Patient Demographics
Patient Information
Patient Name
*
Address
City
State
Zip
Home Phone
*
Cell Phone
Work Phone
Date of Birth
*
Sex
Marital Status
Social Security No.
*
(last 4 digits)
Emergency Contact
Relationship
Phone
Employer Name
Employer Address
City
State
Zip
Guarantor Information
Guarantor Name
Address
City
State
Zip
Home Phone
Cell Phone
Pager
Insurance Information
Do you have healthcare insurance?
Yes
No
Charges for services are the responsibility of the patient/guarantor. Please be informed that you will be responsible for payment if your insurance company does not pay your claim.
Insurance Company Name
Address
City
State
Zip
Policy No.
Co-pay
Group No.
Is primary policyholder same as patient?
Yes
No
Policyholder Name
Address
City
State
Zip
Social Security No.
Date of Birth
Sex
Home Phone
Cell Phone
Work Phone
Employer Name
Employer Address
City
State
Zip
Patient Relationship to Policyholder
Do you have secondary healthcare insurance?
Yes
No
Charges for services are the responsibility of the patient/guarantor. Please be informed that you will be responsible for payment if your insurance company does not pay your claim.
Insurance Company Name
Address
City
State
Zip
Policy No.
Co-pay
Group No.
Is secondary policyholder same as patient?
Yes
No
Secondary Policyholder Name
Address
City
State
Zip
Social Security No.
Date of Birth
Sex
Home Phone
Cell Phone
Work Phone
Employer Name
Employer Address
City
State
Zip
Patient Relationship to Policyholder
I authorize the release of any medical information necessary to process any medical claims. I also authorize Medicare and /or other insurance payment of medical benefits to The Rubin Heart Clinic for services provided to me. I further understand that I am financially liable for all charges incurred and not covered. I authorize refund of overpaid insurance benefits where my coverage is subjected to coordination of benefits. In the event of a default, I agree to pay all cost of collection, including but not limited to reasonable attorney’s fees. I further authorize Rubin Heart Center to complete any credit investigation necessary for the processing of the above referenced medical claims.
Signature of Patient
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Authority to sign, if not patient
Relationship to patient
Patient Authorization for Use/Disclosure of Health Care Information
Patient Name
Address
City
State
Zip
Home Phone
Date of Birth
Social Security No.
I, the undersigned, hereby authorize and request Rubin Heart Clinic, LLC to
Release Information to
Obtain Information from
Name
Address
City
State
Zip
Communication Regarding Your Healthcare Information
Please indicate with whom we may discuss your Healthcare Information
(check all that apply)
Rubin Heart Clinic may not communicate my healthcare information with anyone other than me
Rubin Heart Clinic may communicate my healthcare information with the following listed individuals
Add another?
Add another?
Add another?
Rubin Heart Clinic may leave messages on my
Cell Phone
Home Phone
Work Phone
This request and authorization applies to
Complete Health Records
Progress Notes
Complete Billing Records
Itemized Bills
Procedure Reports
History and Physical
EKG
Appointments
Lab Results
Consultation Report
Films/Images
Films/Images
Drugs and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release
I understand that my medical and/or billing records may contain information in reference to drug and/or alcohol abuse, psychiatric care, sexually transmitted diseases, Hepatitis B or C, HIV/AIDS ( Human Acquired Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome) and /or other sensitive information regarding counseling, treatment, rehabilitation or the risk thereof.
I agree to its release.
Time Limit and Right to Revoke Authorization
Except to the extent action has already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting a notice in writing to Rubin Heart Clinic, LLC (RHC) or by filing out a form supplied by RHC know as the Revocation of Authorization Form. Unless revoked, this authorization will expire on the following date or event
or one (1) year from the date of signature, unless otherwise specified. Once RHC gives out the information that I wanted released, I know that RHC had no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or State privacy laws may no longer protect the information.
I understand that I may have the right to refuse to sign this form and that my refusal will not result in the physician conditioning the provision of healthcare with two exceptions: 1) Refusal to sign this authorization, if it is for disclosure of information created for research that includes treatment, may result in the physician declining to provide the research- related treatment; 2) Refusal to sign this authorization, if it is for disclosure of information created for the sole purpose of disclosure to a third party, may result in the doctor declining to provide the healthcare which is for the sole purpose of creating protected health information for disclosure to a third party.
I understand that I can refuse to sign this authorization. I need not sign this form to obtain medical treatment, payment, health plan enrollment eligibility I understand that any disclosure of information carries with it the potential for re-disclosure by the recipient and that the information may then no longer be protected by Federal confidentiality rules.
Signature of Patient
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
Authority to sign, if not patient
Relationship to patient
No-Show Policy
Patient Name
To our Patients,
We appreciate you choosing The Rubin Heart Clinic, LLC for your cardiac care. As a part of our commitment to you, we strive to fulfill your appointment needs.
To continue to meet your request, we find it has become necessary to implement a charge when patients do not keep their scheduled appointments.
Effective January 3rd, 2024, we will begin charging $50.00 for each “NO SHOW’ visit with Dr. Rubin. A charge of $75.00 will be charged for missed Testing Appointment to cover additional charges incurred by the office.
To avoid this charge, we ask that you give us 24-hour advance notice if you need to change or cancel your appointment. Our appointment schedulers will be happy to work with you to find a time that better meets your scheduling requests.
We thank you in advance for taking the time to cancel or reschedule those appointments that you know that you will not be able to keep.
Management,
The Rubin Heart Clinic, LLC.
Signature of Patient
–
Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.