CSMG - Medical Intake forms

This form is created with a HIPAA compliant software. Securing your medical information.

In which office will be your upcoming appointment?*
This is important to send the form to the appropriate clinic supervisor
Through a series of interlocking regulatory rules, HIPAA compliance is a living culture that health care organizations must implement into their business in order to protect the privacy, security, and integrity of protected health information.

PATIENT INFORMATION 1

Demographic
Today's Date*

MonthDayYear
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Gender
Gender

FemaleMaleOther
Marital Status
Prefered Language
Email (Necessary to receive newsletters, survey, patient portal notifications)
example@example.com
Would you like to receive:

NewsletterA Survey after your visit, to give us your feedbackNone
Would you like to receive:

NewsletterA Survey after your visit, to give us your feedback

PATIENT INFORMATION

RESPONSIBLE PARTY
--- RESPONSIBLE PARTY ---
Check and skip to next section, if not applicable

Not applicable
Name

First NameLast Name
Relationship to patient
Phone Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's Licence
PATIENT INFORMATION

EMERGENCY CONTACT
--- EMERGENCY CONTACT ---
Name

First NameLast Name
Phone Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Relationship with patient

PATIENT INFORMATION

Referral information | Reason for visit
Today's Date*

MonthDayYear
Referring physician*
Please list your wellness goals:
What is the reason for your next appointment?*
Name of your Primary Care Physician*
Additional Info (optional)

	Enter information below
Pharmacy name/brand
Phone
Address
Cross-street (if possible)

MEDICAL RECORDS FROM MEDICAL PROVIDERS

AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL RECORDS FROM MEDICAL PROVIDERS
AUSTUBH V. PATANKAR, MD, FACC | MIMI SEN BISWAS, MD, MHSC | NADER N. ATTIA, DO | NIRAJ V. PAREKH, MD | JEREMY, COX, DO | JATIN N. AMIN, MD | BRADLEY S. MESSENGER, MD | SANDEEP SANGODKAR, DO. FACC | CHRISTOPHER SEAMAN, MD |

Authorization to obtain medical records:

I hereby authorize Cardiology Specialists Medical Group to obtain any and all medical records concerning my care from any physician, hospital, or other healthcare professionals that have or will provide me with medical care.

Authorization to release medical records:

I also authorize Cardiology Specialists Medical Group to release any and all medical records concerning my care to any physician, hospital, or other healthcare professionals that have or will provide me with medical care.

Additionally, I authorize Cardiology Specialists Medical Group to release any and all medical records concerning my care to Medicare, Medicaid, other health insurance companies, third-party administrator, or managed care companies.
I consent to the release of Medical records from medical providers*
Consent to obtain Medical records*

Yes, I authorize CSMG to obtain my medical records as stated aboveI do not consent (This may prevent your Cardiologist from providing a complete evaluation of your health)
I consent to the release of Medical records from medical providers*

I consent to the release of Medical records from medical providersI do not understand an need more information (this will result in delay or rescheduling your next appointment)
Patient Signature (draw with mouse)
Name*

First NameLast Name
Date*

MonthDayYear
Date of Birth*

MonthDayYear

MEDICAL RECORDS RELEASE TO TRUSTEE(S)

AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL RECORDS TO INDIVIDUALS AND/OR FAMILY MEMBERS
Do you Authorize Cardiology Specialists Medical group to discuss your medical condition with designated individuals*

I DO NOT authorize CSMG to release any or all medical information to any individualI DO AUTHORIZE CSMG to release any or all medical information to the following trustees

Your Designated trustees

	FIRST NAME	LAST NAME	RELATIONSHIP	Date of Birth
Designated 1
Designated 2
Designated 3

Signature (draw with your mouse, or finger)
Patient name*

First NameLast Name
Date of Birth*

MonthDayYear

Privacy Policy

HIPPA Compliance
Patient Rights
Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to
protected health information.

You have the right to request a restriction of your protected health information: This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in, for notification purposes, as described in this notice of privacy practices. You must state the specific restriction requested and to whom you want the restrictions to apply towards.

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your health information will not be restricted.
You then have the right to use another healthcare professional.

You have the right to request to receive confidential communications from Cardiology Specialist by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you agreed to accept this notice alternatively, i.e.electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures Cardiology Specialisthave made, if any, of your protected health information:

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to CardiologySpecialistorto the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by notifying our privacy contact. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone a tour main number.

Signature below is the only acknowledgment that you have received this notice of our privacy practices:
Check if true*

I read and understood the Privacy Policy above
Date

MonthDayYear
Name

First NameLast Name

Access of medical Information
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.

This notice ofPrivacyPracticesdescribeshow we may use and disclose yourprotected health information to carry out treatment, payment or health care operationsandforotherpurpose that are permitted orrequirebylaw.It also describes your rights to access and controls your protected health information.“Protected health information” is information about you, including demographic information, that may identify you, and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information
Yourprotected healthinformationmaybe used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you,to pay any health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment
We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care for you. Your protected health information may be provided to a physician to whom you've been referred to, to ensure that the physician has the necessary information to diagnose or treat you in regards to the continuity of your care.

Payment
Your protected health information will be used, as needed, to obtain payment for your health care services.For example, obtaining approval for the hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Health Operations
We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review
activities, training of medical students, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the front desk where you will be asked to sign your name and indicate your physician you are to be seeing. We may also call you by name in the waiting room when you are ready to be seen by the physician.

We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law: public health issues, communicable diseases, health oversight, abuse or neglect, FDA requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity, national security, Workers’Compensation, and inmates. Required u uses and Disclosures: Under the law, we must make disclosures to you and when requirements of section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.
You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

INSURANCE INFORMATION

Insurance

	Primary Insurance	Secondary insurance
Insurance Name
Subscriber
SSN
DOB

I request that my payment of authorized health plan benefits be made on my behalf to Cardiology Specialists Medical Group, inc. for any services provided by that physician/supplier/ facility. I authorize any holder of medical information about me to release to the HCFA (Health Care Finance Administration), and its agents any information needed to determine these benefits payable to related services.

I Understand my signature requests that payments be made and authorizes the release of medical information necessary to pay any claim. If other health insurance is indicated in item 9 of the HCFA 1500 form or elsewhere on the approved claim form, or electronically, submitted claims. My signature authorizes the release of information to the insurer or agency above.
Read above, check the box, print your name and date to confirm your agreement to the above insurance coverage information.*

I read and understand the insurance information above
First and Last Name*
Date*

MonthDayYear

Enclose records

Optional. You can upload your attachments here
Enclose records in PDF, Word, Excel, JPEG, or PNG format (optional)

Browse Files

Cancelof
Should be Empty:

	Past condition	Ongoing condition	N/A
Heart Attack
Tachycardia
Atrial Fibrillation
Congenital Heart Failure
High Blood Pressure
High Cholesterol
Athma
CVA/TIA/Mini-stroke
Diabetes
Periph. Vascular Disease
Abd. Aortic Failure
Fainting
Arrhythmia (irregular heart rate)
Mitral valve prolapse

	MEDICATION NAME	DOSE (MG/TAKE)	FREQUENCY (HOW OFTEN)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

	Yes	No	Comments
Weight change
Unexplained fatigue
Snoring
Allergies
Other

	Yes	No	Comments
Chest Pain Tightness
Heart Pounding
Leg Swelling
Light Hotheadedness
Other

	Yes	No	Comments
Trouble Breathing
Cough
Wheezing
Other

PATIENT INFORMATION

PATIENT INFORMATION

PATIENT INFORMATION

Your Medical Information

Family Medical history

MEDICAL RECORDS FROM MEDICAL PROVIDERS

MEDICAL RECORDS RELEASE TO TRUSTEE(S)

Privacy Policy

Access of medical Information

INSURANCE INFORMATION

Enclose records

	Yes	No	[' Comments
Skin \Rashes or itching
Psychological \ Depression or Anxiety
Gastrointestinal Nausea, blood in stool or black stool
Other

	FATHER	MOTHER	SIBLINGS	N/A
Heart Attack
Heart Surgery
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Other Heart disease

	Yes	No	Comments
Do you drink alcohol
Street drugs
Other