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Delaware Heart & Vascular, P.A. Eden Hill Medical Center

200 Banning Street, Suite 340 Dover, DE 19904

(302) 734-1414 Phone Judith A. Ripper!., D.O., F.A.e.e. (302) 734-2121 Fax Vincent D. Abbrescia, D.O., F.A.e.C.

NEW PATIENT QUESTIONAIRE

Name: Age: ______ Date:

Reason for your visit today: ____________________________________ Other physicians you have seen: ______________________________

Past History: (Please include all your health problems, such as asthma, diabetes, heart disease, high blood pressure:

Surgical operations/ Procedures: Please list al.1 the operations and procedures you have had, such as heart bypass, angioplasty, cardiac catheterization, appendix removal, etc.:

Year Year Year Year Year Year Year Year

Allergies: Please check on the line for any allergies that you know about: __Aspirin Codeine __Penicillin

Anesthetics Demerol __Sulfa Drugs Other than on list.

Do you smoke? Yes _ No _ Have you ever smoked? __ How Long? __Quit_ Medications: Please list al.1 medications you are currently taking with mg and how many times a day you take it. (Example: Toprol XL 50mg one tab daily)

How much aspirin do you take each day (if any)? ___________________________ Do you take birth control pills? _________________________________________ Hobbies and activities

Exercise: Type:____________ Frequency:___________________________

Please turn page over

Please check any problems you are having currently:

".U'"'''''''' in or feet __Difficulty in balance

Dizziness

congestion Shortness of breath

or ankles bleeds

of the heart __Chest pain or tightness

in shoe size blood cholesterol

thirst

of the legs __Cough

up blood __Wbeezing __Night Sweats

more than 5 days __Difficulty swallowing __Vomiting

__Constipation __Bloody bowel movements

pain bowel movements

Hemorrhoids

of appetite

loss gain

sleeping __Difficulty thinking

urination with urination

__Blood in urine in urine

__Difficulty urinating __:L";;;,......,/,;'" of urine

Family History: Please include age, health and cause of (if deceased): Father: [living / deceased] _________________________ Mother: [living /

Thank you for taking time to complete our form! This will help us to review your history more completely.

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Delaware Heart & Vascular, P.A. Eden Hill Medical Center

200 Banning Street, Suite 340 Dover, DE 19904 Vincent D. Abbrescia, D.O., FAC.C.

(302) 734-1414 Phone Judith A. Ripper!, D.O., FAC.C. (302) 734-2121 Fax Sanjeev Patel, MD, MRCP

PATIENT INFORMATION SHEET

Patient Name: Date: _________ Last, First Middle

Mailing Address: ________________________City: _________ State: __Zip:

Date of Birth: Social Security No.: _________________

Gender: Male Female Marital Status: _married _single

Home telephone: May we leave a message? _YES _NO

Cell Phone: May we leave a message? _YES _NO

Primary Care Physician: _____________________ Referring Physician: _________________

E-mail address:

Employer: _______________

Work Phone: __________ May we call you at work? _YES _NO

Who may we contact in an emergency? Name: _________________ Relationship:________ Home Phone: Cell Phone: ________ Work Phone: ________

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you finish reading.

Patients are responsible for the services rendered. Necessary forms (including referrals) will be completed to help expedite insurance carrier payments, however, the patient is responsible for all fees, regardless of insurance coverage. It is also required that payment for co-payments is rendered at the time ofservice. I understand that if incorrect or improper insurance information or referrals are not obtained for my visit(s), my appointment may be cancelled and I may be billed for the amount(s) due on the account.

Patient Signature ______________________________________________ Date _________________

I request that payment of authorized Medicare/Other Insurance company benefits be made directly to Delaware Heart and Vascular on my behalf for any services furnished to me by the party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.

Patient Signature _______________________________________________ Date ___________________

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or related Medicare claim/other Insurance Company claim. I understand that any or all of my medical information may be used for blinded-data research, in which none of the date will be linked to my identity. I understand that my medical information may be electronically submitted to any or all of my treating physicians, hospitals and/or medical insurance benefits to the party who accepts assignment.

Patient Signature _______________________________________________ Date ___________________

ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)

NOTE: If your insurance carrier does not pay for any services rendered by the provider, you will be responsible for the balance of

the fees for services rendered. Primary Health Insurance does not pay for every service provided, includi ng some care that you or

your health care provider have good reason to think you need. The provider of the service will submit all claims to the insurance

carrier (s) listed below in attempt to obtain an official decision on payment. However, if the insurance carrier does not pay for

services rendered, then the healthcare provider is not liable.

PRIMARY INSURANCE: __________________

Member or Policy # Group #: _____

Policy Holder's Name: DOB: _______

Does your insurance require referrals? _YES _NO Co-Payment: $,____

SECONDARY INSlJRANCE: ________________

Member or Policy # ___________ Group#: ______

Policy Holder's Name: __________ DOB: _______

THIRD INSURANCE: ___________________

Member or Policy # ___________ Group #: _____

Policy Holder's Name: __________ D08: _______

MEMBERID: DATE OF BIRTH: Medicaid does not pay for all your healthcare costs. Medicaid only pays for covered tests and services when Medicaid rules are met, based on your coverage program. If you are enrolled in a limited coverage program, you may be balance billed for non-covered services. Limited coverage guidelines apply. Medicaid FulllLimited Coverage Programs include: (please select your plan (s»

o Medicaid of DE 0 Full coverage 0 Family Planning and related services

0 Chronic Renal Disease Program 0 Qualified Medicare Beneficiary

0 DE Healthy Children Program 0 Long Term Care

0 DE Prescription Assistance 0 Hospice

0 DE Cancer Treatment Program 0 Transportation

o Delaware Physicians Care o Diamond State Partners o Unison Health Plan

Patient eli will be verified b the Healthcare Provider's Office

Additional Information:

Signing below means that you have received a copy of this notice and understand its contents. I understand that if my account is placed in collections, I will be responsible for any collection and attorney fees that are incurred to collect my debt.

Date:IS;'....,,'

Note: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in your chart in our office. If a claim is submitted to insurance, your health information on this form may be shared with the payor as per federal guidelines. Revised 2/1113

Delaware Heart & Vascular, P.A. Vincent D. Abbrescia, D.O., F.A.C.C. ▪ Judith A. Rippert, D.O., F.A.C.C. ▪ Sanjeev B. Patel, M.D., M.R.C.P., F.A.C.C. ▪ Laura Gravelin, M.D.

Milford Medical Annex

112 Sussex Avenue, Suite 101 Milford, DE 19963

(302) 393-5500 Phone (302) 422-6129 Fax

 

      Authorization for Disclosure of Health Information  

Patient Name: _______________________________________________________________ Date of Birth: _____/_____/_____/  

Address: ___________________________________________City: ____________________ State: ___________ Zip: _________ 

E‐Mail Address: ______________________________ Phone: ______________________Social Security #: XXX – XX ‐ __ __ __ __ 

 

I request that my protected health information (PHI) from __________________________________________be disclosed to: 

Recipient Name: __________________________________________________________________________________________ 

Address: ___________________________________________ City: ____________________ State: ___________ Zip: ________ 

E‐Mail Address: ______________________________________Phone: _______________________________________________ 

Fax (healthcare provider only): ______________________________________________________________________________ 

 

I authorize the following PHI to be released from my medical record(s): 

 Discharge Summary     Test Results: Date: ____________ Type:__________   Consultation Reports Date:  __________ 

 History and Physical     Radiology Report Date: _________       EKG Report Date _________ 

 Operative Report     Emergency Room Record Date: ___________     Laboratory Report Date: ________ 

  Progress Notes   

Detailed Description: ______________________________________________________________________________________ 

Other: __________________________________________________________________________________________________ 

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency  

syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment  

of alcohol or drug abuse. 

State and Federal Law protect the following information. If this information applies to you, please indicate if you would like this information released/obtained  

(include dates where appropriate): 

Alcohol, Drug, or Substance Abuse Records   Yes    No     Dates: ______________________________________________________________ 

HIV Testing and Results     Yes    No     Dates: ______________________________________________________________ 

Mental Health or Psychotherapy Records   Yes    No     Dates: ______________________________________________________________ 

Covering the period of health care from:   Specific Date(s): _______________________________ to ______________________________  

OR                   All past, present and future encounters/visits. 

 

Purpose for requesting information:  Legal    Insurance   Personal   Continuation of Care 

Disclosure Format (Paper is default if not marked):  US Mail – paper format,   FAX (healthcare provider only)   E‐Mail [Encrypted] OR   CD – secure  

 By signing this authorization form, I understand that:  

 Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations. 

 I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Health Information Management  

   Department at DH&V, 200 Banning Street, Suite 340, Dover, DE 19904). Revocation will not apply to information that has already been disclosed in response to this  

   authorization. 

 Unless otherwise revoked, this authorization will expire on the following date/event/condition: ________________________________ 

   If I fail to specify an expiration date/event/condition, this authorization will expire one year from the date signed. 

 Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization. 

 Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules. 

 

I certify that I have read the provisions set forth in this authorization. I understand and agree to its terms. 

 

________________________________________  ____/____/____     _______________________________________  ____/____/____ 

(Signature of Patient)                               (Date)       (Signature of Witness)                            (Date) 

 

If you are signing as a Personal Representative for the above patient, you will be asked to provide proof of your identity and of your authority to sign for the patient.  

Please fill out and sign below: 

 

Your name (please print): ________________________________________________________ Your relationship to the patient: _______________________________ 

 

Your signature: ________________________________________________________________  Date: _____/_____/_____ 

FOR OFFICE USE ONLY: 

Information released by: _________________________________________________________ Date: _____/_____/_____

Eden Hill Medical Center 200 Banning Street, Suite 340

Dover, DE 19904 (302) 734-1414 Phone

(302) 734-2121 Fax

Smyrna-Clayton Medical Service Center 315 North Carter Road

Smyrna, DE 19977 (302) 734-1414 Phone

(302) 734-2121 Fax

Acknowledgement of Delaware Heart & Vascular Notice of Privacy Practices

The signature below only acknowledges receipt of the DH&V Notice of Privacy Practices,

effective date 1 May 2006

_______________________________________ ________________________

Name of Patient Date

__________________________________________________

Signature

________________________________________ _________________________

Name of Representative Relationship (if applicable)

I hereby authorize DH&V to release my medical information to:

________________________________________ __________________________

Name Relationship to Patient

________________________________________ __________________________

Name Relationship to Patient

________________________________________ __________________________

Name Relationship to Patient

___________ Patient / Representative declined to sign

___________ DH&V staff initials

Delaware Heart & Vascular, P.A. pp.a.

Eden Hill Medical Center

200 Banning Street, Suite 340

Dover, DE 19904

(302) 734-1414 Phone

(302) 734-2121 Fax

Vincent D. Abbrescia, D.O., F.A.C.C.

Judith A. Rippert, D.O., F.A.C.C.

Sanjeev Patel, M.D., M.R.C.P.

Delaware Heart & Vascular, P.A. Vincent D. Abbrescia, D.O., F.A.C.C. ▪ Judith A. Rippert, D.O., F.A.C.C. ▪ Sanjeev B. Patel, M.D., M.R.C.P., F.A.C.C. ▪ Laura Gravelin, M.D.

Milford Medical Annex

112 Sussex Avenue, Suite 101

Milford, DE 19963

(302) 393-5500 Phone

(302) 422-6129 Fax

NOTICE OF PRIVACY POLICY

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU THAT CAN BE IDENTIFIED WITH YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Delaware Heart & Vascular, P.A. is required, by law, to maintain the privacy and confidentiality of your protected health information (PHI) and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. We may use and disclose your health care information in the following ways without specific authorization: Treatment

Delaware Heart & Vascular, P.A. may disclose your PHI to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. Many of the people who work for us, including but not limited to our doctors and nurses, may use your PHI in order to treat you or to help others in your treatment. We may disclose your PHI to others who may assist in your care, such as healthcare providers outside of our practice, or to a spouse, child, or parent who is involved in your care Examples are: We could disclose your PHI if it is necessary to seek consultation regarding your condition from other health care providers associated with our practice. In the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation, without advance notice to you, we could disclose your PHI to a substitute health care provider for the purposes of assessment and treatment of our patients. We may disclose your PHI to a pharmacy when ordering a prescription for you, or to a laboratory when ordering lab tests to help us reach a diagnosis. Payment Delaware Heart & Vascular, P.A. may disclose your health information to your insurance provider for the purpose of payment or health care operations. For example: We may contact your health insurer to certify that you are eligible for benefits and we may disclose your treatment plan to determine if your insurer will pay for your treatment. Our practice may submit an itemized billing statement to your insurance carrier for the purpose of payment for health care services rendered. If you pay for your health care services personally, we may provide an itemized billing to your insurance carrier for the purpose of reimbursement to you, unless you request otherwise. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received. If you request that your insurance not be notified of services that you have paid for out of pocket, we take every reasonable precaution to avoid their notification. Operations Delaware Heart & Vascular, P.A. could use your PHI in our business operations. Operations are any activities that are necessary to run our business. We may use your PHI for the purposes of quality assessment, or to conduct cost management and business planning activities. Your PHI may be disclosed to other health care entities to assist them in their billing or health care business operations. Business Associates Delaware Heart & Vascular, P.A. may disclose your PHI to our business associates under a Business Associate Agreement. Examples of potential business associates include: multiple vendors, answering services, transcription services, accounting services, billing and coding services, document shredding services, or attorney/legal services. Business Associates are HIPAA compliant and are equally accountable for protecting your privacy, and they must notify us immediately if your PHI becomes compromised.

Eden Hill Medical Center 200 Banning Street, Suite 340

Dover, DE 19904

(302) 734-1414 Phone

(302) 734-2121 Fax

Smyrna-Clayton Medical Service Center

315 North Carter Road

Smyrna, DE 19977

(302) 734-1414 Phone

(302) 734-2121 Fax

Workers’ Compensation Delaware Heart & Vascular, P.A. may disclose your health information as necessary to comply with State Workers’ Compensation Laws. Emergencies Delaware Heart & Vascular, P.A. may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death. Public Health

As required by law, Delaware Heart & Vascular, P.A. may disclose your health information to public health authorities for maintaining vital statistics, for preventing or controlling disease, injury or disability, for reporting child abuse, neglect, or domestic violence, for reporting disease or infection exposure, or for reporting to the Food and Drug Administration problems with products and reactions to medications. Judicial and Administrative Proceedings Delaware Heart & Vascular, P.A. may disclose your health information in the course of any administrative or judicial proceeding. Law Enforcement

Delaware Heart & Vascular, P.A. may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, or for compliance with a court order or subpoena, or for other law enforcement purposes. We may disclose your PHI to police if they have a warrant. We may discuss your PHI with police if we believe we have evidence of a crime that occurred on our premises. Deceased Persons Delaware Heart & Vascular, P.A. may disclose your health information to coroners, medical examiners or funeral directors in order for them to carry out their duties. We may disclose your PHI to persons involved in your care or payment, unless it is contrary to your previously expressed preference. Organ Donation Delaware Heart & Vascular, P.A. may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues. Research Delaware Heart & Vascular, P.A. may disclose your health information to only researchers who are conducting research that has been approved by an Institutional Review Board and it has been determined that the disclosure poses no more than minimal risk to your privacy. Additional authorizations may be required. Public Safety Delaware Heart & Vascular, P.A. may disclose your PHI to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. Specialized Government Agencies Delaware Heart & Vascular, P.A. may disclose your health information for military, national security, prisoner and government benefits purposes. Reminder Calls Delaware Heart & Vascular, P.A. may contact you for appointment reminders. As a courtesy to our patients we

may call your home or cell phone prior to your scheduled appointment to remind you of your appointment time. If we call your home phone and you are not at home, we may leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment. If you have provided your cell phone number, the reminder message will be left on your voice mail if you do not answer.

Change of Ownership In the event that Delaware Heart & Vascular, P.A. is sold or merged with another organization, your health information/record will become the property of the new owner. Your Health Information Rights

You have the right to request to this office in writing restrictions on certain uses and disclosures of your health information. You can ask that your PHI not be shared with certain individuals, groups or companies. You can request that your PHI only be shared with certain individuals. This practice is not required to agree, but if we do agree we are bound by this agreement except when it is required by law, in emergencies, or when it is required to treat you. In the case of a minor child, both parents, or the legal guardian may have access the child’s PHI. A court order is needed to restrict parental access.

You have the right to request that your health information is received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery.

You have a right to request an amendment to your protected health information in writing. Please be advised, however, that our practice is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.

You have a right to receive an accounting of disclosures of your protected health information made by our practice.

You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

You have the right to inspect and obtain a copy of your PHI including medical records and billing records, but not including psychotherapy notes, within 30 days of your written request. You may be charged a fee, as determined by Delaware State Code (Title 24 30.0) for the labor and supplies involved with copying. You may request an electronic copy of your record, or you may request electronic transmission of your record to a designated third party. This request must be made in writing. If this practice has the capability of producing an electronic format agreeable to you, it will be provided within 30 days. Otherwise a paper copy will be provided.

Your specific authorization is required for use and disclosure of all information not included in this Notice of Privacy Practices. This includes, but is not limited to, psychotherapy notes, substance abuse treatment, genetic information, HIV/Aids testing or treatment, except as required by law. Authorization is also required for some marketing purposes, including the sale of PHI. Breach of unsecured PHI Delaware Heart & Vascular, P.A. will notify you of a breach of your PHI. A “Breach” is defined as unauthorized acquisition, access, use, or disclosure of your PHI which compromises the security or privacy of that information. We understand that breaches of personal information have the potential to cause reputational, physical, or financial harm. If there is reason to believe that your PHI is breached, our practice will conduct a thorough investigation and risk assessment. If after considering all of the factors our evaluation fails to demonstrate a low probability that your privacy has been compromised, we are required by law to notify you, and the U S Department of Health and Human Services in writing. Information provided will include details of the breach, the correctional actions taken by this practice, and any actions that you should take to protect yourself further. Changes to this Notice of Privacy Practices Delaware Heart & Vascular, P.A. reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, our practice is required by law to comply with this Notice. We are required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact our practice’s Privacy Officer by calling this office at 302-734-1414 ext. 12. If the Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints

Complaints about your Privacy rights or about how Delaware Heart & Vascular, P.A. has handled your health information should be directed to our Privacy Officer by calling this office at 302-734-1414 ext.12. If our Privacy Officer is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days. There will be no retaliation for the filing of a complaint. If you are not satisfied with the manner in which Delaware Heart & Vascular, P.A. handles your complaint; you may submit a formal complaint to the Office of Civil Rights at the address below. Our Privacy officer can provide you with the correct form to file. You will not be retaliated against if you file a complaint to us, or to the Office of Civil Rights.

DHHS, Office of Civil Rights 200 Independence Avenue, S.W.

Room 509F HHH Building Washington, DC 20201

I have read the Notice of Privacy Practices and understand my rights contained in the notice. I acknowledge that I have received or have been given the opportunity to receive a copy of this Notice of Privacy Practices. I also understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the office at any time to obtain a copy. ________________________________________________ Patient’s Name or Representative (print) ________________________________________________ ______________ Patient’s or Representative’s Signature Date Revised 5/22/2013

.,-",'., '.

, I Delaware Heart & Vascular, P.A.

.,1r·· Edell Hill Medical Center.~. 200 Banning Street, Suite 340

Dover, DE 19904 Vincent D. Abbrescia, D.O.. F.A.e.e. (302) 734-1414 Phone Judith A. Rippert, D.O., F.A.e.e.

(302) 734-2121 FAX

Missed Appointment Policy

Our Missed Appointment Policy is as follows:

You will be charged a $25.00 missed appointment fee if you fail to notify our office within 24 hours of your scheduled appointment time.

Our office has an answering service and they will take a message (or you should you call the office aOer hours. All incoming calls accepted by the service are logged and i[you do not leave a message with them, there is no record ofyour call.

- The charge assessed for any missed appointment fee is due on or before your next visit.

If you have any questions regarding this policy please see our Office Manager, Terri Rosetta.

Thank You

By signing this policy, I agree to the terms stated above.

Patient: Date:

DOB: