North Atlanta Heart & Vascular Center, P.C.

PATIENT PROFILE
Doctor you are seeing:
PATIENT INFORMATION [ ] Male [ ] Female
Name: Date of Birth:
Address: Social Security #:
[ ] Married [ ] Single [ ] Divorced
Spouse’s Name:
Home Phone: Referring Physician:
Work Phone: Physician Phone #:
Primary Physician: Physician Fax #:

PATIENT EMPLOYMENT PHARMACY INFORMATION

[ ] Employed [ ] Retired [ ] Unemployed
Employer: Pharmacy Name:
Phone: Pharmacy #:

GUARANTOR (Individual signing this form) GUARANTOR PHONE

[ ] Same as Patient [ ] Other Home #:
Name: Work #:
Address:
EMERGENCY CONTACT & PHONE #:
PRIMARY INSURANCE
*Secondary Insurance: Please Provide Information to Front Desk
Policy Holder’s Name: Relationship to Patient:
Policy Holder’s Phone #: Policy Holder’s SSN:
Insurance Co: Insurance ID #:
Insurance Co Address: Policy Group:
Policy Holder’s DOB:

I consent to have messages regarding test results and appointment reminders left on a voicemail: (Initial)
Voicemail/Home #:
Voicemail/Cell #:
Voicemail/Business #:
I do not consent to have messages regarding my test results or appointment reminders on any voicemail: (Initial)

I voluntarily give consent for my medical treatment or my child’s medical treatment to North Atlanta Heart & Vascular
Center, P.C. I fully understand that payment is required at the time of service and should my claims be filed to my insurance
company, any unpaid balance is my responsibility. When necessary, I further authorize the release of medical records to my
insurance company. In the event that the physician files to my insurance, I authorize benefits to be paid directly to the
physician.

Signature Date

Medications:
Name Dose (mg) How many times a day?
Medical History:
Do you or have you been treated for: (circle all that apply)

Heart Block/Stent High Blood Pressure High Cholesterol Diabetes Stroke Atrial Fibrillation

Asthma Tuberculosis GERD Hyperthyroid Hypothyroid Sleep Apnea Seizures COPD

Cancer: Date______ Site:___________

Other: _____________________________________________________________________________________________

_________________________________________________________________________________________________

Allergies:
Are you allergic to any medications? ____Yes _____No, Please List:____________________________________________

____________________________________________________________________________________________________

Circle all that you are allergic to: Dye used for X-rays (IV dye) Adhesive Tape Latex Shell Fish

Have you ever had any of the following heart tests? (Please give Location and Date)

Cardiac Catheterization: ____________________ Stents, Bypass or Valve replacement_____________________________

Echocardiogram: __________________________ Pacemeker, ICF or Defibrillation Insertion_________________________

Nuclear Stress Test: ________________________Holter Monitor/Event Monitor___________________________________

Surgeries:
Please list date and type of surgery:________________________________________________________________________

____________________________________________________________________________________________________

Hospitalizations:
Please list date and reason: ______________________________________________________________________________

____________________________________________________________________________________________________

Family History:
(Check all that apply.)
CAD /Heart Attack Stroke Stent Unknown
Father: _______ _____ _____ ________

Mother: _______ _____ _____ ________

Siblings: _______ _____ _____ ________

Gparents: _______ _____ _____ ________

Social History:

Do you drink Alcohol? ___No ___Yes. How often? _________________Type?_________________

Do you Smoke? ____No ____Yes.____Former Smoker

How many Years? _______ Packs Daily:_____When did you quit?_______ Interested in Quitting? ______

Do you drink Caffeine? ___No ____Yes How often? _________________Type?_________________

Do you exercise? ____No ____Yes. How often? _________________Type?_________________

North Atlanta Heart & Vascular Center, P.C.

PATIENT CONSENT FORM

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain
rights to privacy regarding my protected health information. I understand that this information can and will be
used to:
 Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be
involved in that treatment directly and indirectly.
 Obtain payment from third party payers.
 Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the
uses and disclosures of my health information. I have been given the right to review such Notice of Privacy
Practices prior to signing this consent. I understand that this organization has the right to change its Notice of
Privacy Practices from time to time and that I may contact this organization at any time at the address below to
obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry
out treatment, payment or health care operations. I also understand you are not required to agree to my requested
restrictions, but if you do agree then you are bound to abide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action
relying on this consent.

Please list to whom we may release your medical records/information.

Name/Relationship:

Patient Name: Signature:

Relationship to Patient: Date:

North Atlanta Heart & Vascular Center, P.C.

FINANCIAL POLICY

We are all aware of the crisis to healthcare financing nationwide. Quality, personalized medical services may
sometimes be expensive and we are working hard to contain costs on your behalf. There is much
misunderstanding regarding the role of insurance and other “Third Party Payors” in the process. The following is
an attempt to explain our policies in this regard:

1. Services are provided to patients, not to insurance companies. Private practice medicine is Fee-For-Service
and implies a contract between patient and provider.
2. Insurance contracts are between companies and beneficiaries (patients) for reimbursement of certain
covered expenses.
3. In cases where we do have contracts with managed care providers we will comply with their regulations.
In other words, we will be filing your claims with the appropriate carriers and collecting your copay at the
time of services.
4. Patients covered under HMO or PPO are responsible for their copay at the time of service. They are also
responsible for any portion of charges designated by the insurance company.
5. In order for our business office to file your insurance correctly, you must give the receptionist a copy of
your most current insurance card along with your referral number.
6. If your HMO policy requires you to have a referral number, you are responsible to provide the number at
time of services.
7. Patients electing to be seen out of network will be responsible for payment at time of services.
8. Patients covered under Medicaid must present current card and copay when applicable.
9. Recipients of medical care are expected to pay for those services whether covered by insurance or not.
Insurance coverage is determined by your contract with the company.
 10. For certain services (i.e. Procedures, Hospitalizations) we will assist you by filing a claim on your behalf to
your insurance company. Bills not paid by insurance remain the responsibility of the patient.
11. In situations of severe financial hardship, this office will consider making special arrangements on a case-
by-case basis. Please discuss this with our office manager immediately if you feel it applies to you.
12. We are all here to serve. If you have remaining questions, out staff is ready to help find the answers.

I hereby understand the financial policy of this office.

Print Name

Signature Date

North Atlanta Heart & Vascular Center, P.C.

Bhaskar R. Reddy, M.D., F.A.C.C. ● Jigishu Dhabuwala, M.D. ● Don Rowe M.D.
1400 Northside Forsyth Drive Suite 380
Cumming, GA 30041
Phone: 770-887-3255
FAX: 770-887-4177

REQUEST FOR RELEASE OF MEDICAL RECORDS

This form to be used if we need to get records from a previous physician or previous hospital stay

Only complete bottom portion of this form

TO:
I hereby request that all my medical records be released to North Atlanta Heart & Vascular Center,
P.C. as soon as possible.

Please Print

Patient Name: Date:

DOB: SSN:

Address:

Patient Signature:

Witness:

PRIVACY PRACTICES ACKNOWLEDGEMENT

North Atlanta Heart & Vascular Center, P.C.

Bhaskar R. Reddy, M.D., F.A.C.C ● Jigishu Dhabuwala, M.D● Don Rowe MD
1400 Northside Forsyth Drive Suite 380
Cumming, GA 30041
Phone: 770-887-3255
FAX: 770-887-4177.
 ACKNOWLEDGEMENT FORM

I have reviewed the Notice of Privacy Practices and have been presented an
opportunity to ask questions:

NAME: ______________________________ Date of Birth:___________

Signature_________________________________ Date:__________