Premier Heart

I certify the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare), for the purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I ACKNOWLEDGE THAT INTEREST OR A FEE, AT THE PROVIDERS CURRENT RATE, MAY BE CHARGED on the balances owing to the provider that are past due.

Notice to all Patients:

IF YOUR MEDICAL INSURANCE REQUIRES A REFERRAL, YOU WILL NEED TO GET IN TOUCH WITH YOUR PRIMARY CARE PROVIDER TO LET THEM KNOW WHEN YOUR SCHEDULED APPOINTMENT IS AND TO ASK THEM TO ENTER A REFERRAL FOR YOU.

All office visits, diagnotic testing, or procedures scheduled at Premier Heart and all hospital testing or procedures billed by Premier Heart are subject to the following cancellation policy as follows:

Cancellations for any of the above must be made 48 hours prior to the scheduled time.

Failure to notify the office in less than 48 hours prior to the scheduled appontment time will result in a bill sent directly to the patient for $50.00. This is not a covered medical insurance benefit and will be payable to the office directly by the patient.

I {name} have read the office cancellation policy stated above. I understand and agree to pay $50.00 for failure to contact the office 48 hours prior to my scheduled appointment per appointment scheduled.

I am presenting myself for treatment at Premier Heart, LLC. I voluntarily consent to the rendering of such care, including diagnostic procedures and medical treatment by the employees and medical staff of Premier Heart, which, in their professional judgement, is necessary or beneficial. I understand that this consent applies to this and to all subsequent visits as a patient relating to the diagnosis and treatment of my medical condition(s).

I agree that my provider can check my external medication history at his/her discretion.

I hereby authorize payment directly to Premier Heart the benefits under the insurance coverage(s) identified by me which may be payable to me but not to exceed the regular charge or all services rendered. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable or provider services or authorize such provider of submit claims to the insurer for payment.

I understand that I am financially responsible for all charges not paid under this assignment. I further understand that my provider cannot know all the terms of my insurance and that if my insurance declines payment for any reason I am responsible for payment of all declined charges. I understand and agree that in the event that I fail to make payment for service rendered to me, my identifying information will be turned over to a collection agency and/or attorney and I will be responsible for all costs associated with collecting payment including but not limited to attorneys fees, court costs, and collection agency fees. 

The undersigned agrees, whether she/he signs as agent or as patient, that in consideration of the services to be rendered to the patient she/he hereby individually obligates herself/himself to promptly pay the account of Premier Heart in full upon presentation of any portion denied or not covered by the patients insurance carrier. Provisional credits are subject to collections thereof by Premier Heart.

I authorize Premier Heart along with any billing service and/or their collection agency or attorney who may work on their behalf, to contact me on my cell phone and or home phone, and/or may use pre-recorded messages, artificial voice messages, automated telephone dialing devices or other computer assisted technology, or by electronic mail, text message or by any other form of electronic communications.

I authorize Premier Heart to electronically share my medical information through Health Information Exchanges for the purpose of coordinating patient care, treatment, payment, health care operations, and other authorized purposed to the extent permitted by law. I acknowledge that I have been informed of my rights to "opt-out" or decline participation in Health information exchanges. 

I certify that the information given by me is correct.

I certify that I have been provided with the HIPAA guidelines for confidentiality as pertain to Premier Heart and its providers. I understand that I may receive additional copies at any time upon request. I understand that staff is available to answer any questions regarding the HIPAA guidelines.

The undersigned certifies that she/he has read and understands the foregoing and is the patient or is duly authorized by the patient as the patient's general agent to execute the above and accepts its terms.

Welcome to Premier Heart!

We are pleased you have chosen Premier Heart for your cardiovascular care. We appreciate your trust in us. We specialize in providing the premier cardiovascular care in South Jersey and Philadelphia.

Our team of medical professionals uses a coordinated approach to care that focuses on each patients' individual needs͘.

Premier Heart offers same day appointments most days of the week for all patients. These convenient appointments are designed to provide you with timely access to our medical care and help you to avoid potential costly and timely hospital emergency room or urgent care visits.

Premier Heart offers an electronic, web-based patient portal to communicate with your provider,  office staff, request prescription refills and labs, view upcoming appointments and more. Please provide your email for this if you are interested and let the office staff know that you would like to be signed up for this.

Appointment Policies:

Please arrive 15 minutes prior to your scheduled appointment time to check in. Patients who arrive more than 15 minutes after their scheduled appointment time may be asked to reschedule. We require 15 hours notice if you are unable to keep your appointment͘. This will allow us ample time to schedule another patient who my have an urgent need.

Medical Records:

We request that you have any recent medical records forwarded to our office prior to your first appointment. Please complete the enclosed form, "Authorization for Release of Information", and submit to your previous physician so we may review those records in collaboration with your current records.

Financials:

Copays are due at the time of your visit. We accept cash, check or credit card. 

All outstanding balances are to be paid in full at the time of your visit unless payment arrangements have been made with our billing department.

All self-pay patients are requested to pay for their visit in full at the time of service.

Failure to get necessary referrals prior to visit may result in you being responsible for the bill.

Prescription Refill request:

Please have pharmacy request a refill electronically. You may also request through the portal or by calling the office.
Please give a minimum of 72 hours' notice for a refill͘.

Patient Code of Conduct:

Our goal at Premier Heart is to treat every patient and their family with dignity and respect. It is our expectation that when communicating with our providers and staff our patients will be respectful and courteous. Patients who exhibit disrespectful, abusive behavior or inappropriate language will be discharged.

I am in receipt of the practice policies and am aware of my rights and responsibilities.

As our patient we may need to reach you when you are not in the practice. For your privacy, please indicate your preferred method for us to communicate confidential medical information, such as lab tests results, to you and/or others involved in your care. Please note that appointment reminder “telephone calls͟ may be left at the contact number(s) you list below. Please list your email address to receive online healthcare information provided by Premier Heart patient secure portal.

Without specific permission, we will not release any medical information to anyone other than you. In some cases, you may wish for another person to have access to your medical information. Please identify those individuals and their relation to you (i.e. spouse, parent, son, daughter, partner, etc.) below if you would like medical information released to anyone other than yourself. Please check yes if a message with medical information can be left at the number you list below.

I assume the responsibility to inform the practice of any changes in my phone number(s) or my preferences or to revoke this specific medical information authorization at any time.

By signing below, I acknowledge that I have been provided Premium Heart's Notice of Privacy Practices, which contains a detailed description of the uses and disclosures of my health information. Additionally, I have been given an opportunity to read the Notice.

https://www.hhs.gov/hipaa

I authorize the use or disclosure of the above-named individual's health information as described below.