Premierheartnj.com - Medical Information Communication

Medical Information Communication Preferences
Patient Name:*
DOB:*

MonthDayYear
Date
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.
Please indicate your communication preferences below:

By listing number(s)/or email(s) below you are giving Premier Heart permission to leave medical information pertaining to you, your dependent, or child.

Method

	Yes	No	Area Code, Phone #, Ext, Email	Yes to leave a message
Home Telephone
Voicemail / Answering machine
Work phone
Mobile phone
Email

Method
Home Telephone*

YesNo
Phone #*
Please enter a valid phone number.
OK to leave a message?*

YesNo
Mobile phone*

YesNo
Phone #*
Please enter a valid phone number.
OK to leave a message?*

YesNo
Work phone*

YesNo
Phone #*
Please enter a valid phone number.
OK to leave a message?*

YesNo
Email*

YesNo
Email*
example@example.com
OK to send a message?*

YesNo
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.

	Name	Relationship	Area Code, Phone #, extension	Yes to leave a message
1
2
3
4
5

Do you want to share your medical information with any other person?*

YesNo
Comments:
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.
Signature of Patient or Legal Representative:*

Clear
Date:*

MonthDayYear
Date
Type Signers Name: *

HIPAA Notice of Privacy Practices Acknowledgement Form
By signing below, I acknowledge that I have been provided Premier 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.
Signature of Patient or Legal Representative:*

Clear
Date:*

MonthDayYear
Date
Type Signers Name:*
https://www.hhs.gov/hipaa

Patient Release
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.
Print Patient Name: *
Date:*

MonthDayYear
Date
Patient Signature/ Legal Representative:*

Clear
Print name of Signature if different than Patient:
Notice to all Patients:

{patientName}, 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: 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 per test or appointment. This is not a covered medical insurance benefit and will be payable to the office directly by the patient.
I {patientName}, 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 at Premier Heart’s Office or at the Hospital with Dr. Kernis.
Financials:

Copays and deductibles 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 refill.

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.
Signature/ Legal Representative:*

Clear
Date:*

MonthDayYear
Date

Medical Information Communication Preferences

Please indicate your communication preferences below:

Method

HIPAA Notice of Privacy Practices Acknowledgement Form

Patient Release

Authorization for Release of Information