Dear Patient:
Welcome to our practice, we thank you for choosing Cardiovascular Interventions, P.A. as your health care provider. We look forward to serving you. To ensure a smooth transition to our care, we request that ALL your medical records and this New Patient Packet be submitted 5 days before your visit. To facilitate this, please complete this packet so we may begin procuring records.

At your first appointment we request that you arrive 30 minutes early so we may verify that all required paperwork is completed. Due to the complexity of your comprehensive office visit, it is reasonable to allow for up to two hours for your appointment time. Please refer to this list for necessary requirements:

• New Patient Packet (complete as soon as possible)
• Medical records: we MUST receive/ have access to all records 5 days prior to your appointment
• Bring your insurance card(s)
• Bring a Photo ID
• Bring any referral or authorization from your primary care physician (if needed)
• Bring Medication bottles/medication list
• Prepare for co‐pays, cost‐share or self‐pay rates that may apply

1900 N. Mills Avenue • Suite 107• Orlando, FL 32803
(407) 894-4880
www.OrlandoCVI.com

When you are ready to begin, please click on the next button.

Please state whether you have the following conditions:

Please check the answers that apply to you. Please understand that this questionnaire is being given to all the patients receiving care at Cardiovascular Interventions, PA. It is not being given to you because your doctor is particularly concerned about your health or well‐being. Instead, all the patients are receiving this questionnaire, because we believe that everyone should become comfortable with these topics. We hope to open discussions and or circumstances that are often left without preparation for family and caregivers for our patients.

To the Patient: 

You have the right, as a patient, to be informed about your condition and the recommended medical and or diagnostic procedure to be used so that you may make the decision whether to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this  consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. I voluntarily accept the physician, and/or mid‐level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

Patient and/or guarantor are responsible for charges incurred. It is a courtesy for our office to file with your insurance; however, you are responsible for your co‐pay and or percentage which the insurance is not responsible for on the day of your visit. It is the patient’s responsibility to obtain any necessary referral forms from your primary care physician when required. If the referral is not obtained before the visit, the patient is liable for payment in full on the date of service. If we are unable to obtain payment within a reasonable amount of time from the patient/guarantor, we will place your account with a collection agency which will leave you liable for any additional charges incurred.

MEDICARE LIFETIME AUTHORIZATION

I certify that the information given to me in applying for payment under Title XVII of the Social Security Act is correct. I authorize any holder of medical 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 payments of authorized benefits be paid on my behalf. I assign the benefits payable for services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. 

Thank you for choosing Cardiovascular Interventions, P.A. as your health care provider. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc).

It is the patient’s responsibility to know if our office is participating with their specific plan.

• Co‐pays / Deductibles / Co‐insurance: The patient is expected to present an insurance card at each visit. All co‐payments, deductibles, co‐insurance and past due balances are due at time of check‐in unless previous arrangements have been made with a billing coordinator. We accept cash, check or credit cards. Absolutely no post‐dated checks will be accepted.  Cost estimates for all services are available upon request.

• Insurance Claims: Insurance is a contract between you and your insurance company. In most cases, we are NOT a party of this contract. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as, any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance. If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately. If your insurance plan is one with which we are not a participating provider, you will be responsible for payment in full. However, as a courtesy, we will file your initial insurance claim and if not paid within 30 days you will be responsible.

• Referrals and Preauthorization’s: Certain health insurances (HMO, POS, etc.) require that you obtain a referral or prior authorization from you Primary Care Provider (PCP) before visiting a specialist. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower or no payment from the insurance company, and the balance will be your responsibility. Alternative payment arrangements or rescheduling of your appointment may be necessary if not obtained.

• Self‐pay Accounts: Self‐pay accounts are for patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. Liability cases will also be considered self‐pay accounts. We do not accept attorney letters or contingency payments. If there is a discrepancy with our information, the patient will be considered self‐pay unless otherwise proven. Please ask to speak with a billing coordinator to discuss a mutually agreeable payment plan. It is never our intention to cause hardship to our patients, only to provide them with the best care possible and the least amount of stress.

• Missed Appointments: Cardiovascular Interventions, P.A. requires 24‐hour notice of appointment cancellation to avoid a missed appointment fee equal to an amount to cover our preparation costs.

• Returned Checks: The charge for a returned check is $35 payable by cash or money order. This will be applied to your account in addition to the insufficient funds amount. You may be placed on a cash only basis following any returned check.

• Medical Record Copies: Patients requesting copies of medical records will be charged: $1 per page plus $1 search fee (if applicable)

• Minors: The parent(s) or guardian(s) is responsible for full payment. A signed release to treat may be required for unaccompanied minors.

• FMLA/ Disability Forms: A request form must be filled out (Personal Information). There is a $40 fee prior to forms being completed by providers, turnaround time is 7 to 10 business days.

• Outstanding Balance Policy: It is our office policy that all past due accounts be sent two statements. If payment is not made on the account, a single phone call will be made to try to make payment arrangements. If no resolution can be made, the account will be sent to the collection agency, or attorney, and possible discharge from the practice. In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collection’s costs including attorney fees and court costs. Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service. Our office will not bill any other third party.

I Agree…
I agree to pay Cardiovascular Interventions, P.A. any monies owed if a referral form authorizing the visit is not brought in at the time of the visit.

The undersigned has read and understands the above statements and willingly and voluntarily agrees, whether as the patient or his/her authorized representative, to release Cardiovascular Interventions, P.A. or its employees, from any and all liability which may arise from this action, whether foreseen at present

Cardiovascular Interventions, P.A. reserves the right to change and/or modify this information at any time.

The Health Insurance Portability and Accountability Act, (HIPAA) requires that all medical providers, insurance companies and others, put in place controls to ensure that your personal medical information is safe.

Our office requests that each patient sign this consent form which allows us to share protected health information with other physician's offices, your hospital, and insurance company. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent, in writing, except when we have already made disclosures in reliance on your prior consent. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent.

AUTHORIZATION TO RELEASE INFORMATION TO FAMILY MEMBERS AND/OR FRIENDS

Many of our patients allow family members such as their spouse, parent(s), guardian(s or others to call and request appointment times, reschedule appointments, review insurance benefits, and/or to review results of tests and procedures. Under the requirements for HIPAA, we are not allowed to give this information to anyone without the patient's written consent. If you wish to have your medical information released to your spouse, parent(s), guardian(s) or others, you must sign this form. Signing this form will only give consent to release appointment times, rescheduling of patient appointment(s), review of insurance benefits, and/or the results of tests and procedures to those listed below. This consent form will not allow our office to release any other information about you. This HIPAA consent is valid up to one year. However, you have the right to revoke this consent, in writing prior to the expiration of that one year, except when we have already made disclosures in reliance on your prior consent.

I authorize this office to speak with the below listed individuals regarding my appointment times, rescheduling of appointment(s), to review insurance benefits, and/or to discuss the results of tests and procedures.

Leaving Messages with Household Members/ Answering Machine

From time to time it is necessary for our office to leave messages for patients. The purposes of these messages are to remind patients that they have an appointment, to review insurance benefits, to notify the patient that we would like to review lab or procedure results, or to ask a patient to call us regarding an issue or concern. At no time will our office discuss your medical circumstances or condition without your consent. The purpose of this consent is to leave messages with members of your household or on your answering machine.

I, or my authorized representative, hereby authorize Cardiovascular Interventions P.A and their respective employees, agents and subcontractors to disclose my Personal Health Information (PHI) and Insurance Record through signature below.
In accordance the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

Place a check next to each statement to indicate that you understand and agree: