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SlideShare utilise les cookies pour améliorer les fonctionnalités et les performances, et également pour vous montrer des publicités pertinentes. Si vous continuez à naviguer sur ce site, vous acceptez l’utilisation de cookies. Consultez notre Politique de confidentialité et nos Conditions d’utilisation pour en savoir plus.
WELCOME TO BROWNSBORO CARDIOLOGY
STEVEN FILARDO, M.D. SYED RAZA, M.D.
Patient Name: _________________________________ Date of Birth: ______/______/______
Street City State Zip Code
Home Phone#: ( ) Cell#: ( )
Social Security Number: Sex: Female Male
Employer: Work Phone#: ( )
Marital Status: Single Married Divorced Widowed
If married, spouse’s name: ______________________________________________________
Spouse’s employer: ___________________________________________________________
Do you have a Living Will? Yes No Do you have a Power of Attorney? Yes No
If yes, who? _________________________________________________________________
Emergency Contact: _______________________________ Relationship: __________________
Home# :( ) Cell# :( ) Work# :( )
Primary Insurance Secondary Insurance
Policy Number Policy Number
Group Number Group Number
Insured’s DOB Insured’s DOB
Referring Physician: _______________________________ Phone# :( )
Primary Care Physician: _____________________________ Phone# :( )
Other Physicians involved in your care: _____________________________________________________
Pharmacy Name: _____________________________ Phone Number ( )__________________
NEW PATIENT MEDICAL HISTORY
Patient: _________________________________________ Date of Birth: _____________
Medical History: Check box if you have ever had any of the following:
Asthma Gallstones Stroke
Angina/Chest Pain Heart Attack Thrombophlebitis
Anemia Heart Murmur Thyroid Disease
Arthritis Headaches Tuberculosis
Glaucoma Hepatitis Ulcers
Cancer High Blood Pressure Other – Please List Below
Chronic Bronchitis High Cholesterol
Cirrhosis HIV positive/AIDS
Clotting Disorder Kidney Disease
Diabetes Kidney Stones
Epilepsy Positive TB Test
Fractures Rheumatic Fever
If any blood relativehas ever had any of the following,please
check box and indicaterelationship.
Pleaseindicatethe age and either
L or D for each of the following: Age
L = Living
D = Deceased
Bleeding Tendency Father
High Blood Pressure
Operations and/or Hospitalizations: List below with approximate date:
Reason Date Reason Date
Allergies to Medications: ________________________________________________________
Review of Symptoms
Check box if you have any of the following symptoms:
Respiratory Cardiology General
shortness of breath chest pain weight gain
congestion palpitations weight loss
cough varicose veins loss of appetite
short of breath on exertion sweating fevers
Endocrine fluttering sensation fatigue
heat intolerance Ophthalmology
difficult or painful urination
blood in urine
difficulty with erection
blurring of vision
loss of vision
Smoking Packs Daily? ______ Coffee: Cups Daily _________ Sleep: Snoring Y N
How Long? _______ Other Caffeine : ____________ Daytime Drowsiness Y N
Interested in stopping? Y N Alcohol: Type ____________ Difficulty Falling Asleep Y N
If you quit, when did you quit? Frequency ________ Continuity Disturbances Y N
___________________________ Amount __________ Early Morning AwakeningY N
How long did you smoke? Diet: Salt Intake ________ Other _______________________
____________________________ Fat Intake ________ ____________________________
Do you exercise routinely? Y N What do you do for exercise? _____________________________
Have you ever used illegal drugs? Y N If so, what drugs? ______________________________
MEDICAL INFORMATION AUTHORIZATION
Patient Name ____________________________________ Date of Birth ______/______/______
I authorize the personnel of Dr. Steven Filardo & Dr. Syed Raza to release all medical information to my
family members and friends listed below.
I may revoke this authorization by phone or in writing at any time.
Name Relationship to patient Phone Number(s)
Permission to leave a message on an answering machine or voice mail Yes No
Patient Signature Today’s Date
Witness signature (other than family) Today’s Date
9501–A Norton Commons Blvd
Prospect, KY 40059
Acknowledgement of Receipt of Privacy Notice
I have received the Brownsboro Cardiology Notice of Privacy Practices. I understand that my
protected health information may be used as described in the notice.
Patient Name Date of Birth
Patient Signature Today’s Date
In order to comply with new government guidelines, we will be submitting prescriptions
electronically to pharmacies as much as possible. This will be of tremendous benefit to
everyone involved. This will not only ensure proper medications and dosages are submitted
to the pharmacy, but will also decrease the number of lost prescriptions and medication errors.
Any prescription data transmitted will be used only for the express purpose of prescription
filling and submission of the necessary codes to the insurer for payment.
I understand purpose of electronic prescriptions and agree that my prescriptions may be
Signature Today’s Date
Authorization and Release for All Patients I permit a copy of this authorization to be used in place of the original.
I understand that:
Billing for Brownsboro Cardiology will be processed through Steven D. Filardo, M.D. of Preferred
Cardiology of Kentuckiana or from Syed Raza, M.D. of Kentuckiana Heart Doctors.
As the patient, I am responsible for the bill, regardless of any insurance coverage, and that all
balances are due upon receipt of the bill.
If I have an office visit co-pay, it is due at the time of the service.
I will be charged a $25.00 returned check fee if my bank returns my check to Preferred Cardiology of
Kentuckiana or Kentuckiana Heart Doctors.
I will be charged a $25.00 for a missed office appointment, $35.00 for a missed echocardiogram, and
$100.00 for a missed stress test if not cancelled 24 hours in advance. If I repeatedly fail to show for
or cancel appointments, I may be asked to find another physician. Preferred Cardiology of
Kentuckiana and Kentuckiana Heart Doctors are required to pay in advance for the technician and
medication used for these tests.
Use of this form on all my insurance submissions and release of information to my insurance
The doctor to act as my agent in helping to obtain payment from my insurance company(ies).
Release of protected health information regarding services rendered by physicians and employees
of Preferred Cardiology of Kentuckiana or Kentuckiana Heart Doctors.
If my insurance company requires an authorization to be seen by or have services performed by the
physician, I understand that is my responsibility to obtain this authorization from the insurance company.
It is not the responsibility of Preferred Cardiology of Kentuckiana or Kentuckiana Heart Doctors or the
hospital to obtain the authorization from the insurance company. If payment is denied by my insurance
company because of my failure to obtain this authorization, I am financially responsible for payment.
In the event that my account is turned over to collections for non-payment, I understand that in addition to
the balance of my account, I am responsible for the cost of placing my account with the collection agency,
plus any and all court costs that may ensue.
Additional Authorization only for Medicare Patients:
I request that payment of authorized Medicare benefits are made to Preferred Cardiology of Kentuckiana
or Kentuckiana Heart Doctors for any services furnished me by that physician or supplier. I authorize any
holder of medical information about me to release to the Health Care Financing Administration and its
agents any information needed to determine these benefits or the benefits payable and related services. I
understand my signature requests that payment be made and authorizes release of medical information
necessary to pay the claim. If “other health insurance” is indicated in Item 9 of the HCFA-1500 form,
elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes
release of the information to the insurer or agency shown.
In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the
Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and
the non-covered services. Coinsurance and the deductibles are based upon the charge determination of the
X__________________________________ ___________________________ _____/______/_____
Signature of Patient Printed Patient Name Date Signed