Name

D.O.B

Date:

By signing this form, I * authorize Advanced Cardiovascular Care Center to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the person(s) or entity listed below.

HIV/AIDS: I consent to the release of any positive or negative test result for AIDS or HIV infection, antibodies to AIDS or infection with any other causative agent of AIDS with the rest of my medical records.

Limitations on the information you may release subject to this Release Form are as follows:

*Release my protected health information to the following person(s)/entity:

Name:

Street:

City:

State:

Zip Code:

The reasons or purpose for this release of information are as follows:

Patient Signature (or parent, guardian or legal representative):

*

Date:

I understand that you will provide this information within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners.

Patient Name: *May we leave messages in your voicemail? Yes or No

Below please list any family member or Physician we may share your medical information with: Release my protected health information to the following person(s)/entity:

Name:

Phone:

street:

City:

State:

Zip:

Name:

Phone:

Street:

City:

State:

Zip:

This authorization shall be in force and effective until the following event and/or date:

The reasons or purposes for this release of information are as follows:

I understand that I have the right to revoke this authorization, in writing, at any time by sending a written notification to the following person at the practice:

Babu Varughese (Privacy Officer), 1011 Medical Plaza Drive, Suite 130, The Woodlands, TX 77380 281-866-7701

I understand that a revocation is not effective to the extent that the practice has relied on this authorization in its actions. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer the right to contest a claim under the policy or the policy itself.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal HIPAA privacy regulations.

The practice will not condition my treatment, payment, and enrollment in a health plan or eligibility for benefits on whether I provide authorization for the requested use or disclosure.

Signature of Patient or Personal Representative: Date:
Name of Patient or Personal Representative : Description of Personal Representative§Ó??s Authority By signing this form, I authorize you to use and disclose the protected health information described below

Signature of Patient or Personal Representative
SName of Patient or Personal Representative

Date
Description of Personal Representative§Ó??s Authority

Name

D.O.B

SOC SEC #

I hereby authorize the release of information contained in my medical records to:

Annie Varughese, M.D, F.A.C.C

(281) 866-7701 PHONE (281) 866-7705 FAX (Woodlands)

*The information being released will be used for medical purposes.
*The authorization is valid for one year from the date of signing.
*The patient of his/her representative may revoke this consent at any time.

Printed Name

Signature

Date

I hereby request that payment of authorized Commercial Insurance and/or Medicare benefits be made on my behalf to Advanced Cardiovascular Care Center. Dr. Annie T. Varughese for any services furnished me by the company listed. I authorize any holder of Medical Information about me to release to Medicare and/or Commercial Insurance and its agents any information needed to determine these benefits or the benefits payable to related services.


I understand my signature below requests that payment be made and authorized release of medical information necessary to pay the claim. If §Ó??other health insurance§Ó?? is indicated in Block 9 of the HCFA1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determined of the Medicare Carrier as full charge, and the patient is responsible for only the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Commercial Insurance and/or Medicare Carrier.

Patient§Ó??s Printed Name:

Patient§Ó??s Signature:

Date

Do you frequently have or have you been told that you have any of the following:

Heart and Lung Problems Y  N 

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Tick those that apply
Chest Pain   High or Low Blood Pressure  High Cholesterol  Rapid or Slow Heart Rate   Past History of Heart Attack  Difficulty Breathing  Congestive Heart Failure (CHF)  Chronic Obstructive Pulmonary Disease (COPD)  

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Digestive Disturbances Y  N 

---

Tick those that apply
Irritable Bowel Syndrome (IBS)   Constipation   Diarrhea   Nausea   Acid Reflux (GERD)  

---

Exercise Intolerance Y  N 
Excessive Fatigue Y  N 
Thyroid Disorders Y  N 
Kidney or Renal Disease Y  N 
Feelings of anxiety, depression or Malaise (a general feeling of §Ó??un-well§Ó??, discomfort, uneasiness) Y  N 
Seizures, Migraines or Other Headaches Y  N 
Chronic Pain Syndromes Y  N 

---

If so tick all that apply
Chronic Fatigue Syndrome (CFS)   Reflex Sympathetic Dystropy (RSD)   Fibromyalgia   Other:  

1. Are you over the age of 65? Y  N 
2. Do you have problems with memory, thinking, with judgments or trouble making decisions? Y  N 
3. Do you have less interest in hobbies and activities? Y  N 
4. Do you repeat the same things over and over again (i.e. questions, stories or statements)? Y  N 
5. Do you have trouble learning how to us a tool, appliance or gadget?label> Y  N 
6. Do you forget the correct month or year? Y  N 
7. Do you have trouble handling complicated financial affairs (i.e. income taxes, paying bills)? Y  N 
8. Do you have trouble remembering appointments? §Ó?| Y  N 
9. Do you have daily problems with thinking and/or memory? Y  N 

Do you have leg pain during activity that goes away with rest? Y  N 
Do you often have leg cramps? Y  N 
Do you have wounds on your legs that heal very slowly? Y  N 

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Do you experience ANY of the following (please circle those that apply):

Radiating pain  Numbness  Tingling  Burning  Coldness  Sharp or Dull Pain 

---

In the neck, shoulders, arms or hands (upper extremities) Y  N 
In the low back, hips or legs (lower extremities)§Ó?| Y  N 
Have you experienced loss of motion or weakness in your neck, shoulders, arms or hands? Y  N 
Have you experienced loss of motion or weakness in your low back, hips or legs? Y  N 

Have you experienced loss of motion or weakness in your neck, shoulders, arms or hands? Y  N 
Have you experienced loss of motion or weakness in your neck, shoulders, arms or hands? Y  N 
Have you experienced loss of motion or weakness in your neck, shoulders, arms or hands? Y  N 
Have you experienced loss of motion or weakness in your neck, shoulders, arms or hands? Y  N 
Have you experienced loss of motion or weakness in your neck, shoulders, arms or hands? Y  N 

Have you been told that you snore loudly? Y  N 
Do you stop breathing, choke, or gasp for air during sleep? Y  N 
Do you tend to get drowsy during the day when you are not occupied? Y  N 
If awakened, do you find it difficult to go back to sleep? Y  N 
Do your legs kick at night and interfere with your sleep? Y  N 
Approximately, how many hours of sleep do you get most nights?

Patient Signature:

Date: