If you are more than 65 years of age, please complete the following:
If Yes, please respond to the following:
I am being treated at Lakeview Cardiology of Texas, Dr. Saima Zafar MD MBA, and I consent to all medical and surgical care, examinations and tests determined by my physician that are necessary for me. Though I accept the care given will meet customary standards, I understand there are no guarantees concerning the results of my care. I also understand that if I do not follow my physician’s recommendations as they may relate to my health, the physician and this office will not be responsible for any injuries or damages that are a result of my non-compliance. I understand that if an employee or any individual associated with the physician’s office is exposed to my blood or body fluid, I will be tested for the hepatitis viruses and the Human Immunodeficiency Virus (HIV). I also understand I will receive education related to this testing and that I will be charged for both testing and education related to the exposure.
Electronic Health Records. I understand that the Physician Office may collaborate with other health care providers to coordinate, manage, and provide health care to me and I consent to the Physicians’ Offices sharing my health information and records electronically for the purposes of treatment, payment and/or operations, including the over all quality health care services provided to me. I consent to the inclusion in the electronic health records of sensitive diagnosis and related information such as HIV/AIDS status, sexually transmitted diseases, genetic information, and mental health and substance abuse etc. The Physician’s Office has implemented administrative physical, and technical safeguards that reasonably and appropriately protect the confidentiality and integrity of my medical information as required by HIPPA.
In addition to the above consent to use and share my health information, I agree that the Physician’s Office may use and disclose my health information for a range of purposes including: treatment, eligibility, verification, and/or payment, to private and public payers, including insurance companies, managed care organizations, my employer (if I am injured at work), state and federal government programs, Worker’s Compensation programs, obtaining pre admission or continued length of stay certifications, quality of care assessment and improving activities, evaluating the performance of qualifications for physician and healthcare workers, conducting medical and nursing training and education programs, conducting or arranging for medical review, adult services, ensuring compliance with legal, regulatory and accreditations requirements and public health oversight services.
I consent to the Physician’s Office request of my health information from other providers providing care to me, receipt of and release of my health information, whether written, verbal or electronic, for the uses described above as well as by Physician’s Office participation in any health information exchange described in the physician offices Notice of Privacy Practices (NPP). Please refer to the NPP for additional, detailed information regarding the uses and disclosures of protected health information.
I hereby assign to and authorize payment of all insurance and health care benefits available to me directly to the physician’s office for services provided to me. I understand that the benefits may be payable to me directly if I do not provide this authorization.
I understand and agree that I am financially responsible for payment of all charges incurred which are not paid by insurance health care benefits, including any and all products provided and/ or services rendered to me which are not eligible for payment (non-covered) under health care plans, Medicare, Medicaid or other insurance payers (e.g., services rendered by healthcare providers who do not participate with my insurance plan). Non-Covered services also may include those services my physician determines to be medically necessary, but are later determined unnecessary by the payer.
I understand and agree that LAKEVIEW CARDIOLOGY OF TEXAS can request and use prescription medication history from other health care providers and/or third-party pharmacy benefit payors for treatment purposes.
As a patient of LAKEVIEW CARDIOLOGY OF TEXAS, I understand payment is due at the time services are rendered, unless prior payment arrangements are made with the office, this includes any deductible, copayment or co-insurance amount. Any balances not paid by my insurance carried are my responsibility to resolve. I further understand that balances due must be paid in a timely manner to avoid further collection action. I understand if my account is forwarded to a collection agency I may be dismissed from the practice; my outstanding balance may be reported to the credit bureau and my balance may be charged an 18% interest rate per year until balance is resolved. I am to present proof to my insurance coverage at EVERY office visit. I UNDERSTAND THAT IF I AM MORE THAN 15 MINUTES LATE FOR MY SCHEDULED APPOINTMENT, I MAY BE ASKED TO RESCHEDULE MY APPOINTMENT FOR ANOTHER DAY. I UNDERSTAND THAT IF I AM UNABLE TO MAKE MY APPOINTMENT FOR ANY REASON, I AM EXPECTED TO NOTIFY THE OFFICE 24 HOURS PRIOR TO MY SCHEDULED APPOINTMENT TO CANCEL OR RESCHEDULE. IF I FAIL TO NOTIFY THE OFFICE, I WILL BE CHARGED A MANDATORY $25.00 NO-SHOW FEE PRIOR TO SCHEDULING MY NEXT APPOINTMENT. Finally, I understand that I am to allow at least 48 hours for my prescription refills.
• Cardiac Ultrasound (Echocardiogram) • Stress Echocardiogram • Treadmill Stress Testing • Abdominal Duplex • Carotid Duplex • Renal Duplex • Lower Extremity Duplex/Venous Duplex • Ankle Brachial Index (ABI’s)
I understand that if I am scheduled for any Cardiac Testing and fail to notify the office of cancellation 24 hours prior to my test, I will be charged a $50.00 fee. When you do not show up for your appointment, we are not able to offer this appointment to another patient that is waiting for this specialized test as these tests require special techs that come in on a limited basis to do this test just for you.
Lakeview Cardiology of Texas participates with electronic prescribing directly to your mail order and local pharmacies. Our goal is to assist our patients with prescription requests in an efficient and timely manner. Due to the volume of prescription requests, we have created the following guidelines to help meet these goals.
1. It is the patient’s responsibility to notify the office in a timely manner when refills are necessary. Approval of your refill may take up to three (3) business days, so do not wait to call. If you use a mail order pharmacy, please contact us fourteen (14) days before your medication is due to run out.
2. Medication refills will only be addressed during regular office hours (Monday – Thursday) (8:00am – 5:00pm). Please notify your Physicians and Nurse Practitioners/Physician Assistants on the next business day if you find yourself out of medication after hours. No prescriptions will be refilled on Friday, Saturday, Sunday or Holidays.
3. Prescription refills require close monitoring by your Physicians and Nurse Practitioners/Physician Assistants to ensure its safety and effectiveness. Your Physicians and Nurse Practitioners/Physician Assistants will prescribe the appropriate number of prescriptions refills to last until your next scheduled appointment. Generally, when you are down to zero refills, it is time to schedule a follow up appointment. We prefer you request any refills of your medications at the beginning of your office visit.
4. Patients requesting new prescriptions or antibiotics must be seen for an appointment. They are not prescribed over the phone because it generally requires an office visit.
5. Refills can only be authorized on medication prescribed by Physicians and Nurse Practitioners/Physician Assistants from our office. We will not refill medications prescribed by other Physicians and Nurse Practitioners/Physician Assistants.
6. Some medications require prior authorization. Depending on your insurance, this process may involve several steps by both your pharmacy and your Physicians and Nurse Practitioners/Physician Assistants. The Physicians and Nurse Practitioners/Physician Assistants and pharmacies are familiar with this process and will handle the prior authorization as quickly as possible. Only your pharmacy is notified of the approval status. Neither the pharmacy nor the Physicians and Nurse Practitioners/Physician Assistants can guarantee that your insurance company will approve the medication. Please check with your pharmacy or your insurance company for updates.
7. It is important to keep your scheduled appointment to ensure that you receive timely refills. Repeated no shows or cancellations will result in a denial of refills.
I hereby authorize Lakeview Cardiology of Texas to use the telehealth/tele visit practice platform AVAYA for evaluating, testing, and diagnosing my medical condition. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment may or may not be started or ended as intended. I accept that the physician/providers can contact me through interactive sessions with video call: however, I am informed that the sessions can be conducted via regular voice communication if the technical requirement such as internet speed cannot be met. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private. I understand that this form may be kept for future tele visit sessions and that I do not have to sign a new consent for every session I have. I may revoke this consent at any time by writing to the office of Lakeview Cardiology of Texas.
In an effort to assist patients in maintaining their financial responsibility and easing the process in making timely payments we ask that you place your debit/credit card on file with our office for future payments and charges.
Card on File: Patients authorize Lakeview Cardiology of Texas to maintain a credit card on file.
I authorize, Lakeview Cardiology of Texas to charge this card for all charges/fees not covered by insurance including copay, coinsurance, denied claims, no show, late cancellation, late reschedule, authorized paperwork, etc. I understand that this information will be saved for future transactions on the patients account and this authorization shall remain in effect until cancelled by contacting this office.*
Please understand If you decide not to fill out this form and have a form of payment online, you may be asked to make payment over the phone via debit or credit prior to your appointment for procedures or office visits. Thanks for your cooperation and understanding.
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