical History

Family History

Family Member

Release Of Records Authorization

to release health records information on

I, Authorize my information to be release to:

SKG Heart Center, PLLC 7737 Southwest Freeway Ste 568 Houston, Texas 77074

1250 Creek Way Ste 150 Sugarland, Texas 77478

Office:713-623-6555 Fax: 713-623-6569

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.

*This Authorization will remain in effect until revoked in writing. The physician and employee are released from any legal responsibility or liability for disclosure of the above information t the extent and authorized herein.*

Consent For Communication Of protected Health Information

give my consent to SKG Heart Center, PLLC to release protected health information to the following people:

• Phone Numbers would you like to receive calls and text regarding appointments, financial, or medical information.

• May appointments, financial, or medical information be left on your answering machine or voicemail?

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 Agreement

Patient Responsibility

• You are responsible to provided SKG Heart Center, PLLC with accurate insurance/billing information for yourself or family member at the time of service. Presenting an invalid or inactive insurance card, will result in full payment by you or delay to verify insurance.
• Inform SKG Heart Center, PLLC if any address, phone number, email, or responsible party has changed.
• If you enroll to a new insurance please inform SKG Heart Center, PLLC 7 days prior to your appointment to prevent delays.
• If you need medication refills please contact your pharmacy 1 week before running out of medications. They will send a refill request and we can refill all medications quickly that way. *To keep up follow-ups for refills, test results, and health care
• $25 NO SHOW FEE.
• If a cardiac clearance is needed, schedule appointment 2 to 3 prior to your scheduled procedure date due to if any cardiac tests are required
• If any paper work is needing to be filled out. Please allow 5-7 business days. Payment is due when papers are picked up.

Co-Payment

• Your insurance company requires you to pay your copay at the time of each visit.
• Your copay may be paid in cash, check, credit card, or debit card.
• If your check is returned a $25 return check fee will be assessed.
• If you do not have medical insurance, you will be expected to pay the starting fee for self pay patients at $250 and up at the time of service.
• Medical insurance does not always cover the entire cost of your medical care. If a service we offer is not covered by your insurance. We will inform you ln some instance, however we would not know, if the service is covered until we submit the claim. You are responsible for the payment If your insurance company refuses to pay for the services.

Deductibles

• It is your responsibility to understand any deductible that may apply to you under your insurance policy.
• Our billing department will send you a statement of the amount your insurance company has determine which is applied to your deductible and is owed by you.
• Our biller is available to provide you with assistance, but will not resolve disputes between you and your insurance company.

Assignment and Release

I understand that I an financially responsible for all charges whether or not paid by my insurance. I hereby authorize SKG Heart Center, PLLC to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all submissions. Recent changes in insurance regulations shorten the time frame for claim submission. I agree to pay any out of pocket expense in full within 30 days from date of service

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.