As a patient at Clipper Cardiovascular Associates, there are important documents that we will ask you to review, fill out, and/or sign. If you are a new patient to the practice, please the take time to read and fill out the forms, particularly the Patient Registration forms, in detail. If you fill them out prior to arriving for your first appointment, please present these forms to the receptionist upon arrival, as this will help to greatly reduce your check-in time.
- Patient Registration form: provides us with your basic demographic and insurance information so that we can contact you as needed and bill your insurance appropriately. Please sign the bottom of this form and make sure to include proper subscriber information.
- Financial Policy form: to help you understand how and why billing is done. Please sign the bottom of the form as acknowledgement that you have read the information.
- Patient Consent form and Notice of Privacy Practices: allows us to treat you; for Medicare patients, allows us to release information as requested to the Social Security Administration; and provides acknowledgement of having received the Notice of Privacy Practices. Please initial the Privacy Practices statement (at bottom of form) and sign and date the bottom of this form
- Permission form: offers you the opportunity to designate individuals with whom you would like us to share information.
- Sender – Authorization for Release of Protected Health Information form: offers you the opportunity to allow for your medical records to be released from Clipper Cardiovascular Associates to parties that you have designated on the form.
- Recipient – Authorization for Release of Protected Health Information form: offers you the opportunity to allow for your medical records to be released from parties that you have designated on the form to Clipper Cardiovascular Associates.
The Privacy Notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.