New Patient Forms

Person Number
NEW PATIENT INSTRUCTIONS

This information is provided to assist you in preparing for your initial appointment with us at Center for Vascular Medicine (CVM).

Please complete the following documents prior to your visit and bring them with you. This will help expedite the registration process.
1. Patient Demographics Form - This includes your personal and insurance information for us to register you with our practice.
2. Patient Medical Information - This captures your pertinent medical history and health information; please document all medications and supplements you may be taking at this time and any allergies you may have.
3. Patient Privacy and HIPAA Protection Form - This explains our compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy regulations, and that our Notice of Privacy Practices is available for review. We require your acknowledgement of certain authorizations and consents.
4. Photograph/Video Release Form - This outlines our policy regarding the use of photography and videography during your medical appointment.
5. Referral Remittance Agreement Form - This outlines the important information about referrals. We require your acknowledgement of company policy if an insurance referral is needed for your appointment.
Most importantly, when you come for your visit, please be sure to bring the following documents as we need copies of them for our records:
- A photo ID, such as: Driver's License, State ID, Military ID, etc.
- Your current insurance card(s)
- Your referral slip from your Primary Care Physician (if required by your insurance plan)
Note: Your initial consultation and scan will take approximately two hours, so please plan accordingly. Please drink plenty of fluids, dress warmly, and bring loose-fitting shorts (if possible) to facilitate your examinations.

We look forward to seeing you at our office soon. If you have any questions or need any assistance regarding the above information, please do not hesitate to contact us at any time on (301) 486-4690.
Your appointment is on:

MonthDayYear
at
At our CVM office in:
PATIENT DEMOGRAPHICS

PATIENT INFORMATION - (Please Complete All Fields)
Name

First NameLast Name
Middle Initial
BIRTH DATE

MonthDayYear
Date
BIRTH SEX
Address

STREET ADDRESS

Street Address Line 2

CITYSTATE

ZIP
Please take a photo of your ID:
FRONT of ID
HOME PHONE
Format: (000) 000-0000.
CELL PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
WORK PHONE
Format: (000) 000-0000.
MARITAL STATUS
RACE / ETHNICITY
PREFERRED LANGUAGE
Please enter your preferred language
EMERGENCY CONTACT PERSON
RELATION
EMERGENCY CONTACT NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
PRIMARY CARE PHYSICIAN (PCP)

First NameLast Name
PCP ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP ADDRESS
PCP PHONE
Format: (000) 000-0000.
PCP FAX
Did your PCP refer you to us?
REFERRING SPECIALITY
REFERRING PHYSICIAN

First NameLast Name
REFERRING ADDRESS
REFERRING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
REFERRING PHONE
Format: (000) 000-0000.
REFERRING FAX
Would you like your records sent to another healthcare provider?
ADDITIONAL REFERRING SPECIALITY
ADDITIONAL REFERRING PHYSICIAN

First NameLast Name
ADDITIONAL REFERRING ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ADDITIONAL REFERRING PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
ADDITIONAL REFERRING FAX

EMPLOYER INFORMATION
EMPLOYER NAME
EMPLOYER ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMPLOYER ADDRESS
PHONE
Format: (000) 000-0000.

Patient Primary Insurace
INSURANCE NAME
Are you the policy holder?
POLICY HOLDER
POLICY HOLDER DOB

MonthDayYear
Date
RELATIONSHIP TO PATIENT
POLICY NUMBER
GROUP NUMBER
SPECIALIST COPAY AMOUNT
POLICY HOLDER EMPLOYER
DO YOU HAVE A SECONDARY INSURANCE?
SECONDARY INSURANCE
INSURANCE NAME
POLICY HOLDER
POLICY HOLDER DOB

MonthDayYear
Date
RELATIONSHIP TO PATIENT
POLICY NUMBER
GROUP NUMBER
SPECIALIST COPAY AMOUNT
POLICY HOLDER EMPLOYER
Please take a photo of your insurance card:
FRONT of card
BACK of card
SIGNATURE OF PATIENT / GUARDIAN
DATE SIGNED

MonthDayYear

Patient Consent, Assignment of Benefits and Acknowledgement
Patient Name:
DOB:
Please read and acknowledge the following consents, assignment, and authorizations.

Consent for Diagnostic, Medical and/or Surgical Treatment: I wish to be evaluated and treated by the Center for Vascular Medicine (CVM I hereby agree and give my consent to the providers/staff of CVM to order, prescribe and provide diagnostic, medical, and surgical treatment to me that they judge is appropriate in diagnosing and/or treating my medical condition(s).

Assignment of Insurance Benefits and Authorization to Pay Insurance Benefits: I authorize CVM to apply for benefits for services rendered to me or the patient under my health insurance policies providing benefits. I assign and authorize payment of benefits from my insurance plan(s) to CVM and grant permission to contact my employer or health plan(s) regarding insurance information and coverage of my health benefits.

No Show/Cancellation Policy: To accommodate scheduling of patient care and provide timely appointments, our practice has a No Show/Cancellation Policy. Any missed or no-show appointments for diagnostic scans or visits that are not canceled 24 hours prior to the appointment time may be charged a $35.00 fee. Our office reserves time for your care in good faith; please extend the same courtesy by contacting our office at least 24 hours prior to your appointment time to cancel or reschedule an appointment - Thank You.

Patient Financial Agreement and Payment Policy: I understand that CVM will bill my health insurance plan(s) for care I receive. I agree that payments from my health plan(s) will go directly to CVM. I understand that CVM can bill me directly when: (1) I choose to have care that my health plan covers but I do not secure needed referral or an approval for the care from my health plan; (2) I choose not to use my health coverage and agree to pay for the care myself; (3) CVM does not participate with my health plan and I agree to pay for 'out-of-network' care; (4) I receive care for service(s) or supplies that are non-covered by my health plan(s); or (5) I am uninsured and agree to pay for the medical services rendered to me at the time of service. I further agree to pay for all related collection costs related to my financial responsibility.

Authorization to Release Records: I hereby authorize Center for Vascular Medicine to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization, or referral to other medical provider.

Individual Financial Responsibility: I understand that I am financially responsible for my health insurance, deductible, coinsurance, and noncovered service.

I understand and agree to the above consents, assignments, and authorizations: (Please sign and date below:)
SIGNATURE OF PATIENT / GUARDIAN
DATE

MonthDayYear
Date

HIPAA Policies
HIPAA permits CVM to discuss information with your family to others involved in your care or payment. To protect your information, please enter the names of specific individuals that you want to grant access to in the table below. Your healthcare providers are automatically included.
"Designee" - Print Name:   First Name   Last Name   Relationship to Patient:   Relationship   Contact Phone:       Phone Number

"Designee" - Print Name:   First Name   Last Name   Relationship to Patient:   Relationship   Contact Phone:      Phone Number

"Designee" - Print Name:   First Name   Last Name   Relationship to Patient:   Relationship   Contact Phone:      Phone Number
Patient Care Communication Methods - Mail, Email, Text, Phone and Online Portal

HIPAA allows CVM to communicate with patients related to their care through the mail, emails, text, and phone. We also encourage patients to access secure Patient Portal to access your account information and send messages to CVM staff. If you would like to discontinue or "opt-out" of a specific method, please inform CVM staff of your preferences.

I give permission for messages to be left at the following contact methods:

Rows	Yes	No
Cell Phone
Home Phone
Work Phone

Preferred Contact Method
Notice of Privacy Practices

We use information that you provide us, including health information, to carry out treatment, payment, and operations. Please refer to our "Notice of Privacy Policy" for a more complete description. You have the right to review the notice before signing. The terms of our Privacy Policy may change. You may obtain a revised notice from our office by calling (301) 486-4690. You have the right to restrict the use of your health information to carry out treatment, payment, or health care operations. We are not required to agree to the restriction. If we do agree to any restrictions, the agreement is binding to us. You have the right to revoke this consent at any time by notifying us in writing. Our address is as follows: 7500 Greenway Center Drive Suite 201, Greenbelt, MD 20770. I hereby consent to The Center for Vascular Medicine contacting my physician's office to release pertinent information for future follow-up care. I hereby consent to the use and disclosure of my individually identifiable health information for treatment, payment, and operations.
SIGNATURE OF PATIENT / GUARDIAN
DATE

MonthDayYear
Date

Photograph / Video Release:
I,   First Name*   Last Name*   hereby acknowledge and agree to the following terms regarding the use ofphotography or videography during my medical appointment:

1. I understand that the medical consultation and treatment provided to me are confidential and protected by privacy laws.
Initials:  Initials*

2. I consent for medical photographs and/or video to be taken of me by staff at The Center for Vascular Medicine. I understand that the information may be used in my medical record, for purposes of medical teaching, or for publication, as well as to ensure patient safety. By consenting to these medical photographs and/or video, I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that some may recognize me.
Initials: Initials*

3. I agree not to take any photographs or videos during my medical appointment without explicit consent from all individuals present, including healthcare providers and staff.
Initials:  Initials*

4. I understand that the unauthorized capture of visual or audio recordings during my medical appointment could compromise the privacy and confidentiality of other patients, healthcare providers, and staff members.
Initials:  Initials*

5. I acknowledge that any violation of this agreement may result in termination of my medical appointment and potential legal consequences.
Initials:   Initials*

By signing below, I confirm that I have read and understood the terms outlined in this consent form regarding the use of photography and videography during my medical appointment.
Signature of Patient / Guardian
Date

MonthDayYear
Date

Referral Remittance Agreement
Important information about referrals

Referrals need to come from your current PCP if you want your plan to cover or help pay for your care when:
- In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don't get a referral first, the plan may not pay for the services.
- A specialist refers you to another specialist.
- You're going to see a specialist who's not in your plan's network.
- You were seeing a specialist before enrolling in an HMO plan and you want to continue seeing that specialist.
- You change your PCP while getting care from a specialist; your new PCP may need to issue a new
Some other things you should know about referrals:
- Referrals expire. You'll have anywhere from 90 days to one year to see the doctor you were referred to, depending on the specialty.
Please initial all the following* If your current insurer does not require an insurance referral, you can omit your initials below. However, we do require a dated signature to acknowledge your understanding of CVM's policy if your insurer changes and requires a referral.
1. I am aware that my insurance provider Insurance Name* requires a referral from my primary care physician for all specialist services. Initial*
2. I agree to obtain a referral for all services rendered on Date*. Initial*
3. I am aware that I will be held financially responsible for services rendered on Date* if I do not supply the required referral. *Services rendered will be subject to CVM's self-pay discount of $240.00. Initial*
Print Name

First NameLast Name
Signature
Date

MonthDayYear
Date

Referral Disclosure Form
You have been referred to the Center for Vascular Medicine for the evaluation and treatment of venous disease.Attached is a list of practices in the area that provide these services. You have the right to receive care from any practiceand at any location of your choosing. You are not required to select a practice from the list provided. We will be pleasedto assist you with scheduling an appointment at the practice you choose.

Please be aware that two physicians who are owners of Center for Vascular Medicine, LLC, Sanjiv Lakhanpal,M.D., and Khanh Nguyen, D.O., also have ownership interests in Center for Vein Restoration, LLC, and therefore derivefinancial benefit from patients receiving services at that practice.

I have read the foregoing statements and have received a copy of the attached list of practices. I understandthat I have the right to have health care services at any practice I choose.
Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

PATIENT DEMOGRAPHICS

EMPLOYER INFORMATION

Patient Primary Insurace

PATIENT MEDICAL INFORMATION

Medications

Allergies

Social History

Past Family History

HEART DISEASE

Patient Consent, Assignment of Benefits and Acknowledgement

HIPAA Policies

Photograph / Video Release:

Referral Remittance Agreement

Referral Disclosure Form