CARDIOLOGY CARE CENTER, PA
1355 S. INTERNATIIONAL PARKWAY, SUITE 1481
LAKE MARY, FL 32746
Dear New Patient:
Welcome to Cardiology Care Center. We look forward to meeting you in our office, and
we will endeavor to provide the highest quality medical care together with compassion
As a new patient, we ask you to complete the enclosed information sheets
which will be held in the strictest confidence and bring them to your
scheduled appointment on ________________________ at __________
Please bring your insurance cards, driver’s license and a list of your
medications. If you have an insurance co-pay, it will be collected at the time
J.B.BITAR, M.D., FACC
MAGDA E. SANCHEZ-VELEZ, M.D.FACC
CARDIOLOGY CARE CENTER
Medical History Addendum
HAVE YOU EVER RECEIVED TREATMENT FOR? IF YES, EXPLAIN
Mental Illness ___ Yes ___ No
HIV Positive/AIDS ___ Yes ___ No
Sexually Transmitted Disease(s) ___ Yes ___ No
Alcohol Abuse ___ Yes ___ No
Illicit Drug Use ___ Yes ___ No
Are you currently pregnant & under age 18___ Yes ___ No
If you have answered YES to any of the above, please initial the corresponding categories listed
below which will authorize Cardiology Care Center to disclose that information to third parties
for treatment or payment purposes in the event that it is requested by said third parties or
required by law.
Initials ______ Mental Illness Information
Initials ______ HIV/AIDS Information
Initials ______ Sexually Transmitted Diseases(s) Information
Initials ______ Alcohol Abuse Information
Initials ______ Illicit Drug Use Information
Initials ______ Pregnancy Information, if patient is under the age of eighteen(18)
I HAVE READ AND UNDERSTAND THE INFORMATION IN THIS CONSENT. I
AM THE PATIENT OR AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO
SIGN THIS DOCUMENT VERIFYING CONSENT TO THE ABOVE STATED
By signing below, I acknowledge and agree to the above conditions. Date_______________
Signature of Patient (or Authorized Representative) Print Name of Patient (or Authorized Representative)
Please explain Representative’s relationship to Patient and include a description of Representative’s authority to
act on behalf of Patient.
Office Use Only:
Authorization added to patient’s medical record on _________________by____________________________.
Cardiology Care Center
1355 S. International Pkwy, Ste 1481
Lake Mary, FL 32746
Please PRINT and answer ALL questions
Name (Last) ( First) (MI)
Social Security#__________________________ Birth Date _________________________ Sex: (M)
Mailing Address City State Zip
Telephone number to contact patient for appointments, test or lab results,
(H) (W) (Cell)______________________Other no.(H) (W)
Marital Status: (M) (S) (D) (W) Spouse
Spouses Work No._________________________Patient E-Mail
Referring Physician _____________________________Primary
Primary Insurance ___________________Policy No.____________________Group
Secondary Insurance__________________Policy No._____________________Group
Policy Holder _______________________SS#_________________________Birth
Emergency contact __________________________________Phone______________________
We reserve the right to charge for telephone calls and missed appointments._________(INITIAL)
I certify the information that I have provided is correct. I authorize the release of medical information
necessary for Treatment, Payment and Healthcare Operations. I authorize payment of medical benefits to
the provider. I acknowledge that interest or a fee, at the provider’s current rate, may be charged on all
balances owing to the provider that are past due.
(Insured or authorized patient or parent of a minor)
New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or
I, ___________________, understand that as part of my healthcare Cardiology Care Center
originates and maintains paper and/or electronic records describing my health history, symptoms,
examination and test results, diagnoses, treatment and any plans for future care of treatment. I
understand that this information serves as:
A basis for planning my care and treatment,
A means of communication among the many health professionals who contribute
to my care.
A source of information for applying my diagnosis and surgical information to my
A means by which a third-party payer can verify that services billed were actually
A tool for routine healthcare operations such as assessing quality and reviewing
the competence of healthcare professionals.
I understand and have been provided with a Notice of information Practices that provides a more
complete description of information uses and disclosures. I understand that I have the following
rights and privileges:
The right to review the notice prior to signing this consent,
The right to object to the use of my health information for directory purposes,
The right to request restrictions as to how my health information may be used or
disclosed to carry our treatment, payment or health care operations.
I understand that Cardiology Care Center is not required to agree to the restrictions requested. I
understand that I may revoke this consent in writing, except to the extent that the organization
ha already taken action in reliance thereon. I also understand that by refusing to sign this consent
or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506
of the Code of Federal Regulations.
I further understand that Cardiology Care Center reserves the right to change its notice and
practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal
Regulation, should Cardiology Care Center change their notice, it will send a copy of any revised
notice to the address I’ve provided.
I wish to have the following restrictions to the use or disclosure of my health information:
My health information may be disclosed to the following persons or organizations, and I
understand that they are not subject to the same Federal privacy rules and may disclose
information without obtaining my permission.
I understand that as part of this organization’s treatment, payment or health care operations, it
may become necessary to disclose my protected health information to another entity, and I
consent to such disclosure for these permitted uses, including via fax and e-mail.
I fully understand and accept/decline the terms of this consent.
Patient’s Signature Date
( ) Consent received by ________on________ ( ) Consent/treatment refused by patient
( ) Consent added to the patient’s medical records on ______________
OUR FINANCIAL POLICY
THANK YOU FOR CHOOSING US AS YOUR CARDIOLOGY SPECIALIST. WE ARE COMMITTED TO
PROVIDING YOU WITH THE BEST POSSIBLE MEDICAL CARE. IN ORDER TO ACHIEVE THIS GOAL, WE
NEED YOUR ASSISTANCE AND YOUR UNDERSTANDING OF OUR PAYMENT POLICY. THE
FOLLOWING IS A STATEMENT OF OUR FINANCIAL POLICY, WHICH WE REQUIRE YOU TO READ AND
SIGN PRIOR TO ANY TREATMENT.
• ALL PATIENTS MUST COMPLETE OUR INFORMATION AND INSURANCE FORM BEFORE
SEEING THE DOCTOR.
• FULL PAYMENT IS DUE AT TIME OF SERVICE.
• WE ACCEPT CASH, CHECKS, MASTERCARD AND VISA
• RETURNED CHECKS ARE SUBJECT TO A $29.00 SERVICE CHARGE.
HEALTHCARE INSURANCE PLAN OBLIGATION:
OUR CARDIOLOGY OFFICE MAINTAINS A LIST OF THE HEALTH CARE SERVICE PLANS WITH WHICH
IT HAS CONTRACTED TO PROVIDE MEDICAL SERVICES. WE HAVE AGREED TO BILL THOSE
INSURANCE CARRIERS FOR ALL SERVICES RENDERED. AUTHORIZATION FROM YOU INSURANCE
DOES NOT ALWAYS GUARANTEE PAYMENT. THE UNDERSIGNED AND/OR PATIENT SHALL REMAIN
RESPONSIBLE FOR ALL CHARGES, APPLICABLE CO-PAYMENT AND DEDUCTIBLES IF YOUR
INSURANCE HAS NOT RESPONDED TO OUR CLAIMS SUBMITTAL WITHIN 60 DAYS. PAYMENT FOR
SERVICES INCURED AND CLAIM STATUS FOLLOW-UP WITH THE INSURANCE CARRIER BECOMES
THE PATIENT’S RESPONSIBILITY.
ALL FEES ARE DUE IN FULL AT THE TIME OF SERVICE. A RECEIPT IS PROVIDED WHICH DETAILS
ALL SERVICES AND PAYMENT FOR THE VISIT. A COPY OF THE RECEIPT CAN BE SUBMITTED TO
YOUR INSURANCE CARRIER FOR PAYMENT.
PPO/HMO/MEDICARE/TRAIDITIONAL WAIVER REGARDING NON-COVERED PATIENT:
MEDICARE UNDER SECTION 1862(A)(1) OF THE MEDICARE LAW AND SOME HEALTH INSURANCE
PLANS WILL ONLY PAY FOR SERVICES THAT DETERMINES TO BE “REASONABLE & NECESSARY”. IF
MEDICARE DETERMINES THAT A PARTICULAR SERVICE IS NOT REASONABLE AND NECESSARY
UNDER THE MEDICARE PROGRAM STANDARDS, OR YOUR INSURANCE DETERMINES THAT A
SERVICE WAS UNAUTHORIZED OR NOT A COVERED BENEFIT UNDER YOUR PLAN, MEDICARE OR
OTHER INSURANCE PLANS WILL DENY PAYMENT FOR THIS SERVICE. WE BELIEVE THAT
ACCORDING TO YOUR INSURANCE PLAN, PAYMENT IS OFTER DENIED FOR THE FOLLOWING
• COPIES OF MEDICAL RECORDS
• CERTAIN LAB TESTS
• OUT OF NETWORK REFERRALS
• PRE-EXISTING CONDITIONS
THE UNDERSIGNED AND/OR PATIENT UNDERSTANDS AND AGREES TO BE PERSONALLY AND FULLY
RESPONSIBLE FOR NON-COVERED SERVICES. OUR PRACTICE IS COMMITTED TO PROVIDING THE
BEST TREATMENT FOR OUR PATIENTS.
THERE IS A $25.00 FOR MISSED APPOINTMENTS UNLESS CANCELLED AT LEAST 24 HOURS IN ADVANCE.
PLEASE HELP US SERVE YOU BETTER BY KEEPING YOUR APPOINTMENT. SHOULD COLLECTIONS
BECOME NECESSARY; THE PATIENT WILL BE RESPONSIBLE FOR ALL COLLECTION COST AND
ATTORNEY’S FEES. THANK YOUFOR UNDERSTANDING OUR FINANCIAL POLICY. PLEASE LET US
KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNS.
I HAVE READ THIS FINANCIAL POLICY AND UNDERSTAND AND AGREE TO THIS FINANCIAL POLICY.
SIGNATURE OF PATIENT OR RESPONSIBLE PARTY
Advance Directive Acknowledgement
Please check one of the following Statements:
I Have Executed an Advance Directive
A Living Will
Designation of a Health Care Surrogate
Durable Power of Attorney
Name of Designee: _____________________________________
(Please bring a copy of any of the above documents for our records.)
I Have NOT executed an Advance Directive, a Living Will, Durable Power of Attorney,
Designation of a Health Care Surrogate.
I AM interested in executing an Advance Directive
I AM NOT interested in executing an Advance Directive
Signature: ______________________________________ Date: __________________
Our notice of Privacy Practices provides information about how we may use and release
protected health information about you. You have the right to review our Notice before
signing this form. As provided in our Notice, the terms of our Notice may change. If we
change our Notice, you may obtain a revised copy by writing our practice or requesting a
copy from our front desk staff.
You have the right to request that we restrict how protected health information about you
is used or released for treatment, payment or health care operations. We are not required
to agree to this restriction, but if we do, we are bound by our agreement.
By signing this form, you consent to our use and release of protected health information
about you for treatment, payment and health care operations as described in our Notice.
You have the right to revoke this consent, in writing, except where we have already made
releases in reliance on you prior consent.
OFFICE USE ONLY
I attempted to obtain the patient’s signature in acknowledgement on this Notice of
Privacy Practices Acknowledgement, but was unable to do so as documented
Date: Initials: Reason: