HRA - New Patient Forms

Heart Rhythm Associates, PA

Patient Health Questionnaire
Please answer all questions. If there is no answer enter N/A or none.
Patient Name*
Date of Visit

MonthDayYear
Date of Birth*

MonthDayYear
Age*
Sex

MF
Height
Weight
What health concern or condition are we seeing you for today?
Who is your general cardiologist?*
Phone Number
Please enter a valid phone number.
Who is your primary care physician?*
Phone Number
Please enter a valid phone number.
Current Medication

Current medications you are taking. Please include all prescribed and over the counter medication.

If there is no answer enter N/A or none.

List Medication: *

	Medication	Strength	How often
1
2
3
4
5
6
7
8
9

Drug and Food Allergies

Please list any medications you are allergic to and reactions you may have due to these medications.

List Drug and Food Allergies:*

	Yes	No	Describe Reaction
Any Medications
Iodine or shellfish
X-ray dye or IV contrast
Other

Do you drink alcohol on a regular basis?*

YesNo
If no, did you drink heavily in the past?

YesNo
If yes, how much do you typically drink in one week?
Do you follow any specific diet?

YesNo
If yes, what kind?
Do you now or have you ever smoked tobacco products?*

YesNo
If cigarettes, number of packs per day?
Number of years
If cigars, number per day?
Number of years
If pipes, number per day?
Number of years
Have you quit?

YesNo
If yes, when was your last cigarette, cigar or pipe?
Do you drink coffee or tea?*

YesNo
If yes, how many cups per day
Do you drink caffeinated energy drinks?*

YesNo
If yes, how many per day
Do you exercise?*

YesNo
If yes, what kind of exercise and how often?
Are you able to perform activities of daily living?*

YesNo
Do you use recreational drugs?*

YesNo
Have you ever been treated for substance abuse?*

YesNo

	Yes
Asthma
Diabetes
Atrial fibrillation
COPD
GERD
Anemia
Palpitations
Pulmonary embolism
Cardiomyopathy
Rheumatic heart disease
Bowel disorders
Thyroid disease
Kidney disease
Mitral valve stenosis
Cirrhosis

	Yes
Hypercholestrolemia
Hypothyroidism
CHF
Arthritis
Gout
Mitral prolapse
DVT
Tuberculosis
Hypertension
Respiratory disease
Varicose veins
Cancer
Mitral valve regurgitation
Aortic stenosis
stroke

	Yes
Cholecystectomy
Tonsillectomy
Hysterectomy, abdominal
Thyroidectomy
Hernia repair

	Yes
Appendectomy
Cesarean section
Cardiac catheterization
Heart stent
Gallbladder

Due to the new law enacted by congress, we are required to have you sign this form to receive treatment by the Cardiologist.
1. You must consent to a medical examination and any procedures or test deemed necessary by Heart Rhythm Associates, PA while you are in our office.
2. You agree that either Heart Rhythm Associates, PA can release medical information to your primary care doctor and or the physician who referred you to our office.
3. You consent to our releasing information about appointments and or test results to anyone you designate.
Name*
Relationship*
This consent to be in effect indefinitely or until you have revoked it. You may revoke this consent at any time. By revoking consent for further treatment does not relieve you from any financial obligations which were incurred during the period this consent was effective.

Assignment of Benefits

I hereby authorize direct payment of surgical/medical benefits to Heart Rhythm Associates, PA for services rendered by him/her or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance.

Authorization for Release of Information

I hereby authorize Heart Rhythm Associates, PA to release my medical information that may be necessary for either medical care of processing applications for financial benefits.

Medicare and Medicaid

I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf.

HIPAA Individual Acknowledgement of Privacy Practice

HIPAA Individual Acknowledgement of Privacy Practice By signing this paper, I am indicating that I have been provided a copy of the Notice of Privacy Rights Practice. I understand that the notice of privacy practice can change. I can obtain a current notice by contacting the staff.

Consent to Treat

I (or my legal guardian or parent) authorize Heart Rhythm Associates, PA to provide medical care reasonable by today's standards.
Patient Signature*

Clear
Date*

MonthDayYear

Release of Medical Information
Patient Name*
Date of Birth*

MonthDayYear
I hereby authorize Heart Rhythm Associates, P.A. to obtain my protected health information (medical records) described below that may be necessary for treatment from:
Choose Type:

Facility/HospitalDoctor's Office
Facility/Hospital
Address
Phone #
Doctor's Office
Address
Phone #
I understand that to the extent any Recipient of this information, as identified above, is not a "covered entity" under Federal or Texas privacy law, the information may no longer be protected by Federal and Texas privacy law once it is disclosed to Recipient and, therefore, may be subject to re-disclosure by the Recipient.
Signature of Patient*

Clear
Date

MonthDayYear

MEMORIAL HERMANN INFORMATION EXCHANGE "MHiE"

PATIENT CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION

Purpose: The MHiE is a health information exchange network developed by Memorial Hermann Healthcare System. Exchange Members include hospitals, physicians and other healthcare providers. Exchange Members are able to share electronically medical and other individually identifiable health information about patients for treatment, payment and healthcare operation purposes. We are an Exchange Member of the MHiE and we seek your permission to share your health information with other Exchange Members via the MHiE. By executing this form, you consent to our use and electronic disclosure of your health information to other MHiE Exchange Members for treatment, payment and healthcare operation purposes. We will not deny you treatment or care if you decline to sign this Consent, but we will not be able to electronically share your health information with your healthcare providers that participate in the MHiE as Exchange Members if you do not sign this Consent.

Instructions: If you agree to allow us to disclose your health information with other MHiE Exchange Members please complete the relevant portions of and sign this Consent.
Patient Name (Last, First, Middle)*
Date of Birth*

MonthDayYear
Information that will be Disclosed; Purpose of the Consent for Disclosure
I [Patient Name]*, hereby consent to the disclosure of my medical, health and encounter information by any and all Memorial Hermann Healthcare System providers (collectively the "Provider") to other participating providers in the MHiE (Exchange Members) who may request such information for treatment, payment or healthcare operation purposes. I understand the information to be disclosed includes medical and billing records used to make decisions about me.
I HEREBY SPECIFICALLY AUTHORIZE PROVIDER TO RELEASE ALL TYPES AND CATEGORIES OF PROTECTED HEALTH INFORMATION TO OTHER HEALTHCARE PROVIDERS THAT PARTICIPATE IN THE MHiE FOR TREATMENT, PAYMENT AND HEALTHCARE OPERATION PURPOSES, [INCLUDING BUT NOT LIMITED TO, YOUR ALCOHOL AND TREATMENT RECORDS, YOUR DRUG ABUSE TREATMENT RECORDS, YOUR MENTAL HEALTH RECORDS, AND YOUR HIV/ACQUIRED IMMUNE DEFICIENCY SYNDROME RECORDS, AS APPLICABLE].

No Conditions: This Consent is voluntary. We will not condition your treatment on receiving this Consent. HOWEVER, IF YOU DO NOT SIGN [AND INITIAL] THIS CONSENT, WHERE REQUIRED, YOU CANNOT PARTICIPATE IN THE MHIE.

Effect of Granting this Consent: This Consent permits all MHiE Exchange Members to access your health information. Exchange Members of the MHiE are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Terms and Revocation

This Consent will remain in effect until you revoke it. You may revoke this Consent at any time by completing the MHiE notice of revocation. The MHiE notice of revocation is available by calling 713-456-MHiE (6443). Revocation of this Consent will not affect any action we took in reliance on this Consent before we received your notice of revocation. Revocation of this Consent will also have no effect on your personal health information made available to Exchange Members during the timeframe in which your Consent was active.

INDIVIDUAL'S SIGNATURE

I have had full opportunity to read and consider the contents of this Consent. I understand that, by signing this Consent, I am confirming my consent and authorization of the use and/or disclosure of my personal health information, as described herein.
Signature*

Clear
Date

MonthDayYear
If this Consent is signed by a personal representative on behalf of the individual, complete the following:
Personal Representative's Name
Relationship to Individual
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Include this Consent in the individual's records.
Should be Empty:

	Yes	No
fatigue
fever
weakness
weight gain
weight loss
loss of appetite
headache
appetite reduced

	Yes	No
sore throat
recent bronchitis
shortness of breath at rest
coughing up blood
chronic cough
chest congestion
expiratory wheezing
COPD exacerbation

	Yes	No
cough
cold symptoms
sinus pain
loss of hearing
ringing in ears
change in voice

	Yes	No
nausea
heart burn
frequent diarrhea
constipation
nocturnal heart burn
vomiting
difficulty swallowing
abdominal pain
blood in stool

	Yes	No
heart murmur
pauses in heart beat
palpitations
chest pain at rest
chest pain with exertion
leg edema
leg pains
shortness of breath at rest
shortness of breath on exertion
dizziness
sweats

Family History

Patient Demographics/ Insurance Information

Emergency Contact Information

Insurance Information

Insurance Information

Pharmacy Information

Release of Medical Information

MEMORIAL HERMANN INFORMATION EXCHANGE "MHiE"

PATIENT CONSENT FOR THE USE AND DISCLOSURE OF HEALTH INFORMATION

	Yes	No
pain in legs with exercise
ankle or leg swelling
discoloration of feet or legs

	Yes	No
“Mini-Stroke” or TIA
fainting / passing out
dizziness or lightheaded

	Yes	No
dribbling or incontinence
pain or burning with urination
kidney stones or infection

	Yes	No
rash
non-healing sores or ulcers
acne

	Yes	No
Erectile dysfunction
Have you had a vasectomy