capitalcardiaccare.com - Patient Registration Form

PATIENT REGISTRATION FORM
PATIENT NAME

First NameMiddle NameLast Name
DATE OF BIRTH

MonthDayYear
Date
HOME ADDRESS

HOME ADDRESS

APT. NO.

CITYZIP CODE

STATE
OCCUPATION

EMPLOYEDRETIREDSTUDENT
SOCIAL SECURITY #
MARITAL STATUS

SINGLEMARRIEDWIDOWEDDIVORCED
SEX

MALEFEMALE
HOME PHONE
Please enter a valid phone number.
EMPLOYER
EMPLOYER’S ADDRESS
EMAIL
example@example.com
CELL #
Please enter a valid phone number.
WORK #
Please enter a valid phone number.
SPOUSE (OR PARENT) NAME
SPOUSE (OR PARENT) EMPLOYER
SPOUSE / PARENT WORK PHONE:
Please enter a valid phone number.
REFERRING DOCTOR NAME:
REFERRING DOCTOR PHONE:
Please enter a valid phone number.
PATIENT AUTHORIZATION
I, Name , hereby authorize, Pankaj Lal MD PC. to apply for benefits on my behalf for covered services rendered. I request payment from BC/BS National Capital Area, Blue Shield of Maryland, Medicare, and / or (Name of other insurance company) Insurance Company, be made directly to the above named provider (or in case of Medicare Part B benefits, to myself or the party who accepts assignment).

I certify that the information I have reported with regarded to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim, to the above named billing agent, (or in the case of Medicare Part B benefits, to the Social Security Administration and Health Care Financing Administration) and / or the insurance company named above. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by either me or the above named carrier at any time in writing.

I request that payment of authorized Medigap benefits be made either to me or on my behalf to the above named provider for any services furnished me by that physician / supplier. I authorize any holder of medical information about me to release to (Name of Medigap Carrier) any information needed to determine these benefits payable for related services.
SIGNATURE OF SUBSCRIBER OR BENEFICIARY

Clear
DATE

MonthDayYear
Date

HIPAA NOTICE ACKNOWLEDGEMENT
We are required by law to maintain the privacy of, and provide individuals with the notice of our legal duties and privacy practices with respect to protected health information (PHI).

Your signature below is an acknowledgement that you have read our HIPAA Notice of privacy practices.

I hereby understand and accept that as per HIPPA policy. NO medical information or records will be released to any person other than myself without my written consent and authorization.
Name
Date

MonthDayYear
Date
Signature

Clear
If you would like an authorized person (family or friends) to have access to your medical information, please fill in below. Otherwise, write ‘self.’
Name
Relationship
Phone Number
Please enter a valid phone number.
Should be Empty:

	YES	NO
1. CHEST PAIN, PRESSURE, DISCOMFORT, HEAVINESS
2. SHORTNESS OF BREATH
3. PALPITATIONS (SKIPPED OR RACING HEARTBEAT)
4. DIZZINESS, FAINTING
5. NUMBNESS, TINGLING IN HANDS OR FEET
6. LEG OR CALF PAIN WHEN WALKING
7. ANKLE SWELLING (FLUID RETENTION)

	YES	NO
1. ANGINA
2. CORNOARY ARTERY DISEASE (BLOCKED ARTERIES)
3. HEART ATTACK
4. HEART FAILURE (WEAKNESS OF THE HEART MUSCLE)
5. ARRHTHMIA (IRREGULAR HEARTBEAT)
6. LEAKING OR NARROWED HEART VALVE
7. ANEURYISM (DILATED OR LEAKING BLOOD VESSEL
8. HIGH CHOLESTEROL
9. HIGH BLOOD PRESSURE (HYPERTENSION)
10. DIABETES
11. ASTHMA OR EMPHYSEMA
12. BLOOD CLOTS IN LEGS OR LUNGS

PATIENT REGISTRATION FORM

PATIENT AUTHORIZATION

PATIENT MEDICAL INFORMATION

HIPAA NOTICE ACKNOWLEDGEMENT