Columbus Cardiology Associates
2525 Williams Road, Columbus, GA 31909
706-243-0446 Fax 706-324-5695

 

HAVE YOU SEEN ANY OF THE DOCTORS IN THIS PRACTICE BEFORE? YES / NO

Alonzo E. Jones, M.D. William Macheski, M.D. John P. Byers, M.D.
Edward A. Matthews, D.O. Mahesh N. Patel, M.D.
Hiren Shah, M.D.


PATIENT INFORMATION
Referred By:
Initial Visit Date:
Name:
 
Date Of Birth:
SSN:
Home Phone:
Work Phone:
Cell Phone:
 
Day Time Phone Mon thru Fri 8:00am to 5:00pm :
 
Age:
Sex:
Home Address: Street: City: State: Zip:
Employer:
 
Spouse Name:
Date of Birth:
Spouse’s SSN:
 
Spouse’s Employer:
Work Phone:
Emergency Contact:
 
Relationship:
Phone #:
PRIMARY INSURANCE
      
Company Name:    
Policy Number:    
Ins. Co 1-800 Number:    
     
 
 
HIPPA Notice of Privacy Practices
Acknowledgement of Receipt
I have been given a copy of the Columbus Cardiology Associates brochure of Privacy Practices.
 
Patient name
date of birth
  
  Patient Signature
 
Authorization for Family, Friends or Advisors to Receive Information About Your Medical Condition Or The Status Of Your Bill.

I authorize the following individual(s) to receive written and /or oral communications about my medical condition, care, appointments, and the status of my bill. I understand that they will need to be able to provide the last four digits of my social security number for oral communication. If they should come to pick up a prescription, or to discuss my care or the status of my bill, they will need to bring a photo id.

Authorized Individual(s) (Please enter name(s))
 
Financial Policy
Look here for help understanding insurance, Medicare and other payment issues.


No Insurance
Patients are expected to pay 100% at time of service, if the visit exceeds the cost of $ 200.00, the patient is responsible for a minimum of $ 200.00, and will be asked to sign a budget payment contract.

Medicare Part B Only
Patients will be asked for 20% at the time of service. Medicare will be filed. Patients are responsible for their yearly deductible. All balances up to $ 200.00 must be paid in full at the time of service.

Medicare with 2nd Insurance Contract
Columbus Cardiology Associates will file the patient’s Medicare and the 2nd insurance.
Both insurances will pay Columbus Cardiology Associates.

Contract Insurance
This is a private insurance company that Columbus Cardiology Associates has signed a contract with. The patient is not asked to make a payment, unless your insurance company requires a co-payment or deductible.

Non U.S. Residents
Columbus Cardiology Associates will file insurance for the patient as a courtesy, but the patient is asked to pay 100% at the time of service.

Non U.S. Insurance
Columbus Cardiology Associates does not have the ability to file insurance for patients with out of country insurance carriers, the patient is asked to pay 100% at the time of service.

Forms of Payment Accepted
Columbus Cardiology Associates accepts cash, check, Visa, MasterCard and Discover. If situations warrant, our patient representatives will be happy to work out a payment plan. If you have any questions or concerns, please feel free to contact our Billing Department at 706-243-0488.

Columbus Cardiology Associates charges $ 25.00 for all forms (disability, handicap and insurance) that requires Physician completion. There is a 30 day turn around time for completion.

 
   
History and Physical
Patient Name:
DOB:
   
Chief Complaint:
Referring M.D
   
Past Medical History
Coronary heart disease (heart disease) Chest Pain
Palpitation (rapid heart beat or fluttering feeling) Anxiety
Hypertension (high blood pressure) Depression
Hyperlipidema (high cholesterol) CVA (Stroke)
PVD (Peripheral Vascular Disease) Claudication Kidney Disease
Asthma/Bronchitis Thyroid Disease
Dizziness/syncope TB, Hepatitis, HIV/AIDS
Smoking Drug Use
Alcohol Consumption Diabetes
WOMEN ONLY   WOMEN ONLY  
Last Menstrual Period Age of Menopause
 
PAST HOSPITALIZATION/SURGERY/INTERVENTIONS/MAJOR ILLNESSES
Date
Reason
Date
Reason
 
Ethnicity: If other, list here
 
FAMILY MEDICAL HISTORY
Disease   Relation/Age of Onset
Heart Disease
High Blood Pressure
Stroke
Peripheral Vascular Disease
Kidney Disorders
Thyroid Disorder
Diabetes
Bleeding Disorders
Allergies to Medications, IV Dye, etc.
Other Concerns:  
     
 

PLEASE READ AND SIGN: 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 intermediates or carriers any information
needed for this or a related Medicare/Insurance claim. I permit a copy of this authorization to be used in
place of the original, and request payment of medical pertaining to Medicare assignment of benefits apply. This
authorization applies to other health coverage I have.
 
Signature:
Date:
* Payment is requested at Time of Service. * Thank you