Thank you for choosing Florida Cardiology Associates for your cardiology needs. We have prepared this packet of information and forms in order to make your first visit with us, a convenient and pleasant experience. We ask that you complete the attached paperwork prior to your arrival.
When you come for your appointment please bring the following:
- NOTE: THERE WILL BE ADDITIONAL FORMS THE PATIENT MUST COMPLETE & SIGN DURING THEIR FIRST VISIT TO OUR OFFICE THAT ARE NOT INCLUDED IN THIS ONLINE VERSION
- Medical Insurance Cards and Photo ID
- Bring with you any records from your previous Cardiologist
- Please let us know if you have been seen in the hospital prior to your appointment
- Bring with you an updated Medication list with current milligrams and dose information
Please be prepares to pay for the following at the time of your visit:
- Co-payment. If your insurance requires a co-pay, your are responsible for this
at the time of your appointment
- If you do not have insurance, payment is expected at the time of service
(unless previous arrangements have been made)
Referral/Authorizations: We will attempt to get referral/authorization from your
Primary care physician; however it is always a good idea for you to call to let them Know of your appointment.
Please check in 15 minutes prior to your scheduled appointment time to allow our staff to complete the administrative portion of your appointment.
Patient Information
Name:
Notify in Case of Emergency:
Insurance Information (Please have cards ready for receptionist)
Patient Health History
Symptoms/Problems check all symptoms you currently have or have had.
Conditions/Illness
Family History Fill in health information about your family
Please fill out this page to its entirety
Father
Mother
Hospitalizations/Surgeries/Serious Illness/Injuries
Please circle if any blood relatives had any of the following and their relation to you
Heart Problems
Fill in date of your last:
Exercise
Health Habits Check which substance you use and answer questions
Previous tobacco use
Recreational Drugs
Alcohol use
Other
Pharmacy:
Medicine
Any additional medications should be brought to the office on a written list
Arterial and Venous Screening Form
Do you experience any of the following in your legs:
Have you had a history of:
When you walk or exercise, do you experience pain in your arms,
*Have you had surgery, balloon procedures or stents to any
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Your Rights
You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we've shared your information
- Get a copy of this privacy notice
- Choose someone to act foryou
- File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and shareinformation as we:
- Tell family and friends aboutyour condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and sell your information
- Raise funds
Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for yourservices
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers' compensation, law enforcement, andother government requests
- Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of ourresponsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask ushow to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request.
We may charge a reasonable, cost-based fee.
Ask us to amend your medical record
- You can ask us to amend health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required toagree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose ofpayment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, whowe shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-basedfee if you ask for another one within 12 months.
Get a copy of this privacy notice - You can ask for a paper copy of this notice at any time.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rightsand make choices about your health information. We will ensure the person has this authority before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 2.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share yourinformation in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, youhave both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situationIf you are not able to tell us your preference we may go ahead and share your information if we believe it is in your best interest. Wemay also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising we may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.
We can use and share your health information to run our practice, improve your care, and contactyou when necessary.
We can use and share your health information to bill and get payment from health plans or other entities.
Electronic Exchange. Your information may be shared w/ other providers, labs and radiology groups through our EHR system as listed:
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as publichealth and research. We have to meet many conditions in the law before we can share your information for these purposes. For moreinformation see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Preventing or reducing a serious threat to anyone's health or safety
- Reporting suspected abuse, neglect, or domestic violence
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services ifit wants to see that we're complying with federal privacy law.
We can use or share health information about you:
- For workers' compensation claims
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
- Respond to lawsuits and legal actions
- For law enforcement purposes or with a law enforcement official
Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will beavailable upon request, in our office, and on our web site.
Florida Cardiology Associates, LLC
727-848-6400
Effective Date: June 19, 2015
