New Patient Information Form

To save you time in the office and to ensure efficiency, please complete the following secure New Patient Information Form prior to your appointment. Complete if you have not been seen in over 2 years or are seeing Dr. Singh for the first time.

If you would like to download and print this form, you may do so by clicking here and saving the PDF to your computer to print, complete, then scan or fax the form to our office.

IMPORTANT NOTE: This form is 256-bit encrypted to ensure your information remains safe at all times. If you have any concerns about the safety of using this webform, please contact our office.

Patient Information



disclosed for















MaleFemale




SingleMarriedDivorcedWidow/Widower

WhiteAfrican AmericanHispanicEast IndianSoutheast AsiansOther







Emergency Contact








Insurance Information









SelfSpouseChildOther









SelfSpouseChildOther

How Did You Hear About Us?

Referred ByIns. DirectoryFriendYellow PagesDirect MailPhysicianLA Fitness



dodo not

Do you currently have an Advanced Directive? yesNo Please list the responsible party for this document

AUTHORIZATION FOR RELEASE OF INFORMATION- I hereby authorize this practice to furnish any medical information requested by insurance companies with whom I have coverage or any public agency which may be assisting in payment of my care.

ASSIGNMENT OF BENEFITS- I hereby authorize payment directly to this practice of benefits otherwise payable to me including major medical insurance and payment of surgical or medical benefit , but not excess the charges for these services understand that I am financially responsible for charges not covered by this assignment.

GUARANTEE OF ACCOUNT- For service furnished by Atlanta Heart Specialists, LLC.. I hereby guarantee the payment of all account for service rendered. For payment of said accounts for service I hereby waive all claims of exemption under the State Of Georgia to pay, if necessary, all costs of collection, including attorney's fee.



Atlanta Heart Specialists - Review Of Systems

(to be filled out if not done in the past 3 months)



Please Indicate Below. Are You Currently Experiencing Any Of These Symptoms:

General, constitutional

noyes
noyes
noyes
noyes

Musculoskeletal

noyes
noyes
noyes
noyes
noyes
noyes

Eyes and vision

noyes
noyes
noyes
noyes

Skin and breasts

noyes
noyes
noyes
noyes

Ears, nose, throat

noyes
noyes
noyes
noyes
noyes
noyes

Neurological

noyes
noyes
noyes
noyes
noyes
noyes

Genitourinary

noyes
noyes
noyes
noyes
noyes

Psychiatric

noyes
noyes
noyes
noyes
noyes

Respiratory

noyes
noyes
noyes
noyes

Endocrine

noyes
noyes
noyes
noyes
noyes

Gastrointestinal

noyes
noyes
noyes
noyes
noyes
noyes

Hematologic/ Lymphatic

noyes
noyes
noyes
noyes
noyes
noyes

Ahs – New Patient Visit Form

(Complete if you have not been seen in over 2 years or are seeing MD for the first time)




malefemale

Cardiac History:


Echo (cardiac ultrasound)Stress testNuclear stress testHeart Cathothers

Do you:

  • yesno
  • yesno
  • yesno
  • yesno
  • :
    :
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno
  • yesno


yesno
yesno

Past Medical History:




Family History:











yesno

#


Psycho-Social History:

SingleMarriedDivorcedWidowedCommon law partner
Employedunemployeddisabledretiredstudent
yesno
yesno

Vascular Screening:

yesno
yesno
yesno
yesno
yesno
yesno
yesno
yesno
yesno



Atlanta Heart Specialists,Llc

Financial Policy

We are committed to meeting your healthcare needs. Our goal is to keep your insurance or other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner, we ask that you adhere to the following guidelines:

  1. You are ultimately responsible for payment of ALL charges for services received from our office.
  2. Our Office will verify benefits for office visits and testing but we rely greatly on the information given to us by your insurance. If you believe that a deductible and co-insurance will apply to any of services provided by Atlanta Heart, please contact your insurance company for a confirmation. It is the responsibility of the patient to know what their insurance benefits are for any given test, office visit or labs.
  3. Our office will provide you with an estimate of your responsibility, upon request. These quotes are estimates only and may be more or less after your insurance company has processed your claims.
  4. If you have been notified by our office that your insurance has approved your testing, this doesn't guarantee that your insurance company will pay the test at 100%. Deductible and co-insurance still applies.
  5. It is your responsibility to provide us with your current address, telephone number and insurance information at each visit.
  6. Medicare patients, please keep us updated with your most current Medicare HMO Plan.
  7. It is your responsibility to contact your insurance carrier to confirm that the doctor you are seeing is a participant of your plan. If you see a doctor that is not currently on your plan, we will bill for that date of service. Upon receipt of payment from your Insurance Company any unpaid balance will be your responsibility.
  8. If your plan requires a referral from your primary care physician we will try to obtain one for you but you are ultimately responsible for knowing if we have received a referral or not. If we do not receive a referral from your primary care physician you will be billed for services provided.
  9. No study will be performed until financial arrangements have been made with the billing office and all balances have been paid off!!! A 50% deposit is required at the time of service for all testing.
  10. Our office charges a $25.00 for a returned check.
  11. We will mail you a monthly statement for any outstanding balance. If your insurance carrier has not paid within 30 days for the date of service, PLEASE contact your carrier and assist us in getting the claim paid.
  12. SELF PAY: You must bring the full amount due to your first visit.A 50% deposit is required at time of services for all test scheduled. Payment plans are offered for the remainder of the balance only.
  13. We will try our best to assist you anyway possible with your Bills. Any balance that is over 90 days old will be transferred to an outside collections agency for credit reporting. A patient that has been placed in collections must pay any prior balance owed to the practice, COLLECTION AGENCY FEES and any attorney fees in cash before the practice will schedule any future appointments.
  14. If you are experiencing financial difficulties that will make the payment of our charges difficult for you, please contact any of a Patient Account Representatives at (770) 638-1400. Please do not leave a message as someone will be able to help you at the time of your call.

If you cannot make a payment in full on your existing balance ONLY (payment plans do not apply to future visits or tests) our payment schedule is as follows:

  • Balance

  • 0-$99
  • $100-$499
  • $500-$999
  • Payment Per Month

  • $25.00
  • $50.00
  • $100.00
  • Balance

  • $1000-$2500
  • $2500-$5000
  • Payment Per Month

  • $200.00
  • $300.00

I acknowledge that I understand and accept this financial policy as a patient at Atlanta Heart Specialists.





Board Certified in Cardiovascular Disease
Consultative & Preventative Cardiology, Echocardiography, Nuclear Stress Testing, Carotid and Peripheral Ultrasound

Atlanta Heart Specialists,Llc

Tucker
Ph:770-638-1400Fax:770-638-1411
1468 Montreal Rd East. Tucker, GA 30084
Johns Creek
Ph:770-622-1622Fax:770-622-1627
4375 Johns Creek Parkway, Ste 350.Suwanee, GA 30024
Cumming
Ph:678-679-6800Fax:678-679-6804
1505 Northside Blvd. Ste 2500.Cumming, GA 30041
Dmc Lithonia
Ph:678-578-8900Fax:678-578-8905
5910 Hillandale Dr. Ste 350. Lithonia, GA 30058
Dmc Decatur
Ph:404-856-3550Fax:404-856-3557
2665 N. Decatur Rd. Ste 320, GA 30030.
  • David H. Song, MD, FACC;
  • Sandeep Chandra, MD, FACC;
  • Linda G. Yan, MD, FACC;
  • David D. Suh. MD, FACC;
  • Anthony Dorsey, MD, FACC;
  • Narendra Singh, MD, FACC;
  • Osman Ahmed, MD, FACC;
  • Tenecia Allen, MD;
  • Zoubin Alikhani, MD, FACC;
  • Binu Kunjummen, MD;
  • Bakhtiar Ali,MD

Patient Communication Preference

I authorize the following persons to have full access to my health information:










I, give my permission for you to leave any medical or laboratory information regarding my health information at the following:





I, the undersigned, give my permission for Atlanta Heart Specialists, LLC, to disclose my health information as described herein. Any changes to my communication preferences must be submitted in writing. Atlanta Heart Specialists is released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.



Atlanta Heart Specialists,Llc

1468 Montreal Rd East. Tucker, GA 30084, Ph: 770-638-1400, Fax:770-638-1411
4375 Johns Creek Parkway, Ste 350.Suwanee, GA 30024, Ph:770-622-1622, Fax:770-622-1627
5910 Hillandale Dr. Ste 350. Lithonia, GA 30058, Ph: 678-578-8900, Fax:678-578-8905
1505 Northside Blvd. Ste 2500.Cumming, GA 30041, Ph:678-679-6800, Fax:678-679-6804
2665 N, Deactur Rd, Ste 320, Decatur, GA 30033, Ph:404-856-3550, Fax:404-856-3558
5669 Peachtree Dunwoody Rd, Ste 345, Atlanta, GA 30342, Ph: 470-225-6117, Fax: 470-225-6120
4120 Five Forks Trickum Rd, Ste 103,Lilburn, GA 30047, Ph: 770-255-3491, Fax: 770-255-3497
771 Old Norcross Rd, Ste 310,Lawrenceville, GA 30046,Ph: 770-513-5999, Fax: 770-513-5994
  • David H. Song, MD, FACC;
  • Sandeep Chandra, MD, FACC;
  • Linda G. Yan, MD, FACC;
  • David D. Suh. MD, FACC;
  • Anthony Dorsey, MD, FACC;
  • Narendra Singh, MD, FACC;
  • Osman Ahmed, MD, FACC;
  • Zoubin Alikhani, MD;
  • Binu Kunjummen, MD;
  • Bakhtiar Ali,MD;
  • Jose A. Torres, MD
  • George Scleparis, MD FACC
  • Nagav Amar Kommuri, MD
  • Taslima Bhuiyan, MD

Authorization For Disclosure of Health Information





1. I hereby authorize Atlanta Heart Specialists,LLC to: (√check one)
disclose information to ORobtain information from







2. This information is to be disclosed for the period(s) of healthcare: (date) to (date)

Information To Be Disclosed (Please Check √)

Entire RecordX-Ray ReportsCardiac Cath ReportLaboratory TestsStress Test ReportOffice NotesEKGEcho ReportVideotape, DigitalOther

3. I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information.
4. I understand this authorization may be revoked by me in writing at any time, except to the extent that action has been taken in reliance on this authorization. Unless otherwise revoked, this authorization will expire in 12 months following the date signed.
5. RESEARCH: Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' needs for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave Atlanta Heart Specialists, LLC. We will almost always ask for your specific permission if the researcher will have access to your name or other information that reveals who you are, or will be involved in your care at Atlanta Heart Specialists, LLC.
6.I have been given a copy of the Atlanta Heart Specialists, LLC, HIPPA policy and E-Prescribe notification.
I, the undersigned, have read above and authorize Atlanta Heart Specialists to disclose such information as herein contained. This office is released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I understand the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer be protected.