Southeast Cardiovascular Associates
Board Certified, Interventional Cardiology, Cardiovascular Disease & Nuclear Cardiology
Patient Registration ‐ WELCOME TO OUR OFFICE
Emergency Contact: (not living at same address)
Release of Information:
Past Medical History: (Note: If yes, please check)
Past Surgical History: (Note: If yes, please check and provide YEAR)
Please list all your prescription medication(s): List Name, Dosage, and Frequency or bring a copy of your medication list
Insured/Responsible party if other than patient
We make every effort to contact your insurance company and verify your benefits. However, verification of insurance benefits is not
a guarantee of payment until claims are submitted and the insurance company reviews all records. If your insurance denies
payment or services are not covered, you will become financially responsible for services.
Please be aware that if you participate in an HMO and need a referral for this visit or any other services, it is your responsibility to
make sure we have the referral in our office before the visit. The office cannot be responsible for obtaining the referral.
Assignment of Benefits and Release of Information
I hereby assign and convey directly to Southeast Cardiovascular Associates as my designated authorized representative, all medical
benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications
rendered or provided, regardless of its managed care network participation status. I understand that I am financially responsible for
all charges regardless of any applicable insurance or benefit payments. I hereby authorize Southeast Cardiovascular Associates to
release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer,
and/or attorney to release to Southeast Cardiovascular Associates any and all Plan documents, summary benefit description,
insurance policy, and/or settlement information upon written request from Southeast Cardiovascular Associates or its attorneys in
order to claim such medical benefits.
Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (healthcare reform legislation), ERSA,
Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the
If you do not have insurance, or if we cannot verify your coverage, payment is due at time of service.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to
privacy regarding my protected health information. I understand that this information can and will be used to:
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses
and disclosures of my health information. I understand that this organization has the right to change its Notice Privacy
Practices from time to time and that I may contact this organization at any time at the address above 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 healthcare operations. I also understand you are not required to agree to my requested
restriction, but if you do agree, then you are bound to abide by such restrictions.
AUTHORIZE ANY LICENSED PHYSICIAN, PRACTITIONER, HOSPITAL, CLINIC OR OTHER MEDICAL FACILITY, OR IT’S
REPRESENTATIVE, TO RELEASE ANY AND ALL INFORMATION WITH RESPECT TO ANY ILLNESS, INJURY, MEDICAL HISTORY,
CONSULTATION, PRESCRIPTION, OR TREATMENT AND COPIES OF ALL MEDICAL RECORDS TO SOUTHEAST
NO SHOW POLICY
A “no show” is when a patient fails to keep a scheduled appointment.
We make every effort to provide prompt medical care to all of our patients. If you are unable to keep a scheduled
appointment, please let us know 24 hours in advance. A no show may generate a $25.00 fee per incident.
In the event that you have a special circumstance regarding your missed appointment, please contact our office. We
understand that there may be issues beyond your control and want to be understanding of special circumstances.
ADMINISTRATIVE PAPERWORK FEE
Southeast Cardiovascular Associates will charge a $25.00 administrative fee for any forms, paperwork that we
are asked to complete or write for you or your family members. The fee is payable at the time the forms are submitted
for completion. Forms requiring the fee would include, but not be limited to FMLA paperwork, supplemental insurance
policy claim forms, detailed release to work forms, medication assistance forms, transportation assistance forms,
disabled parking requests, or debt forgiveness forms.
The patient or family member should fill out their portion of the form themselves as completely as possible prior to
submitting to our office. Please allow 7‐10 business days for all forms to be completed. Completed forms can be picked
up from the front desk or can be faxed, if requested.
Southeast Cardiovascular Associates will provide your records to you once you have completed the appropriate medical
records request form. You can find this form on our website or you can contact our office and we can mail or fax the
form to you. Please be sure to sign the form, unsigned requests cannot be processed and we will either mail or fax the
records to you.
Fee for records will be $15.00. Your request will be processed and fulfilled within 15 business days.
RETURNED CHECKS NSF
There is a $35.00 charge for any returned checks in addition to the insufficient funds amount.