PATIENT INFORMATION CARDIOVASCULAR ASSOCIATES, INC. NAME

CARDIOVASCULAR ASSOCIATES, INC.
PATIENT INFORMATION
NAME ___________________________________________________________________________________________________________________________
LOCAL ADDRESS
CITY
_
_____
PHONE
_
_ __ __ ___ __ __ ___ __ __ ___ ___ __ __ ___ __ __ ___ __ __ ___ ___ __ __ __
CITY
STATE&ZIPCODE
NORTHERN A D D R E S S
STATE & ZIPCODE _____________
DATE OF BIRTH
_
PHONE
AGE
WEIGHT
HUSBAND/WIFE NAME _____________________________________________
_
SOCIAL SECURITY#.
_
SOCIAL SECURITY#
PATIENT'S EMPLOYER______________________________________________________________
_
PHONE
_
PRIMARY INSURANCE_________________________________________________ POLICY NUMBER
ADDRESS
l.D. #
_
__
GROUP
CODE
__
SECONDARY INSURANCE_______________________________________________ POLICY NUMBER
ADDRESS
l.D. #
_
_____
GROUP
___CODE __________________________
PARTY RESPONSIBLE FOR THIS ACCOUNT
__
NAME OF PERSON TO CALL IN AN EMERGENCY
_ _
ADDRESS
PHONE
_
(DIFFERENT THAN YOUR HOME PHONE)
DO YOU SMOKE? YES or N O
DO YOU HAVE A LIVING WILL? YES or N O
PRIMARY PHYSICIAN
_
REFERRED BY_____________________________________________________________________________________________________________________________________
EMAIL ADDRESS ____________________________________________________________________________________________________________________
ASSIGNMENT OF BENEFITS
For Filing Insurance
I hereby assign all medical and/or surgical benefits, to which I am entitled, including Medicare,
Private Insurance, Major Medical Benefits and any other Health Plans to Cardiovascular Associates, Inc.
Johnson P. Massey, M.D., Patrick F. Mathias, M.D., Robert L. Barrett, M.D., Thomas Y. Kim, M.D., Prashanta
A. Laddu, M.D., Mukesh Kumar, M.D., Naushad Shaik, M.D., Deborah Huddleston, A.R.N.P., and Bethanne
Smith, A.R.N.P. This assignment will remain in effect until revoked by me in writing. I understand that I am
financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee
to release all information, including HIV, substance abuse or psychiatric information which may be found in
the record and necessary to secure payment.
MEDICARE PATIENTS: Please read and sign assignment of benefits on the next page. Thank you.
CM4300
CARDIOVASCULAR ASSOCIATES, INC.
Johnson P. Massey, M.D., FACC
Patrick F. Mathias, M.D., FACC, FCCP
Robert L. Barrett, M.D., FACC
Thomas Y. Kim, M.D., FACC
Prashanta A. Laddu, M.D., FACC
Mukesh Kumar, M.D., FACC, FSCAI
Naushad Shaik, M.D., FACC
Deborah Huddleston, A.R.N.P.
Bethanne Smith, A.R.N.P.
LIFETIME AUTHORIZATION FOR MEDICARE
(Patient Name)
(Patient's Medicare Number)
I hereby request payment of authorized Medicare benefits and/or any other insurance benefits to be made either to
me or on my behalf to Cardiovascular Associates, Inc., for services provided by Cardiovascular Associates, Inc.,
Johnson P. Massey, M.D., Patrick F. Mathias, M.D., Robert L. Barrett, M.D., Thomas Y. Kim, M.D., Prashanta A.
Laddu, M.D., Mukesh Kumar, M.D., Naushad Shaik, M.D., Deborah Huddleston, A.R.N.P., and Bethanne Smith,
A.R.N.P. I authorize any holder of medical information about me to release to the Centers for Medicare Services
and its agents any information needed to determine these benefits or the benefits payable to related services.
I understand my signature requests that payment be made and authorizes release of medical information necessary
to pay the claim. If item 9 of the CMS-1500 claim form is completed, my signature authorizes releasing of the
information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept
the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the
deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge
determination of the Medicare carrier.
Patient Signature_______________________________ Date______________________
I request that payment of authorized MEDIGAP benefits be made on my behalf to Cardiovascular Associates, Inc.,
Johnson P. Massey, M.D., Patrick F. Mathias, M.D., Robert L. Barrett, M.D., Thomas Y. Kim, M.D., Prashanta A.
Laddu, M.D., Mukesh Kumar, M.D., Naushad Shaik, M.D., Deborah Huddleston, A.R.N.P., and Bethanne Smith,
A.R.N.P. for any services furnished me by Cardiovascular Associates, Inc.
I authorize any holder of medical information about me to release to Cardiovascular Associates any information
needed to determine these benefits or the benefits payable for related services.
Patient Signature_____________________________________ Date ________________________
CM4300
PATIENT MEDICAL HISTORY
HISTORIAL MEDICO DEL PACIENTE
NAME:
Mr./Sr.
Mrs./Sra.
Miss./srta.
NOMBRE
Last/Apellido
_
First/Nombre de pila
Middle/Inicial
AGE:
DATE OF BIRTH:
EDAD
FECHA DE NACIMIENTO
_
Single/Soltero(a)
Divorced/Divorciado(a)
Married/Casado(a)
Widow(er)Viudo(a)
DATE:
_
FECHA
BIRTH PLACE:
_
LUGAR DE NACIM/ENTO
OCCUPATION:
_
OCUPAC/6N
WHY WERE YOU REFERRED HERE?
CURRENT MEDICATIONS:
¿CUAL ES EL MOTIVO DE SU VISITA?
MEDICAMENTOS QUE TOMA
1.
2.
3.
4._________________________________________
_____________________________________________
Allergies/Alergias: _______________________________________
1.
2.
3.
CURRENT SYMPTOMS/SINTOMAS:
Weight Loss
Stomach Ulcers
Perdida de peso
Ulceras estomacales
Weight Gain
Blood in Stools
Subida de peso
Sangre en las deposiciones (heces)
Fever or Chills
PAST CARDIAC ILLNESSES:
ENFERMEDADES CARO/ACAS PREVIAS
Angina
Angina de pecho
Cardiac Arrhythmias
Black Tarry Stools
Fiebre o escalofrios
Deposiciones alquitranadas
Arritmia cardiaca
Difficulty in Exercising
Varicose Veins
Atrial Fibrillation
Dificultad para hacer ejercicio
Fibrilacion auricular
Varices
Change in Hair
Swelling in the Legs
Cambios en el pelo
Hinchazon en las piernas
Miocardiopatfa
Change in Nails
Arthritis
Congestive Heart Failure
Cambios en la uñas
Artritis
Rashes
Sarpullidos
Skin Lesions
Lesiones en la piel
Cardiomyopathy
lnsuficiencia cardiaca congestiva
Back Pain/Problems
Coronary Artery Disease
Dolores de espalda
Cardiopatia isquemica
History of Depression
Valvular Heart Disease
Historial de depresion
Valvulopatia
Double Vision
Substance Abuse
Prior Heart Attack
Doble vision
Problemas de alcohol o drogas
Ataque previo al corazon
Glaucoma
Glaucoma
Field of Vision Problems
Difficulty in Thinking
Prior Angioplasty or Stent
Dificultades para pensar
Endoprotesis vascular o angioplastia previa
None of the Above
Problemas con el campo de vision
Ninguno de las anteriores
Hearing Loss
Problemas de oido
FAMILY HISTORY
Nose Bleeds
HISTOR/AL FAMILIAR
Hemorragias nasales
Hoarseness
Ronquera
Difficulty Speaking
Dificultades al hablar
Has Any Blood Relative Ever
Had:
Ha tenido fllguno de sus
parientes consangumeos:
Heart Trouble
Problemas cardfacos
Shortness of Breath
Dificultades al respirar
Cough
High Blood Pressure
Tension sanaufnea a/ta
Tos
Wheezing
Silbidos al respirar
Cancer I Cancer
Diabetes I Diabetes
Coughing up Blood
Stroke I Derrame cerebral
Tos con sangre
Other I Otra:
No
Yes
Who
Age on Onset
No
Si
Quien Edad al descubrirse
Prior Coronary Artery Bypass
lnjerto de revascularizacion coronaria previo
Surgery
Prior Valvular Heart Surgery
Cirugia previa de valvulopatia
Prior Pacemaker/Defibrillator
Marcapasos o desfibrilador previo
Other I Otra:
PAST SURGICAL PROCEDURES:
OPERACJONES QUIRURGICAS PREVJAS:
Abdominal Aortic Aneurysm Surgery
Hip Replacement
Gallbladder Surgery
Cirugia de la vesicula
Cirugia de aneurisma aortico abdominal
Amputation
Reemplazo de cadera
Laminectomy
Colostomy
Amputacion
Laminectomia
Colostomia
Colon Surgery
Knee Surgery
Cirugia de radiila
Lung Surgery
Cirugia def pulmon
Cirugia de colon
Back Surgery
Prostate Surgery
Eye Surgery
Cirugia de espalda
Cirugia def ojo
Bladder Suspension/Surgery
Cirugia de la prostata
Shoulder Surgery
Elbow Surgery
Cirugia de codo
Suspensio/cirugia uretropelvica
Breast Surgery (Please circle}:
Cirugia de hombro
Vascular Bypass Surgery of the Legs
Cirugia de mama (rodear con un circulo):
Thyroid Surgery
Cirugia de la glandula tiroidea
Revascularizacion quirurgica de las piernas
Augmentation, Biopsy, Mastectomy
Gastrectomy
Tonsillectomy
Gastrectomia
aumento, biopsia, mastectomia
Carotid Surgery
Amigadalectomia
Tubal Ligation
Gastric Stapling
Cirugia de la carotida
Ligadura de trompas
Grapado gastrico
Cataract Surgery
Hemorrhoid Surgery
Cirugia de cataratas
Ulcer Repair
Cirugia de hemorroides
Carpal Tunnel Surgery
Reparacion de ulceras
Vasectomy
Hysterectomy
Cirugia def tunel carpiano
Histerectomia
Cesarean Section
Vasectomia
Hernia Repair
Cesarea
Vein Stripping
Extirpacion venosa
Reparacion de hernia
PAST MEDICAL HISTORY
HISTORIAL MEDICO PREVIO
HAVE YOU EVER HAD:
HA SUFRID0 ALGUNA VEZ
Abdominal Aortic Aneurysm
Aneurisma aortico abdominal
Anemia
Anemia
Anxiety
Ansiedad
Asthma
Asma
Arthritis
Artritis
Bi-Polar Disease
Trastorno bipolar
Blindness
Ceguera
Prostate Enlargement
Hipertrofia prostatica
Bronchitis
Bronquitis
Cataract
Cataratas
Carotid Artery Disease
Arteriopata carotidea
Ulcerative Colitis
Colitis ulcerosa
Chronic Emphysema (COPD)
Enfisema cronico (COPD)
Stroke/Mini-Stroke
Derrame I miniderrame cerebral
Cancer (Circle what type):
Cancer (rodear con un circulo):
Breast, Cervical, Bladder, Colon,
mama, cuelo uterino, vejiga, colon,
Kidney, Liver, Lung, Pancreas,
riño, higado, pulmon, pancreas,
Prostate, Stomach, Uterus,
prostata, estomago, utero,
Skin, Throat
piel, garganta
Gallbladder Disease/Gallstones
Colescitopatia I calculo vesical
Liver Cirrhosis
Cirrosis def higado
Alzheimer's Disease
Enfermedad de Alzheimer
Depression
Depresion
Diabetes
Diabetes
Diverticulitis/Diverticulosis
Diverticulitis I diverticulosis
Peptic Ulcer Disease
Ulcera peptica
Phlebitis
Flebitis
Endometriosis
Endometriosis
Lymphoma
Erectile Dysfunction/Impotence
Linfoma
Disfuncion erectile / impotencia
Macular Degeneration
Esophagitis/Gastritis
Degeneracion macular
Esofaguitis I gastritis
Obesity
Fibromyalgia
Obesidad
Fibromialgia
Osteoporosis
Glaucoma
Osteoporosis
Glaucoma
Pancreatitis
GERD or Hiatal Hernia
Pancreatitis
GERD o hernia de hiato
Panic Attacks
Gout
Ataques de panico
Gota
Parkinson's Disease
Headaches/Migraines
Enfermedad de Parkinson
Dolores de cabeza / jaqueca
Pneumonia
Hemorrhoids
Neumonia
Hemorroides
Prostatitis
Hernias
Prostatitis
Hernias
Poor Circulation (Peripheral Vascular Disease)
HIV Disease
Mala circulacion (vasculopatia periferica)
VIH
Rheumatic Fever
Hodgkins' Disease
Fiebre reumatica
Enfermedad de Hodgkins
Renal or Kidney Failure
Hyperlipidemia or High Cholesterol
lnsuficiencia renal (riñon)
Hiperlipidemia o colesterol alto
Scoliosis
High Blood Pressure or Hypertension
Escoliosis
Tension sanguinea alta o hipertension
Seizures
Thyroid Disease
Convulsiones
Disfuncion tiroidea
Sleep Apnea
Irritable Bowel Syndrome
Apnea de/ sueño
Sindrome del colon irritable
Varicose Veins
Kidney Stones
Varices
Piedras de riñon
Vertigo
Leukemia
Vertigo
Leucemia
Lupus
Lupus
Do You Smoke?
¿,Fuma?
Year Quit
_
Packs per day
En que año lo dejo
_
Paquetes al dia
Number of Years
_
Cuantos años
Alcoholic Beverages:
Bebidas alcoholicas:
Never
Nunca
Rarely
Casi nunca
Moderate
Moderadamente
Heavily
Mucha
Beer
Cerveza
Number of Years
Wine
_
Cuantos años
Vino
Other
NAMES OF PHYSICIANS THAT ARE FAMILIAR
WITH YOUR M E D I C A L CONDITION:
NOMBRE DE LOS MEDICOS QUE CONOCEN EL
TRASTORNO MEDICO QUE SUFRE
Otras:
What Do You Consider Yourself?
lndique cuanto bebe
Non Drinker
No bebo
Moderate Drinker
Bebo moderadamente
Alcoholic
Alcohoilico
Social Drinker
Bebo en situaciones sociales
Heavy Drinker
Bebo mucho
Formerly an Alcoholic
Ex-alcohoilico
601 Oak Commons Blvd., Kissimmee, FL 34741
4529 Edgewater Drive, Orlando, FL 32804
2900 17th Street, Suite 5, St. Cloud, FL 34769
42719 Hwy. 27 Suite 103, Davenport, FL 33837
410 Celebration Place, Suite 201, Celebration, FL 34747
CONSENT TO THE USE AND DISCLOSURE OF HEALTH
INFORMATIONFOR TREATMENT, PAYMENT, OR HEALTH OPERATION
NAME ________________________________________________________________________________
BIRTHDATE ______________________________________ SOCIAL SECURITY # ______________________
I understand that as part of my healthcare, this organization originates and maintains health records describing my
health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or
treatment. I understand that this information serves as:
•
A basis for planning my care and treatment
•
A means of communication among the many health professionals who contribute to my care
•
A source of information for applying my diagnosis and surgical information to my bill
•
A means by which a third-party payer can verify that services billed were actually provided
•
And a tool for routine healthcare operations such as assessing quality and reviewing the competence of
healthcare professionals.
I understand and have been provided with a Notice of Information Practices that provides a more complete
description of information uses and disclosures. I understand that I have the right to review the notice prior to signing
this consent. I understand that the organization reserves the right to change their notice and practices. I understand
that I have the right to object to the use of my health information for directory purposes. I understand that I have the
right to request restrictions as to how my health information may be used or disclosed to carry out treatment,
payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I
understand that I may revoke this consent in writing, except to the extent that the organization has already taken
action in reliance thereon.
I request the following restrictions to the use or disclosure of my health information.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
PATIENT:
X___________________________________ ________________________ _______________________
Signature of Patient or Legal Representative
Date
OFFICE USE ONLY:
Accepted __________________________________
Denied
Signature
Witness Signature
_________________ ________________
Title
Date
CARDIOVASCULAR ASSOCIATES, INC.
Johnson P. Massey, M.D., FACC
Patrick F. Mathias, M.D., FACC, FCCP
Robert L. Barrett, M.D., FACC
Thomas Y. Kim, M.D., FACC
Prashanta A. Laddu, M.D., FACC
Mukesh Kumar, M.D., FACC, FSCAI
Naushad Shaik, M.D., FACC
Deborah Huddleston, A.R.N.P.
Bethanne Smith, A.R.N.P.
MISSED APPOINTMENT POLICY
Please Read CAREFULLY Before Signing:
Our office has implemented a new cancellation policy effective October 18, 2010. All appointment cancellations
must be made 24 hours prior to your scheduled appointment time. Failure to cancel your appointment will generate
a $25.00 Missed Appointment Fee for regular office visits, Echo, Vascular I Arterial Studies. A $150.00 Missed
Testing Fee for Nuclear Stress Testing will be generated; t h e s e fees are payable before yo u r next appointment will
be scheduled.
We do realize that emergencies and illnesses arise and will consider those circumstances. To cancel your office visit
appointment during normal business hours Monday through Friday from 9:00am till 5:00pm, please call (407) 8460626, choose option 2 and then option 2 again. To cancel your Nuclear Stress Test, please call (407) 846-0626 and
then put in 279, this is the direct extension to the Test Scheduler. After hour calls placed to (407) 846-0626 will be
handled by our Answering Service. Failure to call and cancel your appointment in a timely fashion results in an
additional charge to you and your appointment slot not being made available to someone who may need to be seen.
This Missed Appointment Fee must be paid in full before we can schedule your next appointment.
Please sign the acknowledgement and acceptance of this policy in the space provided below. This notice will become
part of your medical record.
Patient Name
Date of Birth
Patient Signature/Responsible Party
Today's Date
601 Oak Commons Blvd., Kissimmee, FL 34741•Phone: 407.846.0626 •Fax: 407.846.2524
4529 Edgewater Drive, Orlando, FL 32804 •Phone: 407.297.1870 •Fax: 407.292.7988
HIPPA" Notice of Privacy Practices Summary/Acknowledgement
Maintaining privacy of your heal.th information is very important to us. Attached to this letter you will find
our Notice of Privacy' Practices. The following is a brief summary of the content of the attached notice. We
encourage you to read the entire Notice and ask any questions you may have regarding its contents .
How We May Use and Disclose Health Information About You. This section describes the different ways
we may use or disclose your health information without first obtaining a specific authorization from you.
These types of uses and disclosures are specifically permitted by law because it.is assumed you would
want us to use or disclose your information for these purposes, or because such use or disclosure is
recognized as critical to the functioning of our health system.
Your Rights Regarding Your Health Information. This section describes the following rights you have with respect to your
health information and tells you how you may exercise these rights.
 Right to inspect and copy
 Right to request amendment
 Right to an accounting of disclosures
 Right to request restrictions on certain uses and disclosures
 Right to request alternative means of communication
 Right to receive a paper copy of our Notice of Privacy Practices
How to file Complaints Concerning Our Privacy Practice. This section tells you what you can do if you believe
any of your rights have been violated. You will not be penalized for filing a complaint.
'
'
.
.
.
We ask you acknowledge your receipt of this Notice by signing below. You should keep the copy of the attached
Notice, however if you wish to receive another copy you may request at any time. Also, the most current copy of
out Notice will be posted I our office. If there are material changes to this Notice at a later date, you will be provide
a copy of the revised Notice and asked to sign another acknowledgement.
I acknowledge that I received a copy of my providers Notice of Privacy Practices.
Patient Signature: _______________
Witness:________________________________
City, State, Zip:
I
_
, hereby authorize Cardiovascular Associates Inc.
Name of patient
And/or medical facility to release any and all medical information and test results that
pertain to me, to the following individual(s):
Name:
Relationship to patient:
_
Name:
Relationship to patient:
_
Name:
Relationship to patient:
_
I authorize Cardiovascular Associates Inc. or the medical facility to contact the
individual(s) listed above to convey any patient information to me, in the event I am
unable to be reached by the facility.
I understand that I may revoke/cancel this authorization by notifying Cardiovascular
Associates Inc. in writing of my intent to revoke authorization or change in name(s) of
the individuals to whom the information is to be released.
Signature of Patient
Date
Or if applicable
Signature of Legal Guardian or Personal Representative
Date
Name of Witness
Date
Witness Signature