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Thank you for choosing Lake Area Cardiology for your cardiology needs. Your appointment iswith Dr. _________________ on _____/_____/_____ at _________________Please complete the attached forms; as well as follow the listed instructions to ensureno delay in your appointment:? All paperwork MUST be returned to our office 48 hours BEFORE the visit If we do not have your paperwork prior, your appointment will berescheduled.? Please bring originals of your insurance and driver’s license so we may scan acopy.? It is YOUR responsibility to make sure that your prior medical records (cardiacin nature) are either sent to our office by fax, or you may hand carry them in with you.? Bring all your medications with you (including supplements) to yourappointment.? If your insurance requires a referral from your primary physician, it is yourresponsibility to make sure and have it faxed to our office before yourappointment; or you may hand carry it to your appointment.How did you hear about Lake Area Cardiology? FORMCHECKBOX Physician Referral FORMCHECKBOX Advertisement FORMCHECKBOX Friend FORMCHECKBOX Other: ______________________________ Patient InformationName: _____________________________________ Last First MiddleDoctor: ____________________________________Social Security #: ____________________________Email Address: ______________________________Address: ___________________________________City: _______________ State: _____ Zip: _________Home Ph.: (_____) _____________Business Ph.: (_____) __________Cell Ph.: (_____) ____________ FORMCHECKBOX Married FORMCHECKBOX Single FORMCHECKBOX Widow FORMCHECKBOX DivorcedAge: ____ Date of Birth: _____/_____/_____ FORMCHECKBOX Male FORMCHECKBOX FemaleReferring Physician: __________________________Primary Care Physician: _______________________Race: ______________________Ethnicity: FORMCHECKBOX Hispanic or Latino FORMCHECKBOX Not Hispanic or LatinoNotify in Case of Emergency Name: ___________________Relationship: _______Ph:(____)____-______Wk:(____)_____________Name: ___________________Relationship: _______Ph:(____)_____-_____Wk:(____)_____________Insurance Information – Copies of Insurance Cards and Drivers License are RequiredInsurance 1: _____________________________________________________________________________Policy #: __________________________ Group #: _________________________Insurance 2: _____________________________________________________________________________Policy #: __________________________ Group #: _________________________PATIENT CONTACT PREFERENCESI prefer to be contacted in the following manner: FORMCHECKBOX Phone #: (________) __________ - ___________________ FORMCHECKBOX OK to leave message with detailed information FORMCHECKBOX DO NOT LEAVE MESSAGEAll normal test results will be sent via our Patient Portal to Email: ( PLEASE PRINT )_________________________________________________ @ __________________________ . ________Appointment reminders: FORMCHECKBOX Text FORMCHECKBOX Phone FORMCHECKBOX EmailNew Patient Medical QuestionnairePatient Name: _____________________________________ DOB: ______________ Date:_____________Primary Care Physician: ___________________________________________City / State: ________________________Other Physicians:___________________________________________________________________________________Pharmacy: ____________________________________ City/Intersection/Phone: _______________________________Chief ComplaintWhat problems are you here for today? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Cardiac Problem ListPlease check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified. FORMCHECKBOX Yes FORMCHECKBOX NoCardiomegaly (Enlarged Heart) ________ FORMCHECKBOX Yes FORMCHECKBOX NoCoronary Artery Disease __________ FORMCHECKBOX Yes FORMCHECKBOX NoHeart Disease born with(congenital)_____ FORMCHECKBOX Yes FORMCHECKBOX NoHeart Failure / Cardiomyopathy ____ FORMCHECKBOX Yes FORMCHECKBOX NoAtrial Fibrillation ____________________ FORMCHECKBOX Yes FORMCHECKBOX NoArrhythmia / Abnormal Rhythm_____ FORMCHECKBOX Yes FORMCHECKBOX NoMurmur____________________________ FORMCHECKBOX Yes FORMCHECKBOX NoPrevious Cardiac Arrest __________ FORMCHECKBOX Yes FORMCHECKBOX NoAbnormal Heart Valve ________________ FORMCHECKBOX Yes FORMCHECKBOX NoDefibrillated / Shocked ___________ FORMCHECKBOX Yes FORMCHECKBOX NoEndocarditis (infected heart valve)_______ FORMCHECKBOX Yes FORMCHECKBOX NoPericardial(sac surrounding heart) Disease FORMCHECKBOX Yes FORMCHECKBOX NoAbnormal ECG______________________ FORMCHECKBOX Yes FORMCHECKBOX NoMarfan’s Syndrome _____________ FORMCHECKBOX Yes FORMCHECKBOX NoAngina (heart pain)__________________ FORMCHECKBOX Yes FORMCHECKBOX NoHospitalized for cardiac reasons____ FORMCHECKBOX Yes FORMCHECKBOX NoHeart Attack _______________________ FORMCHECKBOX Yes FORMCHECKBOX NoOther type of heart disease________VASCULAR: FORMCHECKBOX Yes FORMCHECKBOX NoCarotid Artery Disease _______________ FORMCHECKBOX Yes FORMCHECKBOX NoStroke or TIA (mini-stroke)_________ FORMCHECKBOX Yes FORMCHECKBOX NoRenal(kidney) Artery Disease __________ FORMCHECKBOX Yes FORMCHECKBOX NoAny history of aneurysm __________ FORMCHECKBOX Yes FORMCHECKBOX NoPeripheral(leg or arm) Artery Disease ____ FORMCHECKBOX Yes FORMCHECKBOX NoDVT (clots in leg) ________________ FORMCHECKBOX Yes FORMCHECKBOX NoPulmonary embolism (clots in lung) _____ FORMCHECKBOX Yes FORMCHECKBOX NoOther type of vascular Disease _____ FORMCHECKBOX Yes FORMCHECKBOX NoVaricose Veins _____________________Coronary Risk Factor FORMCHECKBOX Yes FORMCHECKBOX NoHypertension (high blood pressure) ____ FORMCHECKBOX Yes FORMCHECKBOX NoDiabetes Mellitus ________________ FORMCHECKBOX Yes FORMCHECKBOX NoHistory coronary disease in immediate family? FORMCHECKBOX Yes FORMCHECKBOX NoPeripheral artery disease? (legs, carotids)________ FORMCHECKBOX Yes FORMCHECKBOX NoHigh Cholesterol / Triglycerides____Patient Name: _____________________________________ DOB: ______________ Date: _____________Current MedicationsPlease list ALL the medications that you are taking.Name of MedicationDose/StrengthHow many/How Often/WhenExample Lasix40mgtwice a day – morning and night1) _________________________________________________________________2) _________________________________________________________________3) _________________________________________________________________4) _________________________________________________________________5) _________________________________________________________________6) _________________________________________________________________7) _________________________________________________________________8) _________________________________________________________________9) _________________________________________________________________10) ________________________________________________________________11) ________________________________________________________________12) ________________________________________________________________13) ________________________________________________________________14) ________________________________________________________________15) ________________________________________________________________(Please attach additional pages if necessary)Allergies / Intolerances to Medications No Know Allergies/Intolerances FORMCHECKBOX Please list any medications, or materials you are allergic to, had an adverse reaction to, or do not tolerate and describe the reaction.MedicationReaction (e.g. hives, swelling, short of breath, rash, etc)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient Name: _____________________________________ DOB: ______________ Date: _____________Cardiac Procedures/Diagnostic TestingPlease check if you have had any procedures / diagnostic tests. Write the year and the location of the test in the blank provided.YearLocation FORMCHECKBOX Yes FORMCHECKBOX NoEcho (Cardiac Ultrasound)_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoStress Test_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoHolter/Event Monitor_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoCarotid Artery Ultrasound_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoHeart Catheterization_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoHeart Angioplasty/Stent Placement_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoPeripheral Artery Angiogram (Non Heart)_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoNo Peripheral Artery Angioplasty (Non Heart)_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoElectrophysiology Study_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoHeart Rhythm Ablation_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoPacemaker/ICD(defibrillator)_____________________________________ FORMCHECKBOX Yes FORMCHECKBOX NoCardiac Surgery_____________________________________Past Medical HistoryPlease check any of the following disorders that you HAVE or HAVE HAD, and indicate the year it was first identified.PULMONARY:GASTROINTESTINAL: FORMCHECKBOX Yes FORMCHECKBOX NoAsthma ________ FORMCHECKBOX Yes FORMCHECKBOX NoReflux(GERD) __________ FORMCHECKBOX Yes FORMCHECKBOX NoEmphysema / COPD ____________ FORMCHECKBOX Yes FORMCHECKBOX NoLiver Disease / Hepatitis ______ FORMCHECKBOX Yes FORMCHECKBOX NoSleep Apnea ________ FORMCHECKBOX Yes FORMCHECKBOX NoHiatal Hernia _________RENAL / GENITOURINARY:NEUROLOGICAL / PSYCHOLOGICAL: FORMCHECKBOX Yes FORMCHECKBOX NoDialysis _________ FORMCHECKBOX Yes FORMCHECKBOX NoSeizure Disorder ______ FORMCHECKBOX Yes FORMCHECKBOX NoKidney Disease / Elevated Creatinine __ FORMCHECKBOX Yes FORMCHECKBOX NoDementia _________FEMALE REPRODUCTIVE: FORMCHECKBOX Not Applicable FORMCHECKBOX Yes FORMCHECKBOX NoMultiple miscarriages___________ FORMCHECKBOX Yes FORMCHECKBOX NoCurrently Pregnant (number of weeks?)___ FORMCHECKBOX Yes FORMCHECKBOX NoMenopause (at what age?)______OTHER: FORMCHECKBOX Yes FORMCHECKBOX NoAnemia FORMCHECKBOX Yes FORMCHECKBOX NoVertigo FORMCHECKBOX Yes FORMCHECKBOX NoClotting Disorder FORMCHECKBOX Yes FORMCHECKBOX NoAutoimmune Disorders (i.e. Lupus) FORMCHECKBOX Yes FORMCHECKBOX NoPrevious weight Loss meds (i.e. Fen Phen) FORMCHECKBOX Yes FORMCHECKBOX NoHIV/AIDS FORMCHECKBOX Yes FORMCHECKBOX NoReaction to iodine contrast FORMCHECKBOX Yes FORMCHECKBOX NoAmbulate with assistance FORMCHECKBOX Yes FORMCHECKBOX NoCancer (type?) FORMCHECKBOX Yes FORMCHECKBOX NoBleeding DisorderPlease list any other health problems that are not on the list:__________________________________________________________________________________________________________________________________________________________________________________________________Surgical History / OperationPlease list any surgeries you have had and include the year and location.Surgery:Date_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Social HistoryDo you use Tobacco? FORMCHECKBOX Yes FORMCHECKBOX Formerly FORMCHECKBOX NeverTypeHow much:Start/Quit Date FORMCHECKBOX Cigarettes_______________ per dayYears Smoked? ____________Quit Date? ___________ FORMCHECKBOX Cigars_______________ per dayYears Smoked? ____________Quit Date? ___________ FORMCHECKBOX Pipes_______________ per dayYears Smoked? ____________Quit Date? ___________ FORMCHECKBOX Chewing tobacco_______________ per dayYears Smoked? ____________Quit Date? ___________Do you use Alcohol? FORMCHECKBOX Yes FORMCHECKBOX Formerly FORMCHECKBOX NeverDescribe your use? FORMCHECKBOX Rarely FORMCHECKBOX Social FORMCHECKBOX Daily FORMCHECKBOX Daily FORMCHECKBOX Occasional FORMCHECKBOX Quit (when) _______Type:How much: FORMCHECKBOX Beer______ cansper FORMCHECKBOX day FORMCHECKBOX wk FORMCHECKBOX mo FORMCHECKBOX yrQuit (when) ____________ FORMCHECKBOX Wine_____ glassesper FORMCHECKBOX day FORMCHECKBOX wk FORMCHECKBOX mo FORMCHECKBOX yrQuit (when) ____________ FORMCHECKBOX Liquor _____ glassesper FORMCHECKBOX day FORMCHECKBOX wk FORMCHECKBOX mo FORMCHECKBOX yrQuit (when) ____________Family History Please indicate below if your FATHER, MOTHER, SIBILING(S), or CHILDREN have ever been diagnosed with any of the following conditions, by writing the age (not a check mark!) at which the condition first occurred in the appropriate box. PLEASE NOTE: If there is no history of these conditions or if they are unknown, THEN check the None or Unknown box in the appropriate column. M-Mother’s side P- Father’s SideConditionFatherMotherSister(s)Brother(s)Grandmother M/PGrandfather M/PAnginaHeart AttackAngioplastyHeart SurgeryAbnormal Heart RhythmSudden/Unexpected DeathStroke/TIA (mini stroke)Heart Failure/CardiomyopathyAneurysmNone of the aboveUnknownLake Area Cardiology, LLCArif Abdullah MDAdnan Siddiqui MDRabab Mohsin MD601 River Pointe Drive Suite 105, Conroe Texas 77304 102 Medical Park Lane Suite A, Huntsville Texas 77340Phone: 936-539-5577 Fax: 936-539-5550NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT (“HIPAA”)I UNDERSTAND THAT, UNDER THE Health Insurance Portability & accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.Obtain payment from third-party payers.Conduct normal healthcare operations such as quality assessments and physician certifications.I have received, read and understand the Notice of Privacy Practices contains a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices.I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree with my restrictions, but if you do agree then you are bound to abide by such restrictions.I hereby authorize the following individuals to obtain access to my Private Health informationNAME: ________________________ RELATIONSHIP: ________________________NAME: ________________________ RELATIONSHIP: ________________________NAME: ________________________ RELATIONSHIP: ________________________By signing this form you have read and agree to the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) Patient Name: ____________________________________Relationship to Patient: ______________________Signature: ________________________________________ Date: _____/_____ /_____Print Name: ______________________________________Lake Area Cardiology, LLCArif Abdullah MDAdnan Siddiqui MDRabab Mohsin MD601 River Pointe Drive Suite 105, Conroe Texas 77304 102 Medical Park Lane Suite A, Huntsville Texas 77340Phone: 936-539-5577 Fax: 936-539-5550Authorization and Consent to TreatmentConsent to TreatmentI voluntarily consent to the rendering of such care and treatment as the Lake Area Cardiology Associates LLC providers and personnel, in their professional judgment, deem necessary for my health and well-being. My consent shall include medical examination and diagnostic testing. My consent shall also include the carrying out of the orders of my treating provider by care center staff. I acknowledge that neither Lake Area Cardiology Associates, LLC provider nor any care center staff has made any guarantee or promise as to the results that may be obtained. Rights and ResponsibilitiesYour Responsibilities:Follow your physicians’ instructions.Be on time for your appointment, cancel or reschedule your appointments with advance notice.Let us know if your address, phone numbers or insurance has changed.Bring your insurance card and photo Id with you to every appointment.Co-payments and other payments are due at the time of service.Know all of your insurance benefits.Allow 48-72 hours for all prescription refills and always provide updated pharmacy contact information.Be respectful to fellow patients and our office staff.Your RightsReceive quality health careBe involved in decisions regarding the medical care you receive Expect that all communications and records pertaining to your healthcare will be treated as confidential according to national guidelines.Assignment of Benefits and Authorization to Release Medical InformationI understand and agree that payment of authorized benefits under Medicare, Medicaid, and/or any of my insurance carriers will be made to me or on my behalf to the provider or supplier of any services furnished to me by that provider or supplier. I authorize any holder of my medical information to release it to Lake Area Cardiology LLC, the Health Care Financing Administration (HCFA), the listed insurer and/or agents of the company and/or their listed responsible person(s), and any information necessary to determine my benefits or the benefit for the related services. If my insurance plan does not participate with Lake Area Cardiology LLC providers, or if I am a self-pay patient, assignment of benefits may not apply.Guarantee of Payment & Pre-CertificationIn consideration of services provided to me by Lake Area Cardiology Associates LLC and its care centers, I agree to be financially responsible and to pay charges for all services ordered by my providers(s). I understand that any balance due as a result of being uninsured or under-insured is payable immediately. I further understand that if I fail to maintain consistent payments, my account will be referred to a collection agent and/or attorney and I agree to pay all collection related charges. I understand that if my insurance has a precertification or authorization requirement, it is my responsibility to notify the carrier of services rendered according to the plan’s provisions. I understand that my failure to do so will result in reduction or denial of benefit payment and I will be responsible for all balance.I hereby acknowledge that I have received the Lake Area Cardiology Associates LLC‘s Financial Policy and Notice of Privacy Practices.Name of Patient: _____________________________________Signature: ___________________________________________ Date: _____/_____ /_____Lake Area Cardiology, LLCArif Abdullah MDAdnan Siddiqui MDRabab Mohsin MD601 River Pointe Drive Suite 105, Conroe Texas 77304 102 Medical Park Lane Suite A, Huntsville Texas 77340Phone: 936-539-5577 Fax: 936-539-5550 FINANCIAL POLICYWe are dedicated to providing the best possible care for you and we want you to understand our financial policies to avoid any future misunderstands.Insurance- Patients are ultimately responsible for all charges for services provided. As a service to you we will file your insurance claim if you assign the benefits to us so that your insurance company can pay us directly. We will also follow up for you, but if your insurance company does not pay the claim within a reasonable period, we will have to look to you for payment.Self-pay – If you do not have insurance, or if we cannot verify your coverage, payment is due at the time of service.Benefit Verification – We will contact your insurance carrier to verify your benefits when necessary or when you request us to do so. We do this so that you will have an estimate of what your financial responsibility will be, and to determine what portion of your charges should be paid by you at or before the time of service. When we contact your insurance carrier, we are told that benefits given are not a guarantee of payment. Therefore when your claim is actually processed by your insurance company, it is possible that your portion of the charges could be different from what we were told when we verified your coverage. We cannot guarantee what your insurance company will pay. Therefore you may receive a bill from us if the insurance company denies, changes, or reduces the payment for the service we provide. Benefit verification is an estimate, not a guarantee of your insurance benefits.Co-Payments, Co-insurance and Deductibles – We collect all co-pays, co-insurance amounts and unmet deductible at the time of service, unless arrangements have been made ahead of time. If you are unable to pay at the time of service we will be happy to reschedule your appointment.Prior Authorization – Some Health Maintenance Organizations (HMOs) and Independent Physician Associations (IPAs) require you to obtain authorization for our service from your primary care provider. While we attempt to make sure all visits requiring authorization are authorized, it is ultimately the patient’s responsibility to make sure authorization has been obtained before you visit our office, even when the visit is for an urgent problem. Please contact your insurance or primary care provider if you have question about the need for an authorization.Updated Insurance Information – It is the patient’s responsibility to provide this office with the most up to date insurance information. Please inform the office of any and all changes to your demographics and/or insurance information. Any claims denied due to lack of updated information will be the patient’s responsibility.Last Edited 12/2019 KC ................
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