Patient Registration Form 

Do you wish for your Medical records to be sent to you Primary Care Provider?

Yes

No

Prescriptions will be electronically sent to the pharmacy of your choice, please provide the following information:

INSURANCE CARD(S) OR PROOF OF INSURANCE MUST BE PRESENTED AT TIME OF SERVICE, YOU MAY ALSO UPLOAD WITH THIS FORM.

Consent for Treatment
By signing below, I authorize HEART MD to conduct any diagnostic examinations, procedures, and to provide any medications, treatment, or therapy necessary to effectively assess and maintain my health, and to assess, diagnose, and treat my illness. 1 I also give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.

I certify that I have read and fully understand the above statement.

DISCOSURE AGREEMENT

I recognize that I am responsible for providing my insurance information to Heart MD at the time of service. If I do not have this information, I must pay for my visit at the time of service.

I hereby assign all medical benefits, to which I am entitled, including Medicare, commercial insurance, and other plans to Heart MD. I agree to pay for all medical services I receive from the physicians of this practice that the insurance company refuses to pay for whatever reason. This office will file a claim on your behalf. However, if my insurance company denies payment for any reason (non-covered services, terminated coverage, my failure to secure and authorization or referral from the insurance company.) I will pay for service upon written/verbal notice of their refusal. I understand that if my insurance carrier requires a referral prior to seeing a specialist, our office must receive the referral before arrival. If we do not have it upon you singing in for your appointment, your appointment will be rescheduled, or full payment must be made prior to the visit
.
I understand that if I do not have medical insurance, I am responsible to pay for all the services that are rendered. In the event that the patient does not meet their financial obligation, the patient will be discharged from the practice.
 

OFFICE POLICIES

Thank you for choosing HEART MD for your medical care. We are committed to providing the best healthcare possible.

The following explains our office policies, which we ask you to read carefully and sign below.

* It is the patient's responsibility to inform the office of any address, telephone number or insurance changes.

*The patient's account must be kept current. All self-pay or insurance copays, coinsurance and deductible will be collected at the time of service or billed to you in accordance with your insurance company.

*If the patient does not have their payment, the appointment will be rescheduled.

*Prescription refills require 3 business days' notice. All control medications are completed on Friday, if approved.

*It is the patient's responsibility to provide a current list of all medications, at the time of every appointment.

I understand that my prescriptions will not be refilled if I have not been seen by the physician within the last year.

*If your insurance requires a referral or authorization, it is your responsibility to get all information to your PCP for processing. If the referral or auth is not obtained for the appointment, your appointment will be rescheduled.

*We verify benefits with the insurance, however, please be advised that it is only an estimate of the coverage based on the information given at the time of inquiry.

*It is the patient's responsibility to be aware of the services provided, and their covered benefit under their insurance policy.
Any disability or other medical forms that need to be filled out by the physician will result in a $10 fee.

*I understand that HEART MD has the right to discharge patients who are noncompliant with the doctor's recommended appointment scheduled, testing and or medication therapies.

*I understand that a copy of our American with Disabilities Act is available upon request.

*I am acknowledging that I have read and understand the privacy practices for HEART MD that has been provided to me.

By signing below, I am acknowledging that I understand the office and financial policies and I agree to abide by it
 

DISCOSURE TO FAMILY MEMBERS AND/OR FRIENDS

I give permission for my protected health information to be disclosed for purposes of communication results, findings and care decision to the family members and others listed below.

DISCLOSURE TO OTHER MEDICAL PROVIDERS

I give permission for my protected health information to be disclosed for purposes of continuation of care to my other physicians listed below.

COMMUNICATIONS ABOUT MY HEALTHCARE

I agree the provider or staff from HEART MD may contact me for the purposes of scheduling necessary follow up visits recommended by the treating physician.

I consent to receiving instructions and other healthcare communication by email or text. These instructions may include, but not be limited to post-procedure instructions, follow up instructions, educational information, and prescription information. Other healthcare communication may include, but are not limited to, communications regarding my treatment or conditions, or reminder messages to me regarding appointments for medical care.

I give permission for the provider or staff from Heart MD to forward my medical records for continuation of care to a recommended provider/therapies such as rehab, home health, or other specialties providers if necessary.

I give permission for the provider or staff from Heart MD to obtain my hospital records for the hospital portals.
 

Please upload the front and back sides of your Medical Insurance Cards and Drivers License/ID Cards:

Upload

or Drag and Drop a File

By clicking the above button, I consent to be contacted by Heart MD and Webit, Inc. at any email address or telephone number I provide, including, without limitation, communications sent via text message to my cell phone or communications sent using an autodialer or prerecorded message. This acknowledgement constitutes my written consent to receive such communications. I agree and consent to any applicable Terms and Conditions of Use or Privacy Policy available on this website.