1 Patient Information2 HIPAA Consent3 Insurance And Billing Policies4 Consent To Arbitration Name* First Last Birthdate* Date Format: MM slash DD slash YYYY Sex*Social Security #Marital Status*SingleMarriedSeparatedDivorcedWidowedAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Language (Optional)*Please indicate preferred method for contactHome Phone*Cell PhoneWork PhoneEmail Address* OccupationEmployerEmployer AddressPharmacy NamePharmacy Phone NumberIs this visit job relatedYesNoIf yes date Date Format: MM slash DD slash YYYY Is this Motor Vehicle RelatedYesNoIf yes, date of accident Date Format: MM slash DD slash YYYY Are you currentlyIn a Rehab FacilityIn a Skilled Nursing FacilityIn an Assisted LivingIn a Hospice ProgramNot applicableIf yes please provideFacility NameAddressTo comply with Federal regulations, we are required to ask you to fill out the following Race(OptionalWhiteBlack/African AmericanAsianAmerican Indian/Pacific NativeNative Hawaiian/Alaskan NativePrefer not to discloseOtherIf OtherEthnicity(Optional)Hispanic or latinoPrefer not to discloseEmergency ContactAlternative AddressRelationship to PatientPrimary Care PhysicianPhone NumberReferring DoctorPrimary LanguagePlease provide all pertinent information regarding your insurance coverage. If you have coverage by more than one carrier, please supply information for both.Primary InsuranceID #Group #Subscriber NameRelationship to SubscriberSubscriber Birth Date Date Format: MM slash DD slash YYYY Secondary InsuranceSecondary ID #Secondary Group #Secondary Subscriber NameRelationship to subscriberSubscriber Birth Date Date Format: MM slash DD slash YYYY Patient NameDate of Birth Date Format: MM slash DD slash YYYY Patient Acknowledgement and Consent for Use and Disclosure of Protected Health Information I acknowledge receipt of a Notice of Privacy Practices from Shore Heart Group, PA. With my consent, Shore Heart Group, P.A. nay use and disclose protected health information about me to provide treatment, for payment or healthcare operations. The complete information can be found in the accompanied Shore Heart Group, P.A Notice of Privacy Practices. With my consent, Shore Heart Group, P.A. may call my home or other chosen location and leave a message on voice mail or with a designated person in reference to any items that assist the practice carrying out the provision of treatment, for payment or healthcare operations. For example, this would pertain to appointment confirmations and obtaining payment for care provided; and may be related to my clinical care, including laboratory and test results. With my consent, Shore Heart Group, P.A. can mail to my home or other designated location any items that assist the practice in carrying out my medical care, payment or healthcare operations, such as appointment reminders and patient statements. In accordance with Federal and HIPAA regulations, I hereby give my consent for Shore Heart Group, P.A. to release PHI about me to the following person (s): NameRelationshipI do not wish to have any of my health-related information released to anyone other than myself.I have a right to review the Notice of Privacy Practices prior to signing this consent. I may revoke my consent in writing, except to the extent that the practice already made disclosures regarding me based on my prior consent. Signature of Patient or Legal Representative*Date* Date Format: MM slash DD slash YYYY Patient Name*Dear Patient, We are committed to providing the best possible care in every aspect of your experience. To achieve this goal, your clear understanding of our Patient Financial Policy is an important aspect of this relationship. Your insurance is a contract between you and your insurance company. It is impossible for us to be knowledgeable about every patient’s specific plan coverages and limitations. Please bring your insurance card(s) with you to every visit and notify us of any changes in your insurance. If you are having testing done, don’t assume you only have a co-pay, as most insurances will apply deductibles and co-insurances for testing. If you need to know your responsibility for a service, reach out to your insurance company. We will not know your responsibility until after the insurance company has processed your claims. Insurance Coverage:You will be financially responsible for any and all charges for professional services. Exceptions are when patient responsibility is limited by statutory regulation (such as Medicare, Medicaid, Managed Care Contracts (HMO, PPO, etc.), authorized Workers’ Compensation, or Motor Vehicle carriers. In cases of claims being submitted to your insurance carrier, it is your responsibility to financially cover any deductibles, co-payments and non-covered-services as stipulated by your specific insurance plan. Co-insurances and copays are due at the time of service. Any payment/explanation of benefits issued directly to you for care received from SHG must be forwarded to SHG in a timely fashion for posting of payment and/or appropriate adjustment. Failure to provide accurate insurance information may result in you being responsible for the entire bill. Referrals/ Authorizations: Proof of your insurance coverage must be provided at the time of service, along with any necessary authorizations/referrals. All associated co-payments will be collected at the time of your office visit. If your insurance company requires a referral or pre-authorization you are responsible for obtaining it or you may be responsible for payment or need to reschedule your appointment. Medicare: If you have Medicare, please note that although we participate with and accept assignment with Medicare, you are still responsible for your deductible and coinsurance. If you have a secondary insurance with which we participate, and you have given us all the required information, we will also bill them. Deductibles, co-insurances and co-pays for secondary insurances are due at the time of service. If payment is not received by your secondary insurance carrier within 60 days, you may be billed for the amount owed as per the Medicare explanation of benefits. Disability Forms/Reports: Requests for completion of disability forms, reports or other paperwork will require an advance fee based on the complexity of the form. Please allow 5 business days for completion. Release of Medical Records and Fees: Medical record copies and imaging will require written authorization and pre-paid fees related to preparation. Whenever possible, records going directly to the patient will be provided through the patient portal to reduce costs to the patient. Copying fees in accordance with (N.J.A.C. 13:35-6.5© (4) shall not exceed $1.00 per page or $100 for the first 100 pages. For medical records that contain more than 100 pages, a copying fee of no more than $0.25 per page will be charged thereafter, up to a maximum of $200.00 for the entire record. A search fee of no more than $10.00 will also be charged per request. Imaging copies will be $10.00 per CD. Although, we anticipate your copies to be ready within 10 days, NJ law allows 30 days for this process. Requests being made with patient authorization by attorneys, life or disability insurance companies, etc. will be routed to a third party, Med-Request Solutions. They can be reached at 1-800-483-6040. Medical-Legal Reports/Testimony: The office’s policy regarding Medical-legal reports and testimony is that the physicians do not testify, nor make court appearances. Permanency evaluations and narrative reports are prepared at their discretion. If this policy is unacceptable to you or my attorney, please be aware that you should seek cardiovascular care elsewhere. Cost of Collection: Patient balances should be paid in full upon receipt of your statement. If full payment cannot be made, you can contact our office to make payment arrangements with the billing department. It is the patient’s responsibility to maintain their account in good standing, regardless of insurance or any other circumstances (such as litigation). If an account is submitted to collections, you will be responsible for all costs associated with collecting owed balances including but not limited to: collection agency, attorney and court fees. Workers’ Compensation and Auto Accidents: It is the patient’s responsibility to clearly identify those medical injuries/ conditions which he/she believes are due to a motor vehicle or work related injury at the time of the initial visit on all required documentation. Failure to do so can result in patient liability. Worker’s Compensation Claims: We require written authorization from your employer or its worker’s compensation insurance carrier prior to your first visit. Denied charges due to lack of prior authorization will be your responsibility. Your private insurance cannot be used to cover treatment for work injuries unless workers compensation coverage has been denied, does not exist or your case has been settled. Written denial and affidavit is required. [In the event your WC claim is denied after submission, we will bill your regular health insurance carrier only if we are a participating provider and prior authorization was not required.] Motor Vehicle (PIP) Claims: Injuries involving Motor Vehicle accident/injuries must be submitted to your Motor Vehicle (PIP) carrier and cannot be billed to private insurance unless PIP coverage has been denied, does not exist or private insurance was selected as the primary carrier. You are responsible for any deductible or co-payments under my PIP coverage. Letter of Protection: If you are being seen for an injury that involves legal action, please be advised that you are still responsible for payment at the time of service. We do not accept letters of protection from attorneys in lieu of payment. Uninsured: If you do not have insurance, payment is expected in full at the time of service by cash or credit card. Cancellation Policy: In the event 24 hours’ notice is not provided, you will be charged a fee for the missed appointment of $25 for missed office visits and $150 for missed Nuclear Stress or PET tests. These charges are not covered by insurance and will be the patient responsibility. Return Checks: There will be a $25.00 charge for any check returned unpaid. I understand and acknowledge the financial policy and insurance authorization terms stated above. Medicare Assignment of Benefits: I request that payment of authorized Medicare benefits be made on my behalf to SHORE HEART GROUP, P.A. for any services furnished me by Shore Heart Group, PA. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. Assignment of Benefits: I hereby authorize and instruct any insurance companies involved with my healthcare coverage to make payment directly to SHORE HEART GROUP, P.A. This is for the professional Medical Expense benefits allowable and otherwise payable to me under my current insurance policy as payment towards the total charges for professional services rendered. This payment shall not exceed my indebtedness to the above practice, and I have agreed to pay in current fashion any balance if said professional service charges are over and above this insurance portion of payment. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to my insurance company, or adjuster involved in the case unless I have made alternative arrangements with respect to this data. Signature of Patient or Responsible Party*Date* Date Format: MM slash DD slash YYYY CONSENT TO ARBITRATION AGREEMENT TO ARBITRATE: IT HAS BEEN FULLY EXPLAINED TO ME AND I UNDERSTAND THAT THERE ARE INHERENT RISKS AND DANGERS ASSOCIATED WITH ANY MEDICAL PROCEDURE OR TREATMENT. IT IS MY INTENTION BY SIGNING THIS CONSENT TO HAVE ANY DISPUTE RELATED TO AND/OR ARISING OUT OF ANY TREATMENT, MEDICAL PROCEDURES, SURGERIES, AND/OR DIAGNOSTIC PROCEDURES OR THERAPIES PROVIDED BY THIS OFFICE, INCLUDING ANY CLAIMS OF MEDICAL MALPRACTICE (WHICH INCLUDE ANY CLAIMS REGARDING PROCEDURES CLAIMED BY ME TO BE NEGLIGENTLY PERFORMED) WILL BE SUBMITTED TO BINDING ARBITRATION. BY ENTERING INTO THIS AGREEMENT, I AGREE TO BE BOUND BY THE ARBITRATION PROCEDURE AND PROCESS AND KNOWINGLY INTEND TO UTILIZE THIS METHOD FOR ANY RESOLUTION. BY DOING SO, I AGREE TO CONSCIOUSLY FORGO A JURY TRIAL. I AGREE TO ARBITRATE ANY AND ALL CLAIMS THAT MAY ARISE IN CONNECTION WITH MY MEDICAL TREATMENT AND/OR SERVICES PROVIDED BY THIS OFFICE INCLUDING ANY CLAIM FOR MEDICAL MALPRACTICE. THIS INCLUDES ANY SPOUSE, LEGAL PARTNER, CHILDREN, GUARDIAN, PARENT, ETC. THE PARTIES AGREE THAT THE DECISION AND AWARD OF THE ARBITRATOR SHALL BE FINAL AND CONCLUSIVE UPON THE PARTIES, IN LIEU OF ALL OTHER LEGAL PROCEEDINGS. IN THE EVENT THAT THE MEDICAL GROUP DOES NOT RECEIVE PAYMENT FOR SERVICES RENDERED, IT IS SPECIFICALLY UNDERSTOOD THAT THIS AGREEMENT SHALL NOT WAIVE THE MEDICAL GROUP’S RIGHT TO UTILIZE THE COURT SYSTEM TO COLLECT FEES, INTEREST, AND COURT COSTS FOR SERVICES RENDERED. I UNDERSTAND THAT SHOULD I NOT AGREE TO ARBITRATION, I HAVE THE RIGHT TO SEEK MEDICAL CARE FROM SOME OTHER PHYSICIAN OR MEDICAL GROUP. Print NamePatient Signature*Date* Date Format: MM slash DD slash YYYY Power of Attorney, if applicableDate Date Format: MM slash DD slash YYYY Name First Last Date Date Format: MM slash DD slash YYYY AGEReferring PhysicianHeightWeightWhat is the problem you have been having?AllergiesRecent testing done?Have you ever had a heart catheterization?Angioplasty?Bypass Surgery?Previous echocardiogram?Previous carotid ultrasoundPrevious Stress testMEDICATIONS: Please list ALL medications, prescription or non-prescription, which you are “CURRENTLY” taking and include how many times per day you are taking them and the strength:123456789Do you take aspirin or other Blood thinners?Herbal medications?Vitamins?PAST MEDICAL HISTORY: Hospitalization or Operations?YearReason for HospitalizationDiagnosisREVIEW OF SYSTEM: Do you have any of the following? Yes or NoHeart ProblemsYesNoMurmur/Valve ProblemYesNoHigh Blood PressureYesNoIrregular Heart BeatYesNoChest PainYesNoCVA, TIAYesNoPeripheral Vascular DiseaseYesNoAsthmaYesNoCOPDYesNoEmphysemaYesNoBreathing ProblemsYesNoAnemiaYesNoThyroid ProblemsYesNoKidney ProblemsYesNoBladder ProblemsYesNoProstate ProblemsYesNoSeizure DisordersYesNoArthritisYesNoStomach ProblemsYesNoPlease list any other Medical ConditionsFAMILY HISTORY: Any immediate family members have a history of the following?DiabetesYesNoAsthmaYesNoHeart DiseaseYesNoHigh Blood PressureYesNoHigh CholesterolYesNoHigh CholesterolYesNoStrokeYesNoCancerYesNoArthritisYesNoKidney ProblemsYesNoAnemiaYesNoThyroid ProblemsYesNoPancreatic ProblemsYesNoSocial HistoryOccupationMarital StatusChildren (ages)Do you smoke?YesNoIf yes how much?Do you drink coffee, tea?YesNoCups per day?Do you drink alcohol?YesNoIf yes how much?Do you experience high anxiety?YesNoDo you follow a special diet? 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