Please complete the enclosed forms:

Transcription

1 The Future Of Cardiology Is Here A Proj'>$J'Jollt?1 Association managed by CardlOOf'l5L'l1iar Providt'r Rt'$()l1rcl's John R. Bret, M.D., F.A.e.e. L. Keith Routh, M.D., FAe.e., F.S.e.A.I. Peter A. Frenkel, M.D., FAe.e. Brent Patterson, M.D. Dear Patient, In an effort to adhere to your appointment time we are sending you the enclosed paperwork in advance. Please bring the completed forms along with all of your prescription bottles to your appointment. Please do not fax or mail the paperwork. For your initial visit, we ask that you arrive minutes prior to your scheduled appointment time. Pertinent medical records from other physicians would also be helpful. You will be expected to provide our receptionist with your insurance card and driver's license when you check in for your appointment. We do not call employers, human resource departments, spouses or parents to obtain insurance information. If your insurance requires a referral, our office must have it prior to your appointment. Please be prepared to pay your co-payments/co-insurance or deductibles at the time of your visit. If you have any questions regarding benefits, contact your insurance company. We accept cash, checks, Mastercard, Visa, American Express or Discover. Thank you for taking the time to complete the enclosed forms. We look forward to servmg you. Sincerely, Heartplace Garland Please complete the enclosed forms:./ Patient information./ Patient medical history./ Hipaa Authorization for use or release (Please include any person's name that you would like to give access to your medical information.) 700 Walter Reed Boulevard Suite 208 Garland, TX (972) Fax (972)

2 North Shiloh Road Miles Baylor Garland Campus Map A Westwood Drive This campus map identifies the facilities within our area: medical office buildings, physician offices and outpatient treatment locations. A map of the hospital is included on the reverse side. Physician Information Address Suite Phone Finding Your Way at Baylor Garland B C Walter Reed Boulevard D E G F Welcome to Baylor Medical Center at Garland. This brochure features three maps to assist you in locating areas of interest. The area map below shows the location of Baylor Garland in relationship to cities, major freeways and streets. Marie Curie Boulevard J If you need further assistance, check at the information centers within the hospital, or ask any member of the Baylor Garland team. K A B C D 900 North Shiloh Road (Diabetes Education Center) 800 North Shiloh Road (Baylor Senior Health Center) Medical Plaza II 777 Walter Reed Boulevard (Wound Care Center) 760 North Shiloh Road E F G H Clara Barton Boulevard West Walnut Street Pickett Hartman Annex 705 Walter Reed Boulevard (Outpatient Rehabilitation) Baylor Medical Center at Garland 2300 Marie Curie Boulevard Medical Plaza I 700 Walter Reed Boulevard H I J K L M I Medical Plaza III 601 Clara Barton Boulevard Medical Plaza IV 530 Clara Barton Boulevard 618 Clara Barton Boulevard 2241 Peggy Lane 2231 Peggy Lane 2225 Peggy Lane Peggy Lane L M 2300 Marie Curie Garland, Texas (972) BaylorHealth.com Parking Areas Streets Campbell Arapaho Belt Line Buckingham Walnut Forest Miller Jupiter Shiloh Hwy. 190 N. Garland N. Garland S. Garland Saturn I-635 First St. Lavon Garland Broadway Duck Creek Centerville Northwest Hwy. Pleasant Valley Mesquite Sachse Hwy. 66 Miller Sachse Rd. I-30 Rowlett Rd. Rowlett Wylie Lakeview Dalrock Sunnyvale 2009 Baylor Health Care System. All rights reserved. DH_BMCGAR_305_FY2009

3 Baylor Garland Hospital Map This hospital map is a detailed guide to the medical center; it will be particularly useful if you are visiting someone. A campus map and additional information is included on the reverse side. Women's Center Entrance Patient Information Patient s Room Number Floor/Elevator Patient s Telephone Number Medical Plaza I Entrance Free Valet Parking Labor & Delivery Women s Center North Hall Medical Staff Services Temporary Emergency Entrance West Hall Human Resources Administration/ Nursing Administration Social Services Gift Shop Billing & Cashier Snack Bar Admitting & Registration i Cath Lab Main Hall Respiratory Outpatient Radiology Medical Imaging A.M. Admit/ Surger y Temporary Emergency Check-in Service Elevator Main Elevator Emergency Main Entrance Free Valet Parking Laboratory Surgery Waiting i Patient Towers East Hall East Elevator East Entrance Key Telephone Numbers Administration (972) Admitting and Registration (972) A.M. Admit (972) Breast Center (972) Billing Inquiry (214) Cafeteria (972) Hours: 6:30 a.m. 6:30 p.m. Breakfast: 6:30 a.m. 10:30 a.m. Lunch: 11:00 a.m. 2:00 p.m. Dinner: 4:00 p.m. 6:30 p.m. Chaplain Dial 0 Digestive Disease Center (972) Diabetes Education (972) Gift Shop (972) Guest Relations (972) Heart and Vascular Center (972) Hospital Operator Dial 0 Information Desk (972) Insurance Assistance (972) Outpatient Scheduling (972) Physician Referral Service BAYLOR Radiology (972) Senior Center (972) Sleep Center (972) Social Services (972) Supervisor (Nursing Administration) (972) Support Services and Education Classes (Information) BAYLOR Surgery (972) Volunteer Services (972) Women s Center (972) Wound Center (972) Baylor Breast Center Elevator to Physician Offices Baylor Medical Plaza I Basement Main Elevators Cafeteria Service Elevators Cafeteria Medical Records First Floor Elevators i Information Restrooms Second Floor Main Elevators Chapel Heart and Vascular Center Intensive Care Pastoral Care East Elevators Rooms Third Floor Main Elevators Rooms West/Admit Unit (Rooms ) East Elevators Physical Medicine and Rehabilitation (Rooms ) Fourth Floor Main Elevators Rooms Rooms East Elevators Rooms Fifth Floor East Elevators Digestive Disease Center Baylor Sleep Center

4 Date How did you hear about HeartPlace? Physician Referral Advertisement Friend Other Please Specify Patient Information For Office Use Only Verified Date By: System Account # Date/By: Doctor Name last first middle Social Security # Address City State Zip Home Ph. ( ) Business Ph. ( ) Cell Ph. ( ) Married Single Widow Divorced Age Date of Birth Male Female Employer Name Employer Address Full-Time Part-Time Retired Self-Employed Student - Fulltime Student - Parttime Referring Physician Referring Physician Ph. ( ) Primary Care Physician Primary Care Physician Ph. ( ) Insured Name ( If no insurance, responsible party ) Name Social Security # Relationship Date of Birth Address City State Zip Home Ph. ( ) Business Ph. ( ) Cell Ph. ( ) Employer Name Notify In Case of Emergency Employer Address 1. Name Relationship Home Ph. ( ) Business Ph. ( ) 2. Name Relationship Home Ph. ( ) Business Ph. ( ) Insurance Information - Copies of Insurance Cards and Drivers License are Required Insurance 1 Address Phone ( ) SS# Policy # Group # Insurance 2 Address Phone ( ) SS# Policy # Group # Authorizations For and in consideration of the services rendered by HeartPlace, I agree to pay said provider of services for all services rendered. I understand that I am responsible for all health insurance deductible, copayment and coinsurance charges not covered by my insurance policy and charges not covered as a result of any law settlements or judgements obtained on my behalf. Additionally, I understand that I will be responsible for charges not covered by my insurance policy, to include, charges for services deemed experimental, investigational and/or not medically necessary as determined by my insurance company. In consideration of services rendered, I hereby transfer and assign HeartPlace all rights, title and interest in any payment due me for services described herein as provided in the above mentioned policies of insurance/settlements or judgements. I hereby consent to the release of information necessary to process claims with my insurance policy. I understand that the specific information to be released may include, but is not limited to history, diagnosis, treatment of drug or alcohol abuse, mental illness, or communicable diseases, including HIV and AIDS. I also understand that this authorization may be revoked by the person giving authorization by written and dated notice, except to the extent that disclosure of information that has been made prior to the reciept of the revocation. I have read and understand this consent and I have signed it voluntarily and of my own free will. Signed Patient Name ( Please Print ) Witness Signature Date Date

5 HEARTPLACE PATIENT HISTORY Date: Patient Name: Physician Who Referred You: Why are you here today/symptoms? List all medications you are currently taking: mg mg mg mg mg mg Are you allergic to any medications? Past Medical History: Check all appropriate boxes. Yes No Date Yes No Date Diabetes Echocardiogram Hypertension Cardiac CATH Stroke Balloon Angiography Heart Attack Heart Surgery Heart Murmur ECG Irregular Heartbeat Pacemaker HBV/HIV/TB Palpitations Leg Cramps Swelling Problems with: List Operations: Date: Thyroid 1. Stomach 2. Gallbladder 3. Liver 4. Pancreas 5. Arthritis 6. 1) Do you have any concerns or problems not listed above? 2) Have you had your cholesterol checked? Y/N What was it? 3) Do you smoke? Packs per day? How Long? 4) Family History:

6 HEARTPLACE PATIENT PRIVACY NOTICE SUMMARY Protecting your confidential health information is important to us. Certain federal law referred to as HIPAA protects the confidentiality of your health information (generally referred to as Protected Health Information or PHI ), and we take it seriously. This summary of our Notice of Privacy Practices ( Notice or Privacy Notice ) has been prepared to provide you with a brief description of certain of the key provisions of the Notice regarding how medical and other personal information about you may be used or disclosed, and how you may obtain access to your information and its disclosure. For a more complete description of our privacy practices under HIPAA, please refer to the attached Notice. What is Protected Health Information (PHI)? PHI is information created or received by HeartPlace and transmitted or maintained in written, electronic or any other form, that relates to your past, present or future health condition, the provision of healthcare to you, and/or information about payment for the provision of your healthcare, and, which may identify you or could reasonably be used to identify you. How may my PHI be used or disclosed? HeartPlace may use or disclose your PHI to carry out your Treatment (provision, coordination or management of your healthcare or related services), Payment (obtain payment for your healthcare services, including activities that may be required by your insurer(s) to obtain approval for payment), or for other Health Care Operations (other functions that HeartPlace performs in connection with providing health care, i.e., quality assessments, training of medical students, credentialing, auditing and financial reporting). Use or disclosure of your PHI pursuant to the Notice may include electronic transmittal or disclosure. When might HeartPlace use or disclose my PHI without my authorization? HeartPlace is not required to obtain your authorization or notify you when it uses or discloses your PHI for your treatment, to obtain payment, or for other health care operations as discussed above. In addition, there are some limited exceptions where the law allows your PHI to be used to promote the Government s need to ensure a safe and healthy society. In some cases, you may be given an opportunity to agree or object before the use or disclosure or your PHI. In all cases, HeartPlace will make every effort to ensure that it meets necessary prerequisites and will not use or disclose your PHI more than is permitted under the law. What Are My Rights Under The HIPAA Privacy Standards? Patients have certain rights under the HIPAA Privacy Standards, subject to certain limitations: You have the right to request restrictions on certain uses and disclosures of your PHI by HeartPlace. You have the right to request that we communicate with you in a certain way. We make every effort to honor your reasonable requests for confidential communication. You have the right to read, review and receive copies of your health information. You have the right to request and obtain an accounting of disclosures HeartPlace has made of your PHI. You have the right to request an amendment to your PHI. (HeartPlace reserves the right to deny requests to amend PHI. For example, if the information is accurate, or if the information was not created or is not maintained by HeartPlace.) You have the right to request a copy of the Privacy Notice (the Privacy Notice is attached for you review). You have the right to file a complaint if you believe that HeartPlace has violated your privacy rights or has acted inconsistently with its obligations under the HIPAA Privacy Rules. HEARTPLACE PRIVACY OFFICER HeartPlace has procedures in place for receiving and resolving HIPAA-related complaints, and, handling other HIPAA and PHI requests and concerns. Such issues are handled by the HeartPlace Privacy Officer. You may: Request additional restrictions for release of your PHI Change restrictions/change contact information Request an amendment to your health record Request copies of the Notice Resolve your complaints (complaints must be directed in writing to the Privacy Officer). Contact the HeartPlace Privacy Officer: By Mail: By Phone: HeartPlace Attn: Privacy Officer Dallas Parkway, Suite 200 Dallas, TX Patient Privacy Notice revised 4-12 DALLAS v.2

7 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By my signature below, I acknowledge that I have received a copy of the HeartPlace Notice of Privacy Practices. Patient Name / / Date of Birth Patient Signature / / Date of Acknowledgement RELEASE OF HEALTH INFORMATION TO IMMEDIATE FAMILY MEMBERS HeartPlace may not discuss my healthcare and my not discuss and/or make financial arrangements with anyone, except as permitted by HIPAA and other applicable laws. HeartPlace may discuss my healthcare and may discuss and/or make financial arrangements with only the following individual immediate family members listed below: Name Relationship Phone Name Relationship Phone Name Relationship Phone Name Relationship Phone I understand that if I would like to authorize HeartPlace to disclose my healthcare and/or financial arrangements with anyone other than the immediate family members listed above, I will need to execute an authorization that meets the requirements of the HIPAA Privacy Standards. Name (print): Date: Patient s Date of Birth: / / PATIENT CONTACT PREFERENCES I prefer to be contacted in the following manner: Phone #: ( ) - OK to leave message with detailed information OK to leave message with contact number only Do not leave message Patient Privacy Notice revised 4-12 DALLAS v.2

8 HEARTPLACE PATIENT PRIVACY NOTICE Protecting your confidential health information is important to us. The Federal HIPAA Law is written to protect the confidentiality of your Personal Health Information (PHI), and we take it seriously. This Notice of Privacy Practices (Notice) describes how medical and other personal information about you may be used or disclosed, and how you may obtain access to your information and its disclosure. What is Protected Health Information (PHI)? PHI is information created or received by HeartPlace and transmitted or maintained in written, electronic or any other form, that relates to your past, present or future health condition, the provision of healthcare to you, and/or information about payment for the provision of your healthcare, and, which may identify you or could reasonably be used to identify you. How may my PHI be used? HeartPlace may use or disclose your PHI to carry out your Treatment (provision, coordination or management of your healthcare or related services), Payment (obtain payment for your healthcare services, including activities that may be required by your insurer(s) to obtain approval for payment), or for other Health Care Operations (other functions that HeartPlace performs in connection with providing health care, i.e., quality assessments, training of medical students, credentialing, auditing and financial reporting). When might HeartPlace use or disclose my PHI without my authorization? HeartPlace is not required to obtain your authorization each time it uses or discloses your PHI for your treatment, to obtain payment, or for other health care operations as discussed above. In addition, there are some limited exceptions where the law allows your PHI to be used to promote the Government s need to ensure a safe and healthy society. In some cases, you may be given an opportunity to agree or object before the use or disclosure or your PHI. In all cases, HeartPlace will make every effort to ensure that it meets necessary prerequisites and will not use or disclose your PHI more than is permitted under the law. WHAT ARE MY RIGHTS UNDER HIPAA? Patients have certain rights under the HIPAA Privacy laws: You have the right to request restrictions on certain uses and disclosures of your PHI. You have the right to request that we communicate with you in a certain way. We make every effort to honor your reasonable requests for confidential communication. You have the right to read, review and receive copies of your heath information. You have the right to request and obtain an accounting of disclosures HeartPlace has made of your PHI. You have the right to request an amendment to your PHI. (HeartPlace reserves the right to deny requests to amend PHI. For example, if the information is accurate, or if the information was not created or is not maintained by HeartPlace.) You have the right to request a copy of this Privacy Notice. You have the right to file a complaint if you believe that HeartPlace has violated your privacy rights or has acted inconsistently with its obligations under the HIPAA Privacy Rules. HEARTPLACE PRIVACY OFFICER HeartPlace has procedures in place for receiving and resolving complaints, and, handling HIPAA and PHI requests and concerns. Such issues are handled by the HeartPlace Privacy Officer. You may: Request additional restrictions for release of your PHI Change restrictions/change contact information Request an amendment to your health record Request copies of this Privacy Notice Resolve your Complaint (Complaints must be directed in writing to the Privacy Officer). Contact the HeartPlace Privacy Officer: By Mail: By Phone: HeartPlace Attn: Privacy Officer Dallas Parkway, Suite 200 Dallas, Tx Patient Privacy Notice revised 5-11

9 RELEASE OF INFORMATION AUTHORIZATION By my signature below, I acknowledge that I have received, read and understand the HeartPlace Privacy Notice. I hereby authorize use or disclosure of my Personal Health Information (PHI) by HeartPlace as necessary during the course of my treatment, to obtain payment for my treatment and for other health care operations. I understand that I may request in writing that you restrict how my PHI is used or disclosed to carry out treatment, payment and/or health care operations. I understand that I have Patient Rights under HIPAA laws and that I may contact the HeartPlace Privacy Officer if I have any concerns about the use or disclosure of my PHI. I also understand you are not required to agree to my requested restrictions. I understand that I may revoke this consent in writing at any time, but a revocation is not effective if HeartPlace has already relied on my authorization to make a particular use of disclosure. / / - - Patient Name Date of Birth Social Security Number Patient Signature / / Date of Acknowledgement RELEASE OF INFORMATION PREFERENCES HeartPlace may not discuss my healthcare and may not discuss and/or make financial arrangements with anyone. HeartPlace may discuss my healthcare and may discuss and/or make financial arrangements with any immediate family member. HeartPlace may discuss my healthcare and may discuss and/or make financial arrangements with only the following individual s listed below: Name Relationship Phone Name Relationship Phone Name Name Relationship Phone Relationship Phone I prefer to be contacted in the following manner: Phone #: ( ) - OK to leave message with detailed information OK to leave message with contact number only Do Not leave message Patient Privacy Notice revised 5-11