FLORIDA CARDIOLOGY GROUP
Hudson
7614 Jaque Rd. , Suite C
Hudson, Fl 34667
727-862-8383
Brooksville
15004 Cortez Blvd
Brooksville, Fl 34613
352-596-4422
New Port Richey
4738 Grand Blvd. Suite E
New Port Richey, Fl 34652
727-862-8383
Palm Harbor
Tampa
2595 Tampa Rd. Suite U
Palm Harbor, Fl 34684
727-789-3131
11357 Countryway Blvd.
Tampa Fl, 33626
727-789-3131
Patient Information
Date_______________
Patient_____________________________________________________________________________
Last Name
First Name
Middle
Social Security Number:___________________ D.O.B.:______________________Age:___________
Marital Status: S M D W SEP
Height:______________
Weight:______________
Address:___________________________________________________________________________
City:____________________________ State:________________________ Zip:__________________
Secondary Address:___________________________________________________________________
City:____________________________State:________________________Zip:___________________
Home Phone:_______________________________Work Phone:______________________________
Back-Up Phone or Cell:_______________________________________________________________
Employed By:_______________________________________________________________________
Address:___________________________________________________________________________
Notify in case of emergency:_____________________________Relationship:____________________
Phone:______________________Address:________________________________________________
Reason for Visit:_____________________________________________________________________
Primary Language Spoken:______________________Referred By:____________________________
Insurance Information
Medicare Number:___________________________________________________________________
Insurance/Secondary:___________________________Policy Number:_________________________
Guarator Information:___________________________Spouse’s Name_________________________
Social Security Number:__________________________D.O.B.:_______________________________
Address:_________________________________________________Group # ___________________
Telephone Number______________________________Insured’s Name:________________________
Patient Health / History Form
Patient Name:________________Date of Birth:____________________Todays Date:_________
Allergies:______________________________________________________________________
_______________________________________________________________________________
Symptoms / Problems: Check symptoms you currently have or have had in the past
( ) Dizziness
( ) Constipation
( ) Bleeding Gums
( ) Nose Bleeds
( ) Fainting
( ) Diarrhea
( ) Blurred Vision
( ) Persistent Cough
( ) Forgetfulness ( ) Nausea
( ) Blood in Urine
( ) Vision - Flashes
( ) Numbness
( ) Rectal Bleeding
( ) Difficulty Swallowing ( ) Vision-halos
( ) Sweats
( ) Vomiting
( ) Double Vision
( ) Sore that woulnt heal
Conditions / Illnesses: Check symptoms you currently have or had in the past
( ) AIDS
( ) Cancer
( ) Hernia
( ) Alcoholism ( ) Chemical Dependency ( ) Herpes
( ) Pacemaker
( ) Scarlet Fever
( ) Anemia
( ) Diabetes
( ) High Cholesterol ( ) Stroke
( ) Arthritis
( ) Emphysema
( ) HIV Positive
( ) Thyroid Problems
( ) Asthma
( ) Heart Disease
( ) Kidney Disease
( ) Rheumatic Fever
( ) Hepatitis
( ) Liver Disease
( ) Bleeding disorder
Cardiovascular Symptoms and Problems:
( ) Chest Pain
( ) High Blood Pressure
( ) Poor Circulation ( ) Poor Circulation
( ) Irregular Heartbeat
( ) Low Blood Pressure
( ) Swelling of ankles
( ) Varicose Veins
Muscle / Joint / Bone: pain, weakness, numbness in:
( ) Arms ( ) Back ( ) Feet
( ) Hands ( ) Hips ( ) Legs ( ) Neck ( ) Shoulders
Health Habits: check which substances you use and describe how much you use.
( ) Caffeine: ____________________________________________________________________
( ) Tobacco: ____________________________________________________________________
( ) Drugs: ______________________________________________________________________
( ) Alcohol: _____________________________________________________________________
Family History: Please check all that apply
( ) Heart Disease
( ) Stroke
( ) Hypertension
( ) Diabetes
( ) Heart Attack
I certify that the above information is correct to the best of my knowledge. I will not hold my Doctor of any
members of his/her staff responsible for any errors or omissions that I may have made in the completion of this
form.
Patient Signature: _________________________________ Date: ______________________
Permission For Treatment
I, the undersigned, hereby voluntarily consent to medical care / diagnostic treatment and or minor surgical
treatment by FLORIDA CARDIOLOGY GROUP deemed advisable and necessary in the diagnosis and
treatment of my condition. I am aware that the practice of medicine is not an exact science and I acknowledge that
no guarantees have been made to me as a result of treatment or examination in the office. I authorize the release of
any of my past / current medical records that are needed for my treatment from any prior healthcare providers.
Signature:_____________________________________________
Date:_______________________________
Authorization and Assignment
I request that the payment of Authorized Medicare / Insurance Benefits be made either to me or on my behalf for
any services furnished by FLORIDA CARDIOLOGY GROUP . I authorize any holder of medical information
about me to release to CMS / Insurance Carriers and its agents any information needed to determine these benefits
or benefits related to services.
I hereby authorize FLORIDA CARDIOLOGY GROUP to furnish information to Medicare / Insurance carriers
concerning my medical condition, illness and treatment to determine the benefits for related services. I herby
authorize (assign) my Insurance Carrier(s) / Medicare to make payment directly to FLORIDA CARDIOLOGY
GROUP for medical / diagnostic / surgical benefits payable for the services rendered. I understand and agree
(regardless of my insurance status), that I am ultimately responsible for the balance of any professional services
rendered. I understand that I am responsible for any charges incurred if my account is sent to a collection agency
and for any returned checks. I understand that Medicare and/or other Insurance carriers do not cover all office
services / procedures. I agree to take full responsibility for any unpaid balances and that such payment will be
made to the physician’s office for services. I certify that the information I have given here is true and correct to the
best of my knowledge. I will also notify you of any changes in my status or changes in the above information.
Signature:____________________________________________ Date:__________________________________
Designated Relative
I authorize discussion of my general medical condition and diagnosis (including treatment, payment and health
care option) with: ( ) Spouse ( ) Children
Other:___________________________________________
Please list the family members or significant others, if any, whom we may inform about your medical condition,
and / or in case of emergency:
Name:______________________________Relationship:____________________Phone:____________________
Name:______________________________Relationship:____________________Phone:____________________
Name;______________________________Relationship:____________________Phone:____________________
Messages may be left on my answering machine regarding my health and appointments made ( ) YES ( ) NO
Signature:_____________________________________________Date:_________________________________
Privacy Notice
I received a copy of FLORIDA CARDIOLOGY GROUP’s HIPPA Privacy Notice.
Signature:____________________________________________Date:__________________________________
Patient Name ( print):____________________________________SS#__________________________________
MEDICARE / INSURANCE BILLING INFORMATION
Medicare Part B will reimburse FLORIDA CARDIOLOGY GROUP
80% of the Medicare approved amount for each service / treatment
rendered and billed to them for payment consideration.
Medicare has determined that its Beneficiaries will be responsible for a
20% co-payment and an Annual Deductible of $135.00. If you do not
have a secondary or supplemental insurance then you will be responsible
(expected to pay) for the remaining 20% or other uncovered charges
at the time of service.
I certify that the information given by me in applying for payment under
TITLE XVII of the Social Security Act is correct.
I authorize any holder of medical or other information about me to release
to the Social Security Administration or its intermediaries or carriers any
information needed for this or a related Medicare claim. I request that the
payment of authorized benefits be made on my behalf. I assign the
benefits payable for physician service to the physician or organization
furnishing the services.
I request that this authorization also apply to all other insurances I may
have.
I hereby authorize FLORIDA CARDIOLOGY GROUP to release any
information acquired in the course of my examination or treatment for
insurance purposes to assist directly to the provider. In the event I should
receive payment from my insurance company, I understand that I must
then pay the provider. Any amount due after insurance payment has been
made will be my responsibility.
Your signature below indicates that you understand and agree to the
above information.
Print Name:________________________________________________
Signature:___________________________ Date:__________________
Patient Privacy Rights:
You Have the Right to:
 Inspect and copy medical information from your chart. You may submit a
written request to our office and pay the copy fee and receive a copy of your
record. We must respond within 30 days if the record is readily available and
within 60 days if it is not readily available.
 Amend medical information in your chart. You may identify inaccurate or
incomplete information in your chart. You can do this with a written request to
amend your chart directed to our office. We must respond within 60 days.
 Receive an accounting of any disclosures made from your record over the last
six years, starting April 14, 2003. You can get this with a written request
directed to our office. We must respond within 60 days.
 Request restrictions as the amount of medical information we disclose. This is
limited as noted above, and your request may not supercede the typical
disclosures noted above. You may revoke or restrict consent.
 Request confidential communications. All communications in our office are
confidential. You may specifically request that all communications be
confidential with a written request to our office.
 Receive a copy of this notice by printing it or with written request directed to
this office , and a copy of this notice will be given to you with all new patient
packets.
We may contact you for appointment reminders, and we may provide you with
information about health related or product related benefits and services.
Each patient is given a copy of the Privacy Notice and an opportunity to review and
understand it.
Our Responsibilities Under HIPPA:
We are required by law to maintain the privacy of your personal health information
and to provide you notice of our legal duties and privacy practices and adhere to this
notice.
We reserve the right to make changes to this notice. We will post a notice that the
notice has been changed and the effective date of the change, copies will be made
available.
You can submit a complaint about our privacy practices or its execution either
verbally or in writing to our Privacy Officer at:
Florida Cardiology Group
4738 Grand Blvd. #E NPR, Fl 34652 / 7614 Jaque Road #C, Hudson, Fl 34667
If you get no resolution to your complaint, you can send a written statement to this
office or the Secretary of Health and Human Services.
Effective Date of Notice: April 14, 2003-2004
Ammend Dates:
Notice of Privacy Practices for Protected Health Information
“This notice describes how medical information about you may be
used and disclosed and how you may get access to this information”.
Please review it carefully!
We safeguard information about your health and person:
We collect information from you and store it in a medical record as well as on a
computer. Charts are stored in a secure area and available only to designated staff and
only for designated reasons. Housekeeping, maintenance and other non-office
personnel have no access to the chart area. Service technicians may have access to the
computer, but only for service of computer operations.
Typical uses and disclosures of medical information:
We collect medical information from you. Within our office, we restrict the disclosure
of this information to Doctors, nurses, technicians and billing personnel. We may use
your medical information for treatment and care, payment to insurers and for
healthcare operations. Outside our office, we restrict the disclosure to those people,
entities and agencies for whom you authorize disclosure such as other healthcare
providers (doctors, nurses, extended care facilities), insurance companies, billing
agencies, hospitals and surgery sites, or those agencies and entities for whom legal
and administrative requirements demand disclosure such as:
 When required by law
 Public health activities (deaths, child abuse, neglect, domestic violence,
problems with products, reactions to medications, product recalls,
disease/infection exposure, disease/injury/disability control/prevention).
 Health oversight activities (audits, investigations, inspections).
 Judicial and administrative proceedings (court order).
 Appropriate law enforcement requests (to identify or locate a suspect, fugitive,
material witness, or missing person).
 Deceased person information to coroners, medical examiners, funeral directors.
 Organ and tissue donation.
 Research, provided authorization is IRB-approved or privacy board approved.
 Emergencies or to avert serious threat to health or safety.
 Specialized government functions (military, inmates).
 Workers compensation.
 Disaster relief.
We will not use or disclose your medical information for any purpose not listed
without your specific written authorization. Any specific written authorization
you provide may be revoked at any time by writing to us.
MEDICAL RECORDS RELEASE FOR CONTINUING CARE
Patient Name:
Information Requested and Needed from
(Requestee):
Name: __________________________
Address: ________________________
________________________________
Phone:
SS# :
DOB:
Recipient of Records (Requestor):
Florida Cardiology Group
( ) G. Chalavarya ( ) N. Sharma ( ) M. Moore
( ) J. Augustine ( ) D. Patel ( ) P. DiMartino
Address: 7614 Jaque Road Ste C Hudson Fl 34667
Phone (727) 862-8383
Fax: (727) 863-4766
Fax:
INFORMATION TO BE DISLOSED:
Description:
Description:
Super Confidential Records:
( ) Medical Records for Continuity of
care
( ) Physician Dictated Notes
( ) Office Notes and Reports
( ) Clinician Office chart and notes
( ) Billing Statements
( ) Most recent one year history
( ) Entire Medical Record ( all Info)
( ) Transcribed hospital reports
( ) Diagnostic imaging/X-ray Reports
( ) Laboratory Reports
( ) Alcohol and Drug therapy notes
( ) Communicable Disease
(HIV,HBV,TB)
( ) Psychotherapy office notes
( ) Other_________________
( ) Other_________________
Please send the following: ( ) Recent Progress notes, History and Physical,
Recent Labs, X-Rays, EKG, Testing, Consultations, Medication Sheets and
Summary of Care.
Purpose of Disclosure:
( ) Ongoing Continued Medical Care
( ) Insurance
( ) Patients Request
( ) Legal Follow Up
( ) Disability
( ) Personal Information
I herby authorize the use or disclosure of my individually identifiable health information as described
above. I understand that this authorization is voluntary. I understand that if the organization authorized
to receive the information is not a health plan or health care provider, the released information may no
longer be protected by federal privacy regulations.
I understand that this content shall be valid for a period of 1 year from the date of authorization and
may be revoked at any time upon written notice, except to the extent that the information has already
been released in reliance upon this authorization.
I understand that I may revoke this authorization at any time by notifying the providing organization in
writing, but if I do, it won’t have any effect on any actions they took before they received the
revocation.
I further understand that the confidentiality of this information may be protected by Federal
Regulations 42CFR, Part II, prohibiting any further disclosure of this information without specific
written authorization of the undersigned, or as otherwise regulated.
__________________________________
Print Patients Name
_____________________________
Date
__________________________________
Signatue of Patient or Legal Representative
______________________________
Date
___________________________________
Print Name of Legal Representative
______________________________
Relationship to Patient