Authorization for Treatment / Release of Information

Consent to Treatment: The patient and/ or authorized representative do hereby consent to any and all treatments which may deem advisable by the physician or Cardiac and Vascular Consultants, Inc. Patient Consent to Rx verification, Electronic Data Health Exchange (eEHX Interoperability). Each procedure and diagnostic study will be discussed in detail with patient before procedure is performed. Additional consent will be required at the time of procedure.

Assignment of Insurance Benefits: I assign payment directly to Cardiac and Vascular Consultants, Inc. Insurance Benefits otherwise payable to me. I understand that I am financially responsible for charges paid by this assignment. I will assist in the collection of my insurance should there be any delay in payment. I agree to actively participate in collecting Insurance payment for any claims unpaid after 30 days. If after 45 days the claim remains unpaid, I understand the balance will be due from me.

Medicare Patients: I certify that the information given by me in applying for payment under the XVIII if the Social Security is correct. I authorize Cardiac and Vascular Consultants, Inc. to release to the Health Care Financing Administration of its Intermediaries any information needed for this related Medicare claim, I hereby authorize payment directly to Cardiac and Vascular Consultants, Inc for medical benefits otherwise payable to me as beneficiary of the Medicare Program and such other payments as may be due by other third-party payers. I agree to execute such documents as may be necessary to apply for and obtain payment. I understand that such services as but limited to routine testing may not be covered by Medicare unless the Physician provides medical necessity.

Patient/ Guarantor Agreement: I understand that Cardiac and Vascular Consultants, Inc. is not in business expanding credit. Therefore, it is the policy of Cardiac and Vascular Consultants, Inc. to require payment in full at the time of service. If unable to pay due balance in full at the time of service, I agree to make prior arrangements with the Billing Department.

I understand that I am financially responsible for my/ the patient’s account with Cardiac and Vascular Consultants, Inc. regardless of my insurance benefits. I authorize copies of this form to be valid as the original.

Patient Consent for Use and Disclosure of Protected Health Information

I hereby give my consent for Cardiac and Vascular Consultants to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).

I have the right to review the Notice of Privacy Practices prior to signing this consent. Cardiac and Vascular Consultants reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Cardiac and Vascular Consultants.

With this consent, Cardiac and Vascular Consultants may call my home or other alternative location and leave a message on voice mail or e-mail/text me, publish my records to patient portal in reference to any items that assist the practice in carrying out TPO. This may include appointment reminders, insurance issues, and concerns with my clinical care, such as laboratory test results, diagnostic imaging, Integrated Data records Exchange (eEHX), Marketing, etc.

With this consent, Cardiac and Vascular Consultants may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”

With this consent, Cardiac and Vascular Consultants may text or e-mail to my home or alternative location, any items that assist the practice in carrying out TPO, such as appointment reminders, patient statements, and medical records. I have the right to request that Cardiac and Vascular Consultants restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Cardiac and Vascular Consultants to use and disclose my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures based upon my prior consent. If I do not sign this consent, or later revoke it, Cardiac and Vascular Consultants may decline to provide treatment to me.