Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION

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1 PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific Islander Asian White Black or African American Other Race Home Address (e.g., P.O. Box or Street, City, State, Zip) Mailing Address (if different) Ethnicity: Hispanic or Latino Not Hispanic or Latino Home Phone: Work Phone: Cell Phone: Occupation: If retired, previous occupation: Address: Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: Name of Contact: EMERGENCY CONTACT INFORMATION Relationship to Patient: Address (if different than above): Home Phone: Work Phone: Cell Phone: Do you have medical insurance? Yes No Preferred Lab: INSURANCE INFORMATION Primary Insurance: PHARMACY AND LAB Preferred Pharmacy: Secondary Insurance: Signature:

2 ALLERGIES List all medication or food allergies, as well as your reaction.. CURRENT MEDICATIONS List ALL current medications including over the counter medications/vitamins/herbals/supplements. Medication Name Dosage # Times Daily MEDICAL PROBLEMS Condition Year Condition Year Chest Pain Thyroid Disease Hyper? Hypo? Coronary Artery Disease Heart Attack Heart Failure (CHF) Heart Valve Disease High Blood Pressure High Cholesterol Irregular Heart Rhythm Fainting Peripheral Vascular Disease Leg Pain when walking Lung Disease (COPD) Tuberculosis Asthma Stomach Ulcer Gout Liver Disease Kidney Disease Back Pain if yes, where? Migraine Headaches Seizures Stroke Anemia Bleeding/ Clotting Disorder Cancer Type: GERD Depression Emotional/Behavioral Illness Explain: AIDS/HIV Other Diabetes Type I? Type II? Explain: 502 Elm Street NE,

3 Surgery PREVIOUS SURGERIES 502 Elm Street NE Year 5. FAMILY MEDICAL HISTORY (Does anyone in your immediate family have the following? Who?) Condition Who? Condition Who? Coronary Artery Disease Cancer (type) Heart Attack Sudden Cardiac Death High Blood Pressure High Cholesterol Diabetes COPD Stroke Abdominal Aneurysm CHF/Heart Failure Other Father s cause of death Age Mother s cause of death Age Do you exercise regularly? Yes No SOCIAL HISTORY Type of Exercise? How Often? Never Tobacco Use (Cigarettes, cigars, pipes, and smokeless tobacco) I quit (Year: ) Packs/day? How long? I still smoke Packs/day? No. of years? Smokeless Tobacco No. of cans/day? No. of years? Alcohol and Drug Use How often do you drink? Never Occasionally Socially Daily Weekly No. of drinks per week? Beer Red Wine White Wine Liquor Any alcohol-related legal, personal or health problem? Yes No Previous DT s or Seizures? Yes No Treatment for any alcohol-related problem? Yes No Any drug-related legal, personal or health problem? Yes No 502 Elm Street NE,

4 Name of Patient: FINANCIAL POLICIES The New Mexico Heart Institute is committed to serving our patients as well as working within their financial needs. The Business Office is available to answer any questions regarding fees, payments, policies, or our insurance filing procedures. Please call (505) anytime between 8:00 a.m. to 5:00 p.m., Monday through Friday. You can also contact the Business Office through your patient portal. Proof of Insurance. We ask that you present your insurance card at every visit. If you fail to provide us with the correct insurance information at each visit, you may be responsible for payment for all services provided. We are contracted with most insurance plans. If you are not insured by a plan we are contracted with, payment in full is expected at the time of service. Your health insurance contract is between you and your insurance company. Knowing your insurance benefits is your responsibility. Any questions or complaints regarding your coverage should be directed to your insurance carrier. Co-Payments. Your insurance company along with State and Federal laws requires NMHI to collect co-payments at the time of service. In order to comply with these contracts and laws, your co-payment, deductible, and co-insurance are due at the time of service. Partial payments are not accepted unless previous arrangements have been made with the Business Office. Co-Insurance. Your insurance benefits may include a co-insurance which is due at each visit. An example may be an 80/20 plan, which would require 20% of the allowed amount to be paid at the time of service. Deductible. Your health insurance company may have a deductible or a set amount due from you prior to your insurance covering any service, which is due at time of service. Non-Covered Services. Please be aware that some of the services you receive may be non-covered or not considered necessary by your insurer. You must pay for these services in full prior to receiving these services. Hospital Services. NMHI will submit claims for the professional charges (physician fees) during hospital stays or for reading cardiology tests (EKG, echocardiogram, etc.). These charges do not include hospital charges, outside lab charges or other specialty physician fees. You will receive a separate statement from the hospital, lab, etc. Non Emergent Procedures (Scheduled Procedures in our office and at the Hospital). Non-emergent services will require copayments, deductible, and co-insurance amounts. The patient due amounts are due 24 hours prior to services rendered. Services will be rescheduled if your patient due amounts are not paid 24 hours prior to services rendered. Financial counselors are available to help determine your patient due balances prior to service. Please call for assistance. Services that require a prior authorization may be rescheduled if your insurance company does not complete the authorization prior to the scheduled procedure. Claims Submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to directly supply certain information. It is your responsibility to comply with their request. Patient Due Balances. You will receive a monthly statement for all patient due balances. The balance is due upon receipt of the statement. If you do not make a payment within 10 days of receipt of the statement, you will receive a courtesy or call to remind you of the past due amount. You will continue to receive reminders every 10 days until a payment is received. Accounts with no payments for 60 days may be referred to a collection agency. Accounts with two invoices in collections may be subject to termination of the patient/provider relationship. Self-Pay. NMHI offers a 30% discount to uninsured patients if the full balance is paid prior to services rendered. Payment Plans. The Business Office may establish monthly payment plans for you on balances greater than $ You can mail payments by check or credit card, pay online through our patient portal, or pay automatically with our credit card on file option. With your authorization, you can have payments automatically charged to your credit card. Please speak with the Business Office for details of our payment plan options Credit Cards. As a convenience, we accept Visa, MasterCard, Discover and American Express. Completion of Health Forms. Patients who request physicians to complete forms such as Family Medical Leave Act or disability forms will be charged $ The fee must be paid in advance. Forms submitted without payment will not be processed. All patient information must be completed prior to submission to the physician. Please allow 14 business days for the completion of forms. No Show. An appointment must be cancelled 48 hours prior to the appointment to avoid a fee. 502 Elm Street NE,

5 REFERRAL REQUIREMENTS If my insurance company requires a referral, I understand that I am responsible for obtaining the referral. If the referral is not obtained, I can be held responsible for payment in full for services rendered on the date of service. NOTICE OF PRIVACY PRACTICES I understand that I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or been offered a copy of New Mexico Heart Institute of Privacy Practices (available in our office or on our website) and understand that the Notice may change at any time. I give consent to New Mexico Heart Institute to obtain my prior medical records from outside practices and send office notes to other physicians to coordinate care on my behalf. Patient Name: Signature of Patient or Legal Representative Date I have read and agree to the above policies. SIGNATURE Patient Name: Signature of Patient or Legal Representative Patient Name: 502 Elm Street NE,