New Patient Forms

Type what you want and leave the rest blank. Download and print make a clean copy of the packet, in the same style as the office form. Empty lines stay blank so they can be filled in with a pen.

Leave any line blank. You can print the packet and finish it with a pen. Nothing is sent or saved.

Patient Information Form

Who is your primary/family/referring doctor?

Last nameFirst nameMiddle init

Address

CityStateZip code

Phone homeCellWorkExt

MaleFemale

D.O.B.Soc sec #

StudentRetiredEmployed

Employed whereMarital status

Spouse nameSpouse D.O.B.Spouse soc sec #

Spouse employerSpouse work phone

Local pharmacyLocal pharmacy phone

Mail order pharmacyMail order pharmacy phone

E-mail address

Primary insPrimary ins phone

Primary claim address

Primary ID #Primary group #

Primary insured namePrimary insured D.O.B.

Secondary insSecondary ins phone

Secondary claim address

Secondary ID #Secondary group #

Secondary insured nameSecondary insured D.O.B.

Patient Medication List

DatePatient name / date of birth

Known allergies/sensitivities

MedicationDosageTaken how often

Medication 2Dosage 2Taken how often 2

Medication 3Dosage 3Taken how often 3

Medication 4Dosage 4Taken how often 4

Medication 5Dosage 5Taken how often 5

Medication 6Dosage 6Taken how often 6

Medication 7Dosage 7Taken how often 7

Medication 8Dosage 8Taken how often 8

Medication 9Dosage 9Taken how often 9

Medication 10Dosage 10Taken how often 10

Medication 11Dosage 11Taken how often 11

Medication 12Dosage 12Taken how often 12

Medication 13Dosage 13Taken how often 13

Authorization for Release of Medical Records To

By signing this form, I authorize Texas Heart & Valve Specialist 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 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.

Your name on the authorizationHIV/AIDS initialHIV/AIDS date

Limitations on the information you may release

Release to nameStreetCityStateZip code

Reasons or purpose for this release

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 signature (or parent, guardian, or legal representative)

Date

Authorization for Release of Protected Health Information

Patient nameContact information

May we leave messages in your voicemail

YesNo

Person 1 namePhoneStreetCityStateZip

Person 2 namePhoneStreetCityStateZip

Person 3 namePhoneStreetCityStateZip

This authorization shall be in force untilReasons or purposes for this release

I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to Dr. Mushtaque Ahmed, M.D. A revocation is not effective to the extent that the practice has relied on this authorization, or if this authorization was obtained as a condition of obtaining insurance coverage. Information disclosed may be subject to redisclosure and may no longer be protected by federal HIPAA privacy regulations. The practice will not condition treatment, payment, enrollment, or eligibility for benefits on whether I provide this authorization.

Signature of patient or personal representative

DateName of patient or personal representativeDescription of personal representative's authority

Acknowledgement of Review of Notice of Privacy Practices

I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.

Signature of patient or personal representative

DateName of patient or personal representativeDescription of personal representative's authority

Authorization for Release of Medical Records from Another Facility to THV

Patient nameDOBSocial Security number

I hereby authorize the release of information contained in my medical records to Texas Heart & Valve Specialist, Mushtaque Ahmed, M.D. The information being released will be used for medical purposes. The authorization is valid for one year from the date of signing. The patient or his/her representative may revoke this consent at any time.

Patient signature

Date

Medicare and Commercial Insurance — Signature on File

I hereby request that payment of authorized Commercial Insurance and/or Medicare benefits be made on my behalf to Texas Heart & Valve Specialist, Dr. Mushtaque Ahmed, for any services furnished me. 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 for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare assigned cases, the provider agrees to accept the charge determined by the Medicare carrier as full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services.

Patient's printed name

Patient's signature

Date

Patient Information Form

Patient Medication List

Review of Systems

Cardiovascular

Ears, Nose

Eyes

Psychiatric

Integumentary

Gastrointestinal

Musculoskeletal

Neurological

Respiratory

Genitourinary

Authorization for Release of Medical Records To

Authorization for Release of Protected Health Information

Acknowledgement of Review of Notice of Privacy Practices

Authorization for Release of Medical Records from Another Facility to THV

Medicare and Commercial Insurance — Signature on File