Patient Forms
    
   
Patient Demographics
   
  New Patient Medical Information
   
  Authorization for Disclosure
  (Release of Medical Records)
  Revocation of Authorization

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  (Revoke of Medical Records)    
 
 
 
 
 
 
   
 
New Patients should complete the Patient Demographics and New Patient Medical Information Forms prior to your scheduled appointment.
   
 
SOUTHEASTERN CARDIOVASCULAR CONSULTANTS
PATIENT INFORMATION
 
* Dr. Mr. Ms. Mrs. Rev.
 
Name      
* Last
* First
Middle
Maiden
 
Today's Date: *
/ /
Date of Birth: *
/ /
Age: *
Marital Status: * Single Married Separated Divorced Widowed
 
Address: * Apt:
City: * State: * Zip: *
 
Home Phone: * ( ) -
Social Security #: * - -
Cellular or pager #: ( ) -
Primary Contact #: ( ) -
Driver's License #: *
Occupation:
 
Patient's Employer:
  Business Name Address
Business Phone: ( ) -  
 
Insurance Carrier: *
Insured's Name: *
Policy #: *
_______________________________________________________________________________________
RESPONSIBLE PARTY INSURANCE INFORMATION (If the responsible party is not the patient, please complete this section)
Insured's Name: Date of Birth: / /

Insured's Social Security #:

 - - Occupation:
Insured's Employer: Business Phone: ( ) -
_______________________________________________________________________________________
 Emergency Contacts
Relative Other Than Spouse's: *
Relation: *
Phone: * ( ) -
   
Relative or Friend Not Living With You: *
Relation: *
Phone: * ( ) -
 _______________________________________________________________________________________
 
RELEASE OF INFORMATION
 
1. Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis (including treatment, payment and health care operations).
 
2. Please list the family members or significant others, if any, whom we may inform about your medical condition ONLY IN AN EMERGENCY:
 
3. Please print the address of where you would like your postcards and/or correspondence from our office to be sent if other than your home.
 
4. Please print the telephone number, if any, where you want to receive your calls about your appointments, lab and x-ray results, or other health care information if other than your home phone number:
*I am fully aware that a cell phone is not a secure and private line.
 
5. Can confidential messages (i.e. appointment reminders) be left on your telephone answering machine or voicemail? * YES NO
 
 

6. Have you received a copy of the HIPAA Privacy Notice? * YES NO

 

7. Do you have a Living Will or Advance Directive? * YES NO

 
REFERRAL INFORMATION
Name of your Family Doctor:
Address:
   
 
TV or Radio
Word of Mouth  
Friend
Employer  
Yellow Pages
Hospital Emergency Room  
Family Member
Other
 
Doctor Referred You City,State
I authorize the release of any information to process my insurance claim and/or to other physicians who are also responsible for my care. I hereby authorize payment of medical insurance benefits to Southeastern Cardiovascular Consultants for medical services rendered to me. I am responsible for any remaining balance after the insurance pays. I am in agreement that in the case of my account becoming delinquent that I am responsible for accrued interest in the amount of 1.5% of the unpaid prinicipal balance per month, reasonable attorney fees in the amount of 25% of the unpaid principal balance and interest, court cost, and other expenses related collection procedures on my account. If I am the guarantor for a patient, I as guarantor bind myself, in solido, with the patient herein for all sums owed Southeastern Cardiovascular Consultants.
 
 
 
 
 
 
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