NEW PATIENT FORM

This authorization permits G. Mark Jenkins, M.D., P.A., d/b/a The Cardiac and Vascular Interventional Group (“The CVIG Clinic”) to use or disclose an individual’s protected health information. Individuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information.

Information regarding patient for whom authorization is made:

Information regarding health care provider or health care entity authorized to disclose this information:

Information regarding person or entity who can receive and use this information:

Specific information to be disclosed:

Include: (Indicate by Initialing)

Drug, Alcohol or Substance Abuse Records

Mental Health Records (Except Psychotherapy Notes)

HIV/AIDS-Related Information (Including HIV/AIDS Test Results)

Genetic Information (Including Genetic Test Results)

The individual signing this form agrees and acknowledges as follows:

(i) Voluntary Authorization: This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing of this authorization form.

(ii) Effective Time Period: This authorization shall be in effect until the earlier of: (a) two (2) years after the death of the patient for whom this authorization is made or (b) my written revocation.

(iii) Right to Revoke: I understand that I have the right to revoke this authorization at any time by writing to the health care provider or health care entity listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

(iv) Special Information: This authorization may include disclosure of information relating to DRUG, ALCOHOL, and SUBSTANCE ABUSE; MENTAL HEALTH INFORMATION, except psychotherapy notes; CONFIDENTIAL HIV/AIDS-RELATED INFORMATION; and GENETIC INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated herein.

(v) Signature Authorization: I have read this form and agree to the uses and disclosure of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.

Signatures:

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.

A minor individual’s signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment.

Please mail, email, or fax this form to The CVIG Clinic at the address/fax number listed in the letterhead above. Upon receipt, The CVIG Clinic will release the information within two weeks or contact you if additional information is required.

INFORMED CONSENT TO TREATMENT

This and other informed consent documents are used to communicate information about the proposed treatment, to disclose reasonably foreseeable risks, and to provide information about alternative forms of treatment. The informed consent documents should not be considered all-inclusive in describing methods of care and all potential risks. Your provider may provide you with additional or different information based on the facts in your particular case and the current state of medical knowledge.

By signing below, you consent to the rendering of medical care pursuant to the following terms:

1. I understand that my physician is an employee or independent contractor of G. Mark Jenkins, M.D., P.A. d/b/a Cardiac and Vascular Interventional Group ("CVIG"), and I (or the below-named patient) voluntarily consent to be treated by my physician and other CVIG healthcare providers. I consent to all medical treatment, and health care-related services that the CVIG physicians and health care providers deem necessary, this may include diagnostic procedures, therapeutic, imaging, and laboratory services.

2. I understand that I have the right to consent, or to refuse any proposed procedure or therapeutic course.

3. I understand that the practice of medicine and the services or procedures I am receiving today carry some risks and that my CVIG provider has explained my service or procedure to me, including its potential risks. I understand, and have been informed of, the reasonably foreseeable risks. I have been informed about the methods used by CVIG and have had the opportunity to ask questions and express concerns prior to treatment. I wish to rely on the professional and clinical judgment of my CVIG provider during the course of my treatment.

4. CVIG offers certain services via telehealth, which involves the use of electronic communications intended to improve patient care through efficient medical evaluations and management and which shares information such as patient medical records, medical images, live two-way audio and video, and output data from medical devices and audio and video files. If I choose to participate in telehealth interactions with CVIG for my care, then I understand that there are certain risks and limitations of telehealth, including: information transmitted may not be sufficient to allow for appropriate medical decisions to be made by CVIG (e.g., poor resolution of images); delays in medical evaluation and treatment could occur due to deficiencies in or failures of equipment; security protocols could fail, causing a privacy or security breach of personal and/or protected health information; or a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

I have read and understand the above risks and considerations regarding the use of telehealth for my care, and I voluntarily consent to treatment by CVIG with telehealth technology.

5. I specifically authorize release of my medical records, including: alcohol and drug abuse records protected Code 42 of Federal Regulations, Part 2, psychological services records; social services records, including communications made by me to a social worker or psychologist; records of HIV testing including results, records of treatment for AIDS; and records of a communicable disease to (a) my insurance company or third party payer for the purpose of payment of the medical services provided by CVIG; and/or (b) to another health care provider for the purpose of transferring care to another health care provider.

6. I understand and authorize CVIG to communicate with me via email, text message and other electronic communications to allow for more efficient and expedited feedback from CVIG providers. The electronic communications may contain protected health information. The transmission of the electronic communications will most likely be encrypted or secured. I further understand that any electronic communications, such as texts messages, that are transmitted to my personal device, such as my cell phone, may not be stored or maintained in an encrypted or secured manner. While not all-inclusive, the potential risks of CVIG providers communicating with me via text message, email, and other means electronically include, but may not be limited to: (i) the transmission of information may fail, 146047182v1 be delayed or unclear (e.g., problematic or delayed electronic transmission of the information); or (ii) the communication or storage of the information may be unsecure, or security protocols could fail, causing a breach of personal and protected health information.

I understand and have been informed of the potential risks. I have had the opportunity to ask questions and express concerns prior to such communications. I will notify CVIG if I have any concerns or prefer that my CVIG providers do not communicate with me via text message, email or electronically.

7. I understand that if a healthcare provider at my physician's office sustains a percutaneous (through the skin), mucous membrane (through the mouth or eye), or open wound exposure to my blood or other bodily fluids I (or the below-named patient), may be tested for hepatitis, human immunodeficiency virus (which is the causative agent of AIDS) and syphilis. I understand that any test result obtained under these circumstances does not become part of my (or the below-named patient's) medical record.

8. I understand that CVIG does not assume responsibility for safekeeping of any personal property, which I have with me at the time of my off a visit and hereby release CVIG from responsibility for all personal property, including but not limited to currency, jewelry, electronic device medical equipment, personal documents.

9. I agree to the release of my medical information to my insurance company or third party payor and in consideration of the health care services rendered or about to be rendered to me (or the below-named patient), I hereby assign to CVIG all right, title, and interest in and to any third-party) benefits due from any and all insurance policies and/or responsible third-party payors for the health care services rendered. I authorize such payments from applicable insurance carriers, third party payers, and other third-parties. Except as required by law, I assume responsibility for determining in advance whether the services provided are covered by insurance or other third-party payor, and I understand that I am financially responsible to CVIG for services not covered or payable by my insurance company irrespective of any dispute between my insurance company and myself.

10. Medicare/Medicaid Assignment of Benefits: (Do not complete unless you receive Medicare/Medicaid health care benefits)

I certify that the information given by me in applying for payment under Title XVII of the Social Security Act is correct. I authorize the release of information concerning me to the Social Security Administration or its intermediaries or carriers as well as any information needed for filing a Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign benefits payable for services to the physician or organization submitting a claim to Medicare for me.

I understand that Medicaid recipients are responsible for payment of any medical care or service received that is beyond the amount, duration and/or scope of the Texas Medicaid Program, as determined by the Medicaid Department or its health insuring agency. All payments for non-covered services are due and payable at the conclusion of each office visit unless prior payment arrangements have been made.

11. Notice of Privacy Acknowledgement: CVIG’s Notice of Privacy Practices provides information about how CVIG may use and disclose my protected health information. A copy of the current Notice is posted in the waiting room and one our website at www.thecvig.com. You have the right to review the Notice before signing this acknowledgment, and you have the right to request a copy for your records. The Notice contains the effective date and as provided in Notice, the terms of our Notice may change.

This consent form has been fully explained to me and I understand its contents and the consents made by me. By signing my name at the bottom of this form, I am consenting to CVIG’s treatment for my present and future care. If applicable, I have the legal right to select and authorize healthcare services for the patient named below, and I authorize CVIG to perform the treatment as outlined above to this patient.

SIGNATURES:

THE CVIG CLINIC NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

EFFECTIVE 09/15/2020

This Notice of Privacy Practices (the “Notice”) tells you about the ways we may use and disclose your protected health information (“medical information”) and your rights and our obligations regarding the use and disclosure of your medical information. This Notice applies to G. Mark Jenkins, M.D., P.A., d/b/a The Cardiac and Vascular Interventional Group, including its providers and employees (the “Practice”).

I. OUR OBLIGATIONS.

We are required by law to:

• Maintain the privacy of your medical information, to the extent required by state and federal law;
• Give you this Notice explaining our legal duties and privacy practices with respect to medical information about you;
• Notify affected individuals following a breach of unsecured medical information under federal law; and
• Follow the terms of the version of this Notice that is currently in effect.

II. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU.

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

A. For Treatment. We may use and disclose medical information about you to provide you with health care treatment and related services, including coordinating and managing your health care. We may disclose medical information about you to physicians, nurses, other health care providers, and personnel who are providing or involved in providing health care to you (both within and outside of the Practice). For example, should your care require referral to or treatment by another physician of a specialty outside of the Practice, we may provide that physician with your medical information in order to aid the physician in his or her treatment of you.

B. For Payment. We may use and disclose medical information about you so that we or may bill and collect from you, an insurance company, or a third party for the health care services we provide. This may also include the disclosure of medical information to obtain prior authorization for treatment and procedures from your insurance plan. For example, we may send a claim for payment to your insurance company, and that claim may have a code on it that describes the services that have been rendered to you. If, however, you pay for an item or service in full, out of pocket, and request that we not disclose to your health plan the medical information solely relating to that item or service, as described more fully in Section IV of this Notice, we will follow that restriction on disclosure unless otherwise required by law.

C. For Health Care Operations. We may use and disclose medical information about you for our health care operations. These uses and disclosures are necessary to operate and manage our practice and to promote quality care. For example, we may need to use or disclose your medical information in order to assess the quality of care you receive or to conduct certain cost management, business management, administrative, or quality improvement activities or to provide information to our insurance carriers.

D. Quality Assurance. We may need to use or disclose your medical information for our internal processes to assess and facilitate the provision of quality care to our patients.

E. Utilization Review. We may need to use or disclose your medical information to perform a review of the services we provide in order to evaluate whether that the appropriate level of services is received, depending on condition and diagnosis.

F. Credentialing and Peer Review. We may need to use or disclose your medical information in order for us to review the credentials, qualifications and actions of our health care providers.

G. Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that we believe may be of interest to you.

H. Appointment Reminders and Health Related Benefits and Services. We may use and disclose medical information, in order to contact you (including, for example, contacting you by phone and leaving a message on voicemail, or by email if you have provided us your email address) to provide appointment reminders and other information. We may use and disclose medical information to tell you about health-related benefits or services that we believe may be of interest to you.

I. Business Associates. There are some services (such as billing or legal services) that may be provided to or on behalf of our Practice through contracts with business associates. When these services are contracted, we may disclose your medical information to our business associate so that they can perform the job we have asked them to do. To protect your medical information, however, we require the business associate to appropriately safeguard your information.

J. Individuals Involved in Your Care or Payment for Your Care. We may disclose medical information about you to a friend or family member who is involved in your health 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 (with an opportunity for you to agree or object when required under the law), or in accordance with your prior authorization.

K. As Required by Law. We will disclose medical information about you when required to do so by federal, state, or local law or regulations.

L. To Avert an Imminent Threat of Injury to Health or Safety. We may use and disclose medical information about you when necessary to prevent or decrease a serious and imminent threat of injury to your physical, mental or emotional health or safety or the physical safety of another person. Such disclosure would only be to medical or law enforcement personnel.

M. Organ and Tissue Donation. If you are an organ donor, we may use and disclose medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

N. Research. We may use or disclose your medical information for research purposes in certain situations. Texas law permits us to disclose your medical information without your written authorization to qualified personnel for research, but the personnel may not directly or indirectly identify a patient in any report of the research or otherwise disclose identity in any manner. Additionally, a special approval process will be used for research purposes, when required by state or federal law. For example, we may use or disclose your information to an Institutional Review Board or other authorized privacy board to obtain a waiver of authorization under HIPAA. Additionally, we may use or disclose your medical information for research purposes if your authorization has been obtained when required by law, or if the information we provide to researchers is “de-identified.”

O. Military and Veterans. If you are a member of the armed forces, we may use and disclose medical information about you as required by the appropriate military authorities.

P. Workers’ Compensation. We may disclose medical information about you for your worker’ compensation or similar program. These programs provide benefits for work-related injuries. For example, if you have injuries that resulted from your employment, workers’ compensation insurance or a state workers’ compensation program may be responsible for payment for your care, in which case we might be required to provide information to the insurer or program.

Q. Public Health Risks. We may disclose medical information about you to public health authorities for public health activities. 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. The types of information generally include information used:

• To prevent or control disease, injury, or disability (including the reporting of a particular disease or injury).
• To report births and deaths.
• To report suspected child abuse or neglect.
• To report reactions to medications or problems with medical devices and supplies.
• To notify people of recalls of products they may be using.
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
• To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
• To provide information about certain medical devices.
• To assist in public health investigations, surveillance, or interventions.

R. Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include audits, civil, administrative, or criminal investigations and proceedings, inspections, licensure and disciplinary actions, and other activities necessary for the government to monitor the health care system, certain governmental benefit programs, certain entities subject to government regulations which relate to health information, and compliance with civil rights laws.

S. Legal Matters. If you are involved in a lawsuit or a legal dispute, we may disclose medical information about you in response to a court or administrative order, subpoena, discovery request, or other lawful process. In addition to lawsuits, there may be other legal proceedings for which we may be required or authorized to use or disclose your medical information, such as investigations of health care providers, competency hearings on individuals, or claims over the payment of fees for medical services.

T. Law Enforcement, National Security and Intelligence Activities. In certain circumstances, we may disclose your medical information if we are asked to do so by law enforcement officials, or if we are required by law to do so. We may disclose your medical information to law enforcement personnel, if necessary to prevent or decrease a serious and imminent threat of injury to your physical, mental, or emotional health or safety or the physical safety of another person. We may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

U. Coroners, Medical Examiners and Funeral Home Directors. We may disclose your medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about our patients to funeral home directors as necessary to carry out their duties.

V. Inmates. If you are an inmate of a correctional institution or under custody of a law enforcement official, we may disclose medical information about you to the health care personnel of a correctional institution as necessary for the institution to provide you with health care treatment.

W. Marketing of Related Health Services. We may use or disclose your medical information to send you treatment or healthcare operations communications concerning treatment alternatives or other health related products or services. We may provide such communications to you in instances where we receive financial remuneration from a third party in exchange for making the communication only with your specific authorization unless the communication: (i) is made face-to-face by the Practice to you, (ii) consists of a promotional gift of nominal value provided by the Practice, or (iii) is otherwise permitted by law. If the marketing communication involves financial remuneration and an authorization is required, the authorization must state that such remuneration is involved. Additionally, if we use or disclose information to send a written marketing communication (as defined by Texas law) through the mail, the communication must be sent in an envelope showing only the name and addresses of sender and recipient and must (i) state the name and toll-free number of the entity sending the market communication; and (ii) explain the recipient’s right to have the recipient’s name removed from the sender’s mailing list.

X. Fundraising. We may use or disclose certain limited amounts of your medical information to send you fundraising materials. You have a right to opt out of receiving such fundraising communications. Any such fundraising materials sent to you will have clear and conspicuous instructions on how you may opt out of receiving such communications in the future.

Y. Electronic Disclosures of Medical Information. Under Texas law, we are required to provide notice to you if your medical information is subject to electronic disclosure. This Notice serves as general notice that we may disclose your medical information electronically for treatment, payment, or health care operations or as otherwise authorized or required by state or federal law. We may communicate with you via email, text message and other electronic communications to allow for more efficient and expedited feedback from our providers. The electronic communications may contain protected health information. The transmission of the electronic communications will most likely be encrypted or secured. Any electronic communications, such as texts messages, that are transmitted to your personal device, such as your cell phone, may not be stored or maintained in an encrypted or secured manner

III. OTHER USES OF MEDICAL INFORMATION

A. Authorizations. There are times we may need or want to use or disclose your medical information for reasons other than those listed above, but to do so we will need your prior authorization. Other than expressly provided herein, any other uses or disclosures of your medical information will require your specific written authorization.

B. Psychotherapy Notes, Marketing and Sale of Medical Information. Most uses and disclosures of “psychotherapy notes,” uses and disclosures of medical information for marketing purposes, and disclosures that constitute a “sale of medical information” under HIPAA require your authorization.

C. Right to Revoke Authorization. If you provide us with written authorization to use or disclose your medical information for such other purposes, you may revoke that authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your medical information for the reasons covered by your written authorization. You understand that we are unable to take back any uses or disclosures we have already made in reliance upon your authorization, and that we are required to retain our records of the care that we provided to you.

IV. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU.

Federal and state laws provide you with certain rights regarding the medical information we have about you. The following is a summary of those rights.

A. Right to Inspect and Copy. Under most circumstances, you have the right to inspect and/or copy your medical information that we have in our possession, which generally includes your medical and billing records. To inspect or copy your medical information, you must submit your request to do so in writing to the Practice’s HIPAA Officer at the address listed in Section VI below. If you request a copy of your information, we may charge a fee for the costs of copying, mailing, or certain supplies associated with your request. The fee we may charge will be the amount allowed by state law. If your requested medical information is maintained in an electronic format (e.g., as part of an electronic medical record, electronic billing record, or other group of records maintained by the Practice that is used to make decisions about you) and you request an electronic copy of this information, then we will provide you with the requested medical information in the electronic form and format requested, if it is readily producible in that form and format. If it is not readily producible in the requested electronic form and format, we will provide access in a readable electronic form and format as agreed to by the Practice and you. In certain very limited circumstances allowed by law, we may deny your request to review or copy your medical information. We will give you any such denial in writing. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by the Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will abide by the outcome of the review.

B. Right to Amend. If you feel the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by the Practice. To request an amendment, your request must be in writing and submitted to the HIPAA Officer at the address listed in Section VI below. In your request, you must provide a reason as to why you want this amendment. If we accept your request, we will notify you of that in writing. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that (i) was not created by us (unless you provide a reasonable basis for asserting that the person or organization that created the information is no longer available to act on the requested amendment), (ii) is not part of the information kept by the Practice, (iii) is not part of the information which you would be permitted to inspect and copy, or (iv) is accurate and complete. If we deny your request, we will notify you of that denial in writing.

C. Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures" of your medical information. This is a list of the disclosures we have made for up to six years prior to the date of your request of your medical information, but does not include disclosures for Treatment, Payment, or Health Care Operations (as described in Sections II A, B, and C of this Notice) or disclosures made pursuant to your specific authorization (as described in Section III of this Notice), or certain other disclosures.

If we make disclosures through an electronic health records (EHR) system, you may have an additional right to an accounting of disclosures for Treatment, Payment, and Health Care Operations. Please contact the Practice’s HIPAA Officer at the address set forth in Section VI below for more information regarding whether we have implemented an EHR and the effective date, if any, of any additional right to an accounting of disclosures made through an EHR for the purposes of Treatment, Payment, or Health Care Operations.

To request a list of accounting, you must submit your request in writing to the Practice’s HIPAA Officer at the address set forth in Section VI below.

Your request must state a time period, which may not be longer than six years (or longer than three years for Treatment, Payment, and Health Care Operations disclosures made through an EHR, if applicable) and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a twelve-month period will be free. For additional lists, we may charge you a reasonable fee for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

D. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a restriction or limitation on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. Except as specifically described below in this Notice, we are not required to agree to your request for a restriction or limitation. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment. In addition, there are certain situations where we won’t be able to agree to your request, such as when we are required by law to use or disclose your medical information. To request restrictions, you must make your request in writing to the Practice’s HIPAA Officer at the address listed in Section VI of this Notice below. In your request, you must specifically tell us what information you want to limit, whether you want us to limit our use, disclosure, or both, and to whom you want the limits to apply. As stated above, in most instances we do not have to agree to your request for restrictions on disclosures that are otherwise allowed. However, if you pay or another person (other than a health plan) pays on your behalf for an item or service in full, out of pocket, and you request that we not disclose the medical information relating solely to that item or service to a health plan for the purposes of payment or health care operations, then we will be obligated to abide by that request for restriction unless the disclosure is otherwise required by law. You should be aware that such restrictions may have unintended consequences, particularly if other providers need to know that information (such as a pharmacy filling a prescription). It will be your obligation to notify any such other providers of this restriction. Additionally, such a restriction may impact your health plan’s decision to pay for related care that you may not want to pay for out of pocket (and which would not be subject to the restriction).

E. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at home, not at work or, conversely, only at work and not at home. To request such confidential communications, you must make your request in writing to the Practice’s HIPAA Officer at the address listed in Section VI below. We will not ask the reason for your request, and we will use our best efforts to accommodate all reasonable requests, but there are some requests with which we will not be able comply. Your request must specify how and where you wish to be contacted.

F. Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this Notice, you must make your request in writing to the Practice’s HIPAA Officer at the address set forth in Section VI below.

G. Right to Breach Notification. In certain instances, we may be obligated to notify you (and potentially other parties) if we become aware that your medical information has been improperly disclosed or otherwise subject to a “breach” as defined in and/or required by HIPAA and applicable state law.

V. CHANGES TO THIS NOTICE.

We reserve the right to change this Notice at any time, along with our privacy policies and practices. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well, as any information we receive in the future. We will post a copy of the current notice, along with an announcement that changes have been made, as applicable, in our office and on our website, www.thecvig.com. When changes have been made to the Notice, you may obtain a revised copy by sending a letter to or calling the Practice’s HIPAA Officer at the address listed in Section VI below or by asking the office receptionist for a current copy of the Notice.

VI. COMPLAINTS.

If you believe that your privacy rights as described in this Notice have been violated, you may file a complaint with the Practice at the following address or phone number:

The CVIG Clinic | Attn: HIPAA Officer | 221 W. Colorado Blvd, Pavilion II, Suite 933 Dallas, Texas 75208 | 469-437-3560

To file a complaint, you may either call or send a written letter. The Practice will not retaliate against any individual who files a complaint. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services.

In addition, if you have any questions about this Notice, please contact the Practice’s HIPAA Officer at the address or phone number listed above.

VII. ACKNOWLEDGMENT AND REQUESTED RESTRICTIONS.

By signing below, you acknowledge that you have received this Notice of Privacy Practices prior to any service being provided to you by the Practice, and you consent to the use and disclosure of your medical information as set forth herein except as expressly stated below.

SIGNATURES:

H I S T O R Y

P A S T M E D I C A L H I S T O R Y

TESTS DONE TO EVALUATE YOUR HEART CONDITION

P A S T S U R G I C A L H I S T O R Y

R E V I E W O F S Y S T E M S

ARE YOU CURRENTLY OR HAVE HAD PROBLEMS WITH:

*PLEASE EXPLAIN AND DESCRIBE ALL YES ANSWERS BELOW

S O C I A L H I S T O R Y

F A M I L Y H I S T O R Y

M E D I C A T I O N S

PERIPHERAL VASCULAR QUESTIONNAIRE

Peripheral vascular disease is a common circulation problem in which the blood vessels, which carry blood to the legs and/or arms, become narrowed or clogged. Please fill out the questionnaire to help us identify if you have symptoms of peripheral vascular disease. Check yes or no to the following questions:

If you answered “yes” to question number 1, circle the area of the body on the diagram below where you feel pain:

Patient Questionnaire

Please complete the following section(s) that are pertinent to your visit today:

CHEST PAIN

SHORTNESS OF BREATH

IRREGULAR HEART BEATS

SWELLING

Refills remaining can be picked up at your local pharmacy of choice

The CVIG | 221 W. Colorado Blvd., Pavilion 2, Suite 933, Dallas TX 75208 | 469-437-3560 (P) 214-946-7445(F)