Ocean Heart Group
Patient Name: _________________________________________ First Initial LastMailing Address: _______________________________________City: _________________________________________State: _______________ Zip: ______________Occupation: ___________________________________Employer: _____________________________________Employer Address: ______________________________City: __________________ State: _______ Zip: __________Birthdate: ______/______/______ Sex: □F □MSocial Security #: ______-______-______Marital Status: □S □M □Sep □D □W*Please Indicate preferred method for contact:_____ Home Phone: __________________________ Cell Phone: ____________________________ Work Phone: ___________________________ Email Address: _____________________Emergency Contact Information:Name: _______________________________________Relationship: __________________________________Telephone #: __________________________________To comply with Federal regulations, we are required to ask you to fill out the following:Race: Ethnicity:□ White □ Hispanic or Latino□ Black/African American □ Not Hispanic or Latino□ Asian □ Prefer not to disclose□ American Indian/ Alaskan Native□ Native Hawaiian/ Pacific Native□ Other: ______________□ Prefer not to disclose Primary Language: _____________________________Pharmacy Information:Pharmacy Name: ________________________________City & State: ____________________________________Telephone #: ___________________________________Please identify the Laboratory your Insurance Company requires you to use.□Quest □LabCorp □CDS □Hospital ______________ □Other _____________Please provide all pertinent information regarding your insurance coverage. If you have coverage by more than one carrier, please supply information for both. Primary Insurance: ______________________ID #: _____________________________________Group #: __________________Subscriber Name: ________________________________Relationship to SubscriberSelf ____ Spouse____ Child____ Other____Subscriber Birthdate: ____________________________Secondary Insurance: ______________________ID #: _____________________________________Group #: __________________Subscriber Name: ________________________________Relationship to SubscriberSelf ____ Spouse____ Child____ Other____Subscriber Birthdate: _____________________________Assignment of Insurance Benefits: I request that payment of authorized benefits be made on my behalf by any Insurance Company involved in my benefits, Medicare or Medicaid, or any insurance involved in my benefits. I understand I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I assign directly to your office all insurance benefits. I authorize the use of this signature on all insurance submissions, whether manual or electronic.Patient Signature: ___________________________________________________ Date: ______________________PAST MEDICAL HISTORY:PAST SURGICAL HISTORYDIABETES: □ NO □ YES HYPERTENSION: □ NO □ YES CHOLESTEROL: □ NO □ YES HEART ATTACK: □ NO □ YES HEART FAILURE: □ NO □ YESATRIAL FIBRILLATION: □ NO □ YES ARRHYTHMIA: □ NO □ YES KNEE PAIN: □ NO □ YES LUNG PROBLEMS: □ NO □ YESSMOKER: □ NO □ YES □FORMEROTHER: _______________________________ IF YES, PLEASE SPECIFY WHEN.BYPASS SURGERY: □ NO □ YES: _______LEG SURGERY: □ NO □ YES: _______VALVE REPAIR: □ NO □ YES: _______VALVE REPLACEMENT: □ NO □ YES: _______PACEMAKER IMPLANT: □ NO □ YES: _______DEFIBRILLATOR IMPLANT: □ NO □ YES: _______APPENDECTOMY: □ NO □ YES: _______TONSILLECTOMY: □ NO □ YES: _______CHOLECYSTECTOMY: □ NO □ YES: _______HERNIORRHAPHY: □ NO □ YES: _______ HAVE YOU HAD ANY OF THE FOLLOWING TESTING? IF YES, PLEASE SPECIFY WHENCARDIAC CATHETERIZATION: □ NO □ YES: _____________ECHOCARDIOGRAM: □ NO □ YES: _____________EXERCISE STRESS TEST: □ NO □ YES: _____________NUCLEAR STRESS TEST: □ NO □ YES: _____________PVR: □ NO □ YES: _____________CAROTID ULTRASOUND: □ NO □ YES: _____________ABDOMINAL ULTRASOUND: □ NO □ YES: _____________HOLTER MONITOR: □ NO □ YES: _____________EVENT RECORDER: □ NO □ YES: _____________FAMILY HISTORYDo any immediate family members have a history of the following?HEART ATTACK: □ NO □ YESBYPASS SURGERY: □ NO □ YESANGIOPLASTY: □ NO □ YESHIGH BLOOD PRESSURE: □ NO □ YESDIABETES: □ NO □ YESCANCER: □ NO □ YES SOCIAL HISTORYSPOUSE’S NAME: _____________________________CHILDREN’S NAME(S): _______________________ _______________________ _______________________ _______________________HOBBIES: _______________________________________________________________________________________________________________________________________________________________________________________________________________________COMPLAINTS OR SYMPTOMSPLEASE CHECK THE CORRESPONDING BOX IF YOU HAVE OR HAD ANY OF THE FOLLOWING:CONSTITUTIONAL:□ WEIGHT LOSS□ FEVERS□ CHILLS□ FATIGUE□ ACHESEYES:□ ITCHING□ PAINS□ VISION CHANGESEARS, NOSE, OR THROAT:□ PAIN□ SORE THROAT□ STUFFY NOSE□ DISCHARGE□ RINGING IN EARSCARDIOVASCULAR:□ CHEST PAIN□ CHEST DISCOMFORT□ PALPITATIONS□ TROUBLE BREATHING WHILE SLEEPING□ SLEEP ON MORE THAN 1 PILLOW□ SHORTNESS OF BREATH ON EXERTION□ SWOLLEN LEGS□ LEG PAIN WHILE WALKING RESPIRATORY:□ COUGH□ SPUTUM PRODUCTION□ SHORTNESS OF BREATH□ WHEEZING□ SNORINGGENITOURINARY:□ TROUBLE URINATING□ URGENCY/FREQUENCY□ INVOLUNTARY LEAKING□ DISCHARGENEUROLOGICAL:□ HEADACHES□ WEAKNESS□ SLURRED SPEECH□ FAINTING□ DIZZINESS□ NUMBNESSINTEGUMENTARY:□ RASHES□ SKIN LESIONS□ ITCHING ENDOCRINE:□ SWEATING□ HEAT OR COLD INTOLERANCE□ EXCESSIVE PRODUCTION OF URINE□ EXCESSIVE THIRST GASTROINTESTIONAL:□ NAUSEA□ VOMITING□ DIFFICULTY SWALLOWING□ ABDOMINAL PAINS□ DIARRHEA□ CONSTIPATION □ HEARTBURN□ BLEEDING FROM THE RECTUM 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.WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).We are legally required to protect the privacy of your health information. We call this information “protected health information,” or “PHI” for short, and it includes information that can be used to identify you that we’ve created or received about your past, present, or future health condition, the provision of health care to you, or the payment for this health care. We must provide you with this notice about our privacy practices that explains how, when, and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION.We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your specific authorization. Below, we describe the different categories of used and disclosures. Uses and Disclosures Which Do Not Require Your Authorization.We may use and disclose your PHI without your authorization for the following reasons:For treatment. We may disclose your PHI to hospitals, physicians, nurses, and other health care personnel who provide you with health care services or are involved in your care. For example, if you’re being treated for a knee injury, we may disclose your PHI to an x-ray technician in order to coordinate your care.To obtain payment for treatment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get paid for health care services we provided to you.For health care operations. We may disclose your PHI in order to operate this practice. For example, we may use your PHI in order to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided health to you. We may also provide your PHI to our accountants, attorneys, consultants, and others in order to make sure we’re complying with the laws that affect us. When a disclosure is required by federal, state of local law, judicial or administrative proceedings, or law enforcement. For example, we make disclosures when a law remains that we report information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence; when dealing with A gunshot or other wounds; or when ordered in a judicial or administrative proceeding. For public health activities. For example, we report information about births, deaths, and various diseases to government officials in charge of collecting that information and we provide coroners, medical examiners, and funeral directors necessary information relating to an individual’s death. For health oversight activities. For example, we will provide information to assist the government when it conducts and investigation or inspection of a health care provider or organization. For purposes of organ donation. We may notify organ procurement organizations to assist them in organ, eye, or tissue donation and transplants. For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research. To avoid harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm. For specific government functions. We may disclose PHI of military personnel and veterans in certain situations and we may disclose PHI for national security purposes or conducting intelligence operations.For worker’s compensations purposes. We may provide PHI in order to comply with workers compensation laws.Appointment reminders and health related benefits or services. We may use PHI to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits we offer. Use and Disclose Where You Have the Opportunity to Object:Disclosures to family, friends, or others. We may provide your PHI to a family member, friend or other person that you indicate is involved in your care of the payment for your health care, unless you object in whole or in part. All Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described above, we will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke that authorization in writing to stop any future uses and disclosures (to the extent that we haven’t taken any action relying on the authorization). OCEAN HEART & MEDICAL GROUPNOTICE OF PRIVACYOCEAN HEART & MEDICAL GROUPDATE: _________________________I _______________________________________________________________________________________ (PRINT NAME)HAVE BEEN GIVEN A COPY OF OCEAN HEART GROUP’S “NOTICE OF PRIVACY”. SIGNATURE DATEOCEAN HEART & MEDICAL GROUPAUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATIONI authorize my physician and/or administrative and clinical staff to disclose the following protected health information to:□ Myself Only□ My Spouse/Significant other□ Other (Specify Name) ___________________________Information to be disclosed:□ Laboratory Results□ X-Ray Results□ Diagnosis □ Other Test Results (Specify) __________________________This protected health information is being used or disclosed for the following purposes:□ At the request of myself □ OtherI would like to be contacted at my:□ Home Phone __________________________□ Cell Phone ____________________________□ Work Phone ___________________________□ Mail _________________________________□ Other ________________________________Regarding the office staff or physician leaving information or confirming appointments on my answering machine, voice mail or with my answering service:□ Yes, I give my permission for medical information to be left on my answering systems.□ No, I do not want messages or medical information left on my answering systems. This authorization shall be in force an effect until 6 years from the date below, at which time this authorization expires. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the office’s Privacy Contact at the above address. I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has legal right to contest a claim. ________________________________________________________________________________________Signature of Patient or Personal Representative Date_________________________________________________________________________________________________________Print Name of Patient of Personal Representative Description of personal representative’s Authority MEDICATIONSPATIENT NAME: _____________________________________________ D.O.B: _____________________MEDICATION NAMEDOSAGEFREQUENCYDATE LAST FILLED ................
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