Forms

NEW PATIENTS:

We appreciate the opportunity to participate in your health care. Please complete the following forms and bring them with you to your appointment. Please complete all blanks as sometimes insurance cards become separated from the chart and we rely on this information.

PATIENT REGISTRATION

NOTICE OF PRIVACY PRACTICES
AUTHORIZATION TO RELEASE MEDICAL RECORDS

We will need to scan a copy of your insurance card and driver's license at your initial appointment, and insurance card every time thereafter.

If your insurance is through a managed care program (HMO, EPO, POS), be sure to bring the appropriate authorization (referral) to see us. Without a referral, your appointment may need to be rescheduled or paid in full at the time of your visit. It is the patient's responsibility to have a current referral on file for any future appointments.

The following items are essential to us in performing an effective evaluation:
-Past records from your referring doctor or previous Cardiologist.
-Please bring all your medications to each appointment.
-If you are being referred for evaluation of chest pain or arrhythmia, we will need prior EKGs to compare to the EKG in our office.
-If you are being referred for hypertension (high blood pressure), we need a list of all your medications tried by your referring doctor and blood pressure readings.

ADDITIONAL FORMS:

Authorization to Release Medical Records
Directions to Tuscan Cardiovascular Center
Endovenous Laser Therapy Informed Consent
Instructions Before Your Endovenous Laser Procedure
Instructions for Chemical Stress Test
Instructions for Stress Test
Leg Care After Your Endovenous Laser Procedure
Notice of Privacy Practices
Patient Registration
Varicose Vein Office Examination Questionaire