CARDIOVASCULAR ASSOCIATES, INC. PATIENT INFORMATION NAME ___________________________________________________________________________________________________________________________ LOCAL ADDRESS CITY _ _____ PHONE _ _ __ __ ___ __ __ ___ __ __ ___ ___ __ __ ___ __ __ ___ __ __ ___ ___ __ __ __ CITY STATE&ZIPCODE NORTHERN A D D R E S S STATE & ZIPCODE _____________ DATE OF BIRTH _ PHONE AGE WEIGHT HUSBAND/WIFE NAME _____________________________________________ _ SOCIAL SECURITY#. _ SOCIAL SECURITY# PATIENT'S EMPLOYER______________________________________________________________ _ PHONE _ PRIMARY INSURANCE_________________________________________________ POLICY NUMBER ADDRESS l.D. # _ __ GROUP CODE __ SECONDARY INSURANCE_______________________________________________ POLICY NUMBER ADDRESS l.D. # _ _____ GROUP ___CODE __________________________ PARTY RESPONSIBLE FOR THIS ACCOUNT __ NAME OF PERSON TO CALL IN AN EMERGENCY _ _ ADDRESS PHONE _ (DIFFERENT THAN YOUR HOME PHONE) DO YOU SMOKE? YES or N O DO YOU HAVE A LIVING WILL? YES or N O PRIMARY PHYSICIAN _ REFERRED BY_____________________________________________________________________________________________________________________________________ EMAIL ADDRESS ____________________________________________________________________________________________________________________ ASSIGNMENT OF BENEFITS For Filing Insurance I hereby assign all medical and/or surgical benefits, to which I am entitled, including Medicare, Private Insurance, Major Medical Benefits and any other Health Plans to Cardiovascular Associates, Inc. Johnson P. Massey, M.D., Patrick F. Mathias, M.D., Robert L. Barrett, M.D., Thomas Y. Kim, M.D., Prashanta A. Laddu, M.D., Mukesh Kumar, M.D., Naushad Shaik, M.D., Deborah Huddleston, A.R.N.P., and Bethanne Smith, A.R.N.P. This assignment will remain in effect until revoked by me in writing. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information, including HIV, substance abuse or psychiatric information which may be found in the record and necessary to secure payment. MEDICARE PATIENTS: Please read and sign assignment of benefits on the next page. Thank you. CM4300 CARDIOVASCULAR ASSOCIATES, INC. Johnson P. Massey, M.D., FACC Patrick F. Mathias, M.D., FACC, FCCP Robert L. Barrett, M.D., FACC Thomas Y. Kim, M.D., FACC Prashanta A. Laddu, M.D., FACC Mukesh Kumar, M.D., FACC, FSCAI Naushad Shaik, M.D., FACC Deborah Huddleston, A.R.N.P. Bethanne Smith, A.R.N.P. LIFETIME AUTHORIZATION FOR MEDICARE (Patient Name) (Patient's Medicare Number) I hereby request payment of authorized Medicare benefits and/or any other insurance benefits to be made either to me or on my behalf to Cardiovascular Associates, Inc., for services provided by Cardiovascular Associates, Inc., Johnson P. Massey, M.D., Patrick F. Mathias, M.D., Robert L. Barrett, M.D., Thomas Y. Kim, M.D., Prashanta A. Laddu, M.D., Mukesh Kumar, M.D., Naushad Shaik, M.D., Deborah Huddleston, A.R.N.P., and Bethanne Smith, A.R.N.P. I authorize any holder of medical information about me to release to the Centers for Medicare Services and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the CMS-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. Patient Signature_______________________________ Date______________________ I request that payment of authorized MEDIGAP benefits be made on my behalf to Cardiovascular Associates, Inc., Johnson P. Massey, M.D., Patrick F. Mathias, M.D., Robert L. Barrett, M.D., Thomas Y. Kim, M.D., Prashanta A. Laddu, M.D., Mukesh Kumar, M.D., Naushad Shaik, M.D., Deborah Huddleston, A.R.N.P., and Bethanne Smith, A.R.N.P. for any services furnished me by Cardiovascular Associates, Inc. I authorize any holder of medical information about me to release to Cardiovascular Associates any information needed to determine these benefits or the benefits payable for related services. Patient Signature_____________________________________ Date ________________________ CM4300 PATIENT MEDICAL HISTORY HISTORIAL MEDICO DEL PACIENTE NAME: Mr./Sr. Mrs./Sra. Miss./srta. NOMBRE Last/Apellido _ First/Nombre de pila Middle/Inicial AGE: DATE OF BIRTH: EDAD FECHA DE NACIMIENTO _ Single/Soltero(a) Divorced/Divorciado(a) Married/Casado(a) Widow(er)Viudo(a) DATE: _ FECHA BIRTH PLACE: _ LUGAR DE NACIM/ENTO OCCUPATION: _ OCUPAC/6N WHY WERE YOU REFERRED HERE? CURRENT MEDICATIONS: ¿CUAL ES EL MOTIVO DE SU VISITA? MEDICAMENTOS QUE TOMA 1. 2. 3. 4._________________________________________ _____________________________________________ Allergies/Alergias: _______________________________________ 1. 2. 3. CURRENT SYMPTOMS/SINTOMAS: Weight Loss Stomach Ulcers Perdida de peso Ulceras estomacales Weight Gain Blood in Stools Subida de peso Sangre en las deposiciones (heces) Fever or Chills PAST CARDIAC ILLNESSES: ENFERMEDADES CARO/ACAS PREVIAS Angina Angina de pecho Cardiac Arrhythmias Black Tarry Stools Fiebre o escalofrios Deposiciones alquitranadas Arritmia cardiaca Difficulty in Exercising Varicose Veins Atrial Fibrillation Dificultad para hacer ejercicio Fibrilacion auricular Varices Change in Hair Swelling in the Legs Cambios en el pelo Hinchazon en las piernas Miocardiopatfa Change in Nails Arthritis Congestive Heart Failure Cambios en la uñas Artritis Rashes Sarpullidos Skin Lesions Lesiones en la piel Cardiomyopathy lnsuficiencia cardiaca congestiva Back Pain/Problems Coronary Artery Disease Dolores de espalda Cardiopatia isquemica History of Depression Valvular Heart Disease Historial de depresion Valvulopatia Double Vision Substance Abuse Prior Heart Attack Doble vision Problemas de alcohol o drogas Ataque previo al corazon Glaucoma Glaucoma Field of Vision Problems Difficulty in Thinking Prior Angioplasty or Stent Dificultades para pensar Endoprotesis vascular o angioplastia previa None of the Above Problemas con el campo de vision Ninguno de las anteriores Hearing Loss Problemas de oido FAMILY HISTORY Nose Bleeds HISTOR/AL FAMILIAR Hemorragias nasales Hoarseness Ronquera Difficulty Speaking Dificultades al hablar Has Any Blood Relative Ever Had: Ha tenido fllguno de sus parientes consangumeos: Heart Trouble Problemas cardfacos Shortness of Breath Dificultades al respirar Cough High Blood Pressure Tension sanaufnea a/ta Tos Wheezing Silbidos al respirar Cancer I Cancer Diabetes I Diabetes Coughing up Blood Stroke I Derrame cerebral Tos con sangre Other I Otra: No Yes Who Age on Onset No Si Quien Edad al descubrirse Prior Coronary Artery Bypass lnjerto de revascularizacion coronaria previo Surgery Prior Valvular Heart Surgery Cirugia previa de valvulopatia Prior Pacemaker/Defibrillator Marcapasos o desfibrilador previo Other I Otra: PAST SURGICAL PROCEDURES: OPERACJONES QUIRURGICAS PREVJAS: Abdominal Aortic Aneurysm Surgery Hip Replacement Gallbladder Surgery Cirugia de la vesicula Cirugia de aneurisma aortico abdominal Amputation Reemplazo de cadera Laminectomy Colostomy Amputacion Laminectomia Colostomia Colon Surgery Knee Surgery Cirugia de radiila Lung Surgery Cirugia def pulmon Cirugia de colon Back Surgery Prostate Surgery Eye Surgery Cirugia de espalda Cirugia def ojo Bladder Suspension/Surgery Cirugia de la prostata Shoulder Surgery Elbow Surgery Cirugia de codo Suspensio/cirugia uretropelvica Breast Surgery (Please circle}: Cirugia de hombro Vascular Bypass Surgery of the Legs Cirugia de mama (rodear con un circulo): Thyroid Surgery Cirugia de la glandula tiroidea Revascularizacion quirurgica de las piernas Augmentation, Biopsy, Mastectomy Gastrectomy Tonsillectomy Gastrectomia aumento, biopsia, mastectomia Carotid Surgery Amigadalectomia Tubal Ligation Gastric Stapling Cirugia de la carotida Ligadura de trompas Grapado gastrico Cataract Surgery Hemorrhoid Surgery Cirugia de cataratas Ulcer Repair Cirugia de hemorroides Carpal Tunnel Surgery Reparacion de ulceras Vasectomy Hysterectomy Cirugia def tunel carpiano Histerectomia Cesarean Section Vasectomia Hernia Repair Cesarea Vein Stripping Extirpacion venosa Reparacion de hernia PAST MEDICAL HISTORY HISTORIAL MEDICO PREVIO HAVE YOU EVER HAD: HA SUFRID0 ALGUNA VEZ Abdominal Aortic Aneurysm Aneurisma aortico abdominal Anemia Anemia Anxiety Ansiedad Asthma Asma Arthritis Artritis Bi-Polar Disease Trastorno bipolar Blindness Ceguera Prostate Enlargement Hipertrofia prostatica Bronchitis Bronquitis Cataract Cataratas Carotid Artery Disease Arteriopata carotidea Ulcerative Colitis Colitis ulcerosa Chronic Emphysema (COPD) Enfisema cronico (COPD) Stroke/Mini-Stroke Derrame I miniderrame cerebral Cancer (Circle what type): Cancer (rodear con un circulo): Breast, Cervical, Bladder, Colon, mama, cuelo uterino, vejiga, colon, Kidney, Liver, Lung, Pancreas, riño, higado, pulmon, pancreas, Prostate, Stomach, Uterus, prostata, estomago, utero, Skin, Throat piel, garganta Gallbladder Disease/Gallstones Colescitopatia I calculo vesical Liver Cirrhosis Cirrosis def higado Alzheimer's Disease Enfermedad de Alzheimer Depression Depresion Diabetes Diabetes Diverticulitis/Diverticulosis Diverticulitis I diverticulosis Peptic Ulcer Disease Ulcera peptica Phlebitis Flebitis Endometriosis Endometriosis Lymphoma Erectile Dysfunction/Impotence Linfoma Disfuncion erectile / impotencia Macular Degeneration Esophagitis/Gastritis Degeneracion macular Esofaguitis I gastritis Obesity Fibromyalgia Obesidad Fibromialgia Osteoporosis Glaucoma Osteoporosis Glaucoma Pancreatitis GERD or Hiatal Hernia Pancreatitis GERD o hernia de hiato Panic Attacks Gout Ataques de panico Gota Parkinson's Disease Headaches/Migraines Enfermedad de Parkinson Dolores de cabeza / jaqueca Pneumonia Hemorrhoids Neumonia Hemorroides Prostatitis Hernias Prostatitis Hernias Poor Circulation (Peripheral Vascular Disease) HIV Disease Mala circulacion (vasculopatia periferica) VIH Rheumatic Fever Hodgkins' Disease Fiebre reumatica Enfermedad de Hodgkins Renal or Kidney Failure Hyperlipidemia or High Cholesterol lnsuficiencia renal (riñon) Hiperlipidemia o colesterol alto Scoliosis High Blood Pressure or Hypertension Escoliosis Tension sanguinea alta o hipertension Seizures Thyroid Disease Convulsiones Disfuncion tiroidea Sleep Apnea Irritable Bowel Syndrome Apnea de/ sueño Sindrome del colon irritable Varicose Veins Kidney Stones Varices Piedras de riñon Vertigo Leukemia Vertigo Leucemia Lupus Lupus Do You Smoke? ¿,Fuma? Year Quit _ Packs per day En que año lo dejo _ Paquetes al dia Number of Years _ Cuantos años Alcoholic Beverages: Bebidas alcoholicas: Never Nunca Rarely Casi nunca Moderate Moderadamente Heavily Mucha Beer Cerveza Number of Years Wine _ Cuantos años Vino Other NAMES OF PHYSICIANS THAT ARE FAMILIAR WITH YOUR M E D I C A L CONDITION: NOMBRE DE LOS MEDICOS QUE CONOCEN EL TRASTORNO MEDICO QUE SUFRE Otras: What Do You Consider Yourself? lndique cuanto bebe Non Drinker No bebo Moderate Drinker Bebo moderadamente Alcoholic Alcohoilico Social Drinker Bebo en situaciones sociales Heavy Drinker Bebo mucho Formerly an Alcoholic Ex-alcohoilico 601 Oak Commons Blvd., Kissimmee, FL 34741 4529 Edgewater Drive, Orlando, FL 32804 2900 17th Street, Suite 5, St. Cloud, FL 34769 42719 Hwy. 27 Suite 103, Davenport, FL 33837 410 Celebration Place, Suite 201, Celebration, FL 34747 CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATIONFOR TREATMENT, PAYMENT, OR HEALTH OPERATION NAME ________________________________________________________________________________ BIRTHDATE ______________________________________ SOCIAL SECURITY # ______________________ I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: • A basis for planning my care and treatment • A means of communication among the many health professionals who contribute to my care • A source of information for applying my diagnosis and surgical information to my bill • A means by which a third-party payer can verify that services billed were actually provided • And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I request the following restrictions to the use or disclosure of my health information. ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ PATIENT: X___________________________________ ________________________ _______________________ Signature of Patient or Legal Representative Date OFFICE USE ONLY: Accepted __________________________________ Denied Signature Witness Signature _________________ ________________ Title Date CARDIOVASCULAR ASSOCIATES, INC. Johnson P. Massey, M.D., FACC Patrick F. Mathias, M.D., FACC, FCCP Robert L. Barrett, M.D., FACC Thomas Y. Kim, M.D., FACC Prashanta A. Laddu, M.D., FACC Mukesh Kumar, M.D., FACC, FSCAI Naushad Shaik, M.D., FACC Deborah Huddleston, A.R.N.P. Bethanne Smith, A.R.N.P. MISSED APPOINTMENT POLICY Please Read CAREFULLY Before Signing: Our office has implemented a new cancellation policy effective October 18, 2010. All appointment cancellations must be made 24 hours prior to your scheduled appointment time. Failure to cancel your appointment will generate a $25.00 Missed Appointment Fee for regular office visits, Echo, Vascular I Arterial Studies. A $150.00 Missed Testing Fee for Nuclear Stress Testing will be generated; t h e s e fees are payable before yo u r next appointment will be scheduled. We do realize that emergencies and illnesses arise and will consider those circumstances. To cancel your office visit appointment during normal business hours Monday through Friday from 9:00am till 5:00pm, please call (407) 8460626, choose option 2 and then option 2 again. To cancel your Nuclear Stress Test, please call (407) 846-0626 and then put in 279, this is the direct extension to the Test Scheduler. After hour calls placed to (407) 846-0626 will be handled by our Answering Service. Failure to call and cancel your appointment in a timely fashion results in an additional charge to you and your appointment slot not being made available to someone who may need to be seen. This Missed Appointment Fee must be paid in full before we can schedule your next appointment. Please sign the acknowledgement and acceptance of this policy in the space provided below. This notice will become part of your medical record. Patient Name Date of Birth Patient Signature/Responsible Party Today's Date 601 Oak Commons Blvd., Kissimmee, FL 34741•Phone: 407.846.0626 •Fax: 407.846.2524 4529 Edgewater Drive, Orlando, FL 32804 •Phone: 407.297.1870 •Fax: 407.292.7988 HIPPA" Notice of Privacy Practices Summary/Acknowledgement Maintaining privacy of your heal.th information is very important to us. Attached to this letter you will find our Notice of Privacy' Practices. The following is a brief summary of the content of the attached notice. We encourage you to read the entire Notice and ask any questions you may have regarding its contents . How We May Use and Disclose Health Information About You. This section describes the different ways we may use or disclose your health information without first obtaining a specific authorization from you. These types of uses and disclosures are specifically permitted by law because it.is assumed you would want us to use or disclose your information for these purposes, or because such use or disclosure is recognized as critical to the functioning of our health system. Your Rights Regarding Your Health Information. This section describes the following rights you have with respect to your health information and tells you how you may exercise these rights.  Right to inspect and copy  Right to request amendment  Right to an accounting of disclosures  Right to request restrictions on certain uses and disclosures  Right to request alternative means of communication  Right to receive a paper copy of our Notice of Privacy Practices How to file Complaints Concerning Our Privacy Practice. This section tells you what you can do if you believe any of your rights have been violated. You will not be penalized for filing a complaint. ' ' . . . We ask you acknowledge your receipt of this Notice by signing below. You should keep the copy of the attached Notice, however if you wish to receive another copy you may request at any time. Also, the most current copy of out Notice will be posted I our office. If there are material changes to this Notice at a later date, you will be provide a copy of the revised Notice and asked to sign another acknowledgement. I acknowledge that I received a copy of my providers Notice of Privacy Practices. Patient Signature: _______________ Witness:________________________________ City, State, Zip: I _ , hereby authorize Cardiovascular Associates Inc. Name of patient And/or medical facility to release any and all medical information and test results that pertain to me, to the following individual(s): Name: Relationship to patient: _ Name: Relationship to patient: _ Name: Relationship to patient: _ I authorize Cardiovascular Associates Inc. or the medical facility to contact the individual(s) listed above to convey any patient information to me, in the event I am unable to be reached by the facility. I understand that I may revoke/cancel this authorization by notifying Cardiovascular Associates Inc. in writing of my intent to revoke authorization or change in name(s) of the individuals to whom the information is to be released. Signature of Patient Date Or if applicable Signature of Legal Guardian or Personal Representative Date Name of Witness Date Witness Signature