New Patient Packet

For your convenience, you can fill out the form below, or download the PDF, print it, and complete it before your next visit to our office. We look forward to seeing you!

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New Patient Form

Step 1 of 13

Contact & Insurance Info

Name(Required)

First Middle Last

Date(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Email(Required)

Social Security No

*Required in person

Marital Status

Single

Married

Widowed

Divorced

Address(Required)

Street Address City ZIP / Postal Code

Home Phone No

Cell Phone/Work Phone No(Required)

Emergency Message Phone(Required)

Emergency Contact(Required)

Relationship(Required)

Name of Spouse

Phone

Address (If different than above)

Street Address City ZIP / Postal Code

Responsible Party(Required)

Address(Required)

Employer Name

Address(Required)

Primary Insurance Carrier(Required)

Subscriber Identification #(Required)

Subscriber Name(Required)

Referred By(Required)

Primary Physician(Required)

HEALTH APPRAISAL QUESTIONNAIRE

Patient Name:

MRN:

Date:

MM slash DD slash YYYY

Date of Birth:

MM slash DD slash YYYY

Age: _

Sex:

Male

Female

Weight:

Height:

Marital Status:

Single

Married

Widowed

Divorced

Referred by:

Primary Medical Doctor:

What is your chief complaint or referral: _

History of Present Illness:

Pressure or pain in the chest, arms, neck?

Yes

Swelling of ankles, feet, or stomach?

Yes

Dizziness, lightheadedness, blackouts, or fainting

Yes

Pain, discomfort, or cramping in legs when walking?

Yes

Palpitations, fast, skipped, or irregular heartbeats?

Yes

Temporary loss or disturbance of speech?

Yes

With activity?

Yes

Difficulty breathing?

Yes

When lying flat?

Yes

Temporary weakness of one side of body?

Yes

Other:

Current/Past Medical History

Yes

Month/Year

Coronary artery disease

Yes

Month/Year

Heart Attack

Yes

Month/Year

Cardiac catheterization/angiogram

Yes

Month/Year

Bypass Surgery

Yes

Month/Year

Angioplasty/stent

Yes

Month/Year

Defibrillator

Yes

Month/Year

Pacemaker

Yes

Month/Year

Congestive Heart Failure

Yes

Month/Year

Heart Murmur

Yes

Month/Year

Heart Valve Surgery

Yes

Month/Year

Stroke

Yes

Month/Year

Mini Stroke/TIA

Yes

Month/Year

Peripheral Ventricular Disease

Yes

Month/Year

Blood clots (lungs Legs)

Yes

Month/Year

Aneurysm

Yes

Month/Year

Hypertension

Yes

Month/Year

High Cholesterol

Yes

Month/Year

Diabetes

Yes

Month/Year

Cancer (specify _____________________ )

Month/Year

Other

Month/Year

List all surgeries:

Hospitalizations:

HEALTH APPRAISAL QUESTIONNAIRE

Patient Name:

Date:

MM slash DD slash YYYY

Tobacco use:

Current use: YES

Current use: No

Ounces/week

Liquor

Wine

Beer

Street Drugs: Marijuana

Yes

Caffeine: Current use:

Yes

Type

Amount/day:

Heart Disease

Yes

High Blood Pressure

Yes

Bypass Surgery

Yes

Stroke

Yes

Heart Attack (age under 60)

Yes

Cancer

Yes

High Cholesterol

Yes

Diabetes

Yes

Do you currently, or have you ever had any problems in the following areas?

Weight loss/gain

Yes

Tire easily, weakness

Yes

Emphysema

Yes

Asthma

Yes

Chronic Bronchitis

Yes

Wheezing

Yes

Chronic Cough

Yes

Emphysema

Yes

Chronic Bronchitis

Yes

Tuberculosis

Yes

Valley Fever

Yes

Headache

Yes

Migraine

Yes

Lumps in neck

Yes

Goiter

Yes

Blocked arteries in neck

Yes

Epilepsy

Yes

Seizures disorder

Yes

Numbness/weakness in arms/legs

Yes

Problems with speech

Yes

Blurred Vision

Yes

Cataract

Yes

Glaucoma

Yes

Dry Mouth/throat

Yes

Sinus congestion

Yes

Double vision

Yes

Ringing in the ears

Yes

Hearing Loss

Yes

Hoarseness

Yes

Allergies/Hay fever

Yes

Vertigo

Yes

Diarrhea

Yes

Constipation

Yes

Poor Appetite

Yes

Heartburn

Yes

Colitis

Yes

Indigestion

Yes

Intestinal Bleeding

Yes

Ulcers

Yes

Diverticulitis

Yes

Liver Disease

Yes

Hepatitis

Yes

Difficulty Swallowing

Yes

Hiatal Hernia

Yes

Diabetes

Yes

Thyroid Problems

Yes

HEALTH APPRAISAL QUESTIONNAIRE

Pain during Urine

Yes

Blood in urine

Yes

Difficulty in urination

Yes

Incontinence

Yes

Scaling

Yes

Easy bruising

Yes

Rash

Yes

Difficulty walking

Yes

Joint Pain

Yes

Back pain

Yes

Anxiety

Yes

Suicidal thoughts

Yes

Depression

Yes

Do you have any drug allergies?

Yes

Have you been vaccinated for pneumonia?

Yes

Have you been vaccinated for influenza?

Yes

Name of meds that you are allergic to

Penicillin:

Yes

Seafood:

Yes

Aspirin:

Yes

Iodine:

Yes

Medications take at home:

I hereby authorize__________________________________________________________________________________________ Name of Physician, Hospital, or Health Care Provider to disclose to Atul Aggarwal MD cardiology Clinic, 1018 Calloway Drive, Bakersfield CA 93312, Tel no. 6616640100, Fax no. 66166640111 my medical records and information pertaining to medical history, physical condition, services rendered, or treatment of

Patient Name:(Required)

First Middle Last

Date of Birth:(Required)

MM slash DD slash YYYY

Social Security No

*Required in person

Address:(Required)

Street Address City ZIP / Postal Code

Phone No.(Required)

The purpose of this release is:

to disclose the protected health information at my request

other

I authorize the below information to be disclosed on my behalf:

Clinic Notes

Discharge summary

Stress test report

Echo report

Catheterization report

OEKG

Any and all records for

From

Authorization shall remain in effect for one (1) year from date of signature. I understand that I may revoke this authorization at any time by sending a written request to: Atul Aggarwall MD Cardiology Clinic 1018 Calloway Drive Bakersfield CA 93312 The fact that I revoke this authorization will not affect actions taken while the authorization is voluntary and that Atul Aggarwal MD Cardiology Clinic will not sign this authorization. I understand that Information disclosed pursuant to this be considered protected health information. I am entitled to a copy of this authorization.

Signature of Member

*Required in person

Date(Required)

MM slash DD slash YYYY

: If signing as a guardian or legal representative on behalf of the member, the following information must be completed. If signing as a legal representative, a copy of a health care power of attorney, a court order, or other legal documentation demonstrating your authority as legal representative to act on the member’s behalf must be attached.

Full Name of legal representative:

Legal relationship to member:

Signature of Representative

*Required in person

Date(Required)

MM slash DD slash YYYY

I hereby assign to Atul Aggarwal MD Cardiology Clinic all medical and/or surgical benefits to which Atul Aggarwal MD Cardiology Clinic is due for my bill. By signing below, I am consenting that payments from authorized Medicare, Medicaid, Government and any other insurance or third-party benefits can be made on my behalf, and/or on behalf of all members covered under my insurance plan, directly to Atul Aggarwal MD Cardiology Clinic for services provided. This assignment will remain in effect until revoked by myself. I understand that I am financially responsible for all charges whether or not paid by my insurance. I agree to pay all the costs of collection, including, but not limited to, reasonable attorneys' I hereby authorize said assignee to release all information necessary to secure payment of said benefits.

Date(Required)

MM slash DD slash YYYY

Patient Signature:

*Required in person

Insured’s Signature:

*Required in person

If you have Medicare, please sign the following: I request that payment of authorized Medicare benefits be made either to me or on my behalf to Atul Aggarwal MD Cardiology Clinic for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance coverage is indicated in item 9 of the CMS-1500 claim form or elsewhere on their 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 physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.

Patient Signature:

*Required in person

Date(Required)

MM slash DD slash YYYY

If signature is other than patient’s signature, write in patient’s name followed by the signature of person signed, and compete the following:

Name of signing party:

Address of signing party:

Relationship of patient:

Reason patient could not sign:

I hereby authorize Atul Aggarwal MD Cardiology Clinic to furnish information to any referring physician, agency or insurance company(s) I have listed on the Patient Information Form.

Patient Signature:

*Required in person

Date(Required)

MM slash DD slash YYYY

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at openpaymentsdata.cms.gov.

Patient Signature

*Required in person

Date(Required)

MM slash DD slash YYYY

Signature of Representative

Date

MM slash DD slash YYYY

Patient Name:

Date of Birth:

MM slash DD slash YYYY

I authorize Atual Aggarwal MD Cardiology Clinic to release

All information

Limited information, as further described:

Name Relationship

I authorize Atul Aggarwal MD Cardiology Clinic, its physicians and employees to leave messages regarding:

Any information (including test results)

Limited information, as further described: _

Home:

YES

Number

Cellular:

YES

Number

Work:

YES

Number

The purpose of this release is to disclose the protected health information at my request. I understand that this authorization will remain in effect for one year from the date of signature. I also understand that I may revoke this authorization for Release of Medical Information at any time by sending a written request to: Atul Aggarwall MD Cardiology Clinic 1018 Calloway Drive Bakersfield CA 93312 The face that I revoke this authorization will not affect actions take while the authorization was in effect, before the revocation is received. I understand that this authorization is voluntary and that Atul Aggarwal MD cardiology Clinic will not condition treatment, payment, enrollment, or eligibility for benefits upon whether I sign this authorization. I understand that information disclosed pursuant to this authorization could be subjected to re-disclosure by the recipient and might no longer be considered protected health information. I am entitled to a copy of this authorization.

Signature of Member

*Required in person

Date(Required)

MM slash DD slash YYYY

If singing as a guardian or legal representative on behalf of the member, the following information must be completed. If signing as a legal representative, a copy of a health care power attorney, a court order, or other legal documentation demonstrating your authority as a legal representative to act on the member’s behalf must be attached.

Full Name of legal representative:

Legal relationship to member:

Signature of Representative

*Required in person

Date

MM slash DD slash YYYY

I hereby give consent/authorization to Atul Aggarwal MD Cardiology Clinic to use or disclose, either verbally or in-writing, my protected health information for the purposes described in this Notice of Privacy Practices.

Signature of Patient or Legal Guardian

*Required in person

Date(Required)

MM slash DD slash YYYY

Print name of Patient

Date

MM slash DD slash YYYY

Print Name of Parent of Legal Guardian

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY. This Notice of Privacy Practices (the “Notice”) describes the legal obligations of Atul Aggarwal MD Cardiology Clinic (the “Clinic”) and your legal rights regarding your protected health information held by the Clinic under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). This notice of privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control of your protected health information. “Protected Health Information” (“PHI”) is individually identifiable health information, including demographic information, collected from you or created by a health care provider, that relates to (1) your past, present, or future physical or mental health or condition; (2) the provision of health care to you; or (3) the past, present or future payment for the provision of health care to you

Maintain the privacy of your PHI; • Provide you with certain rights with respect to your PHI; • Provide you with a copy of this Notice of our legal duties and privacy practices with respect to your PHI; and • Follow the terms of the Notice that is currently in effect. We reserve the right to change the terms of this Notice and to make new provisions regarding your PHI that we maintain, as allowed or required by law.

Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, billing for services provided,, to supporting the operation of the physician’s practice, and any other use required by law.

We may use or disclose your PHI to facilitate medical treatment or services by providers. We may disclose medical information about you to providers, including doctors, nurses, technicians, medical students, or other hospital personnel who are involved in taking care of you. For example, the clinic might disclose information about you to a another physician who is treating you.

We may use or disclose your PHI to facilitate payment for the treatment and services you receive. For example, the Clinic may tell your health insurance plan about treatment to obtain approval or to determine whether your plan will pay for the treatment.

We may use and disclose your PHI for other health care operations. These uses and disclosures are necessary to run the Clinic. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, the Clinic may use and disclose your protected health information to medical students involved in direct patient care in our office. In addition, we may use a sign-in sheet at the registration desk to obtain your name and physician. We may also call you by name in the waiting room when you are being escorted to the back office.

We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services. In order to perform these functions or to provide these services, Business Associates will receive, create, maintain, use, or disclose your PHI, but only after they agree in writing with use to implement appropriate safeguards regarding your PHI.

When you request, we are required to disclose to you certain portions of your PHI. We are also required, when requested, to provide you with an accounting of most disclosures of your PHI where the disclose was for reasons other than for payment, treatment or health care operations, and where the protectedPHI not disclosed pursuant to your individual authorization.

The Clinic may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose your PHI in certain situations when required by state or federal law without your authorization. These situations include: As required by Law: Public Health issues as required by law; Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners; Medical Examiners; Funeral Directors; Organ Donation; Research; Criminal activity, Military Activity; National Security; Worker’s Compensation; Inmates - required Uses and Disclosures; Government Audits. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of 45 CFR Subpart E.

We will disclose your PHI to individuals authorized by you, or to an individual designated as your personal representative, attorney-in-fact, etc., so long as you provide us with a written notice/authorization and any supporting documents (i.e., power of attorney). Note: Under the Privacy Rule, we do not have to disclose information to a personal representative if we have a reasonable belief that: 1. You have been, or may be, subjected to domestic violence, abuse or neglect by such person; 2. Treating such person as your personal representative could endanger you; or 3. In the exercise of professional judgment, it is not in your best interest to treat the person as your personal representative.

Other uses or disclosures of your PHI not described above will only be made with your written authorization. Uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI require authorization. You may revoke written authorization at any time, so long as the revocation is in writing. Once we receive your written revocation, it will be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon written authorization and prior to receiving your written revocation.

The Following is a statement of your rights with respect to your PHI:

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information complied in reasonable anticipation of or use in, a civil, criminal or administrative action or proceeding, and PHI that is subject to law that prohibits access to protect health information.

You have the right to request a restriction or limitation on your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or healthcare operation. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care of for notification purposed as described in this Notice of Privacy Practices. You have the right to restrict certain disclosures of PHI to health plan where you pay out of pocket in full for the health care items or services we provide. Your request must state the specific restriction requested and to whom you want the restriction to apply. Except in limited circumstance, or where you pay out of pocket in full, we are not required to agree to a requested restriction.

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy

If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request, in writing, an amendment for as long as the information is kept by or for the Plan. If we deny your request or amendment, you have the right to file a statement of disagreement with us and any future disclosures of the disputed information will include your statement. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured PHI

You have the right to receive an accounting of certain disclosures we have made, if any of your PHI.

If the Clinic were to decide to engage in fundraising, you would have the right to opt out of receiving these fundraising communications at the time of the solicitation.

You may complain to use or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by Atul Aggarwal MD Cardiology Clinic. You may file a compliant with Atul Aggarwal MD Cardiology Clinic by notifying our office of your compliant. Retaliation against any patient of this practice for filing a complaint against this practice is strictly prohibited

If you have any questions about this policy or need further information, please contact Sonali Aggarwal, the Clinic’s Privacy Officer, at (661) 664-0100.

This notice was published and became effective on or before April 14, 2003. Rev.(2): February 1, 2023 You may revoke any authorization at any time in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

If an appointment for an ultrasound or treadmill stress test is missed, canceled or changed with less than 24 hours notice, there will be a $25 charge. By signing below, you acknowledge that you have read and understand the Cancellation Policy for Dr. Atul Aggarwal, MD Cardiology Clinic as described above. Thank you for your understanding and cooperation.

Patient Name:(Required)

Date(Required)

New Patient Packet

New Patient Form

Contact & Insurance Info

HEALTH APPRAISAL QUESTIONNAIRE

HEALTH APPRAISAL QUESTIONNAIRE

HEALTH APPRAISAL QUESTIONNAIRE

Email:

Tel:

Address:

Main Office

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