Please complete all of the following information. If you have any questions, please do not hesitate to ask.

PATIENT INFORMATION

INSURANCE INFORMATION (Please present insurance card at time of check in)

IN CASE OF EMERGENCY

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible to the provider of service for remaining balances after my insurance. I also authorize Pacific Endovascular to release any information required to process my claims. I acknowledge the notification of privacy practices and I am aware of how my health information may be used or disclosed. I may obtain a revised copy of the Notice at anytime by calling (808) 748-4488 or by requesting a copy at this office.

MEDICAL HISTORY QUESTIONAIRE

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

HIPAA PRIVACY AUTHORIZATION FORM

Authorization for Disclosure of Protected Health Information (required by the Health Insurance Portability and Accountability Act, 45C.F.R. parts 160 and 164)

1. Authorization I authorize Pacific Endovascular to disclose my protected health information as described below to the following individual (s):

2. Extent of Authorization- I authorize the release of my medical records

• in full with no restrictions
• not including records related to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse.
• This medical information may be used by the person(s) I authorized to receive this information for medical treatment, consultation, billing and claims payment, or other purpose as I may direct.
• This authorization shall be in force and effect until the time which I indicated on this form.
• I understand I have the right to revoke this authorization in writing at any time. I understand a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
• I understand my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
• I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received a copy of the Notice of Privacy Practices provided to me by Pacific Endovascular Clinic.

FOR OFFICE USE ONLY:

A good faith effort was made to obtain from the patient a written acknowledgment of his/her receipt of the Notice. However, such acknowledgment was not obtained because:

AGREEMENT OF FINANCIAL RESPONSIBILITY

Thank you for choosing Pacific Endovascular as your healthcare provider. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.

• The patient (or legal guardian) is ultimately responsible for the payment for treatment and care.
• The patient (or legal guardian) is required to provide the most accurate and updated information regarding insurance.
• As a courtesy, we will file your insurance claims for you. However, in the event your insurance denies payment for any reason, you and and/or guarantor will be responsible for any balance due.
• The patient (or legal guardian) is responsible for payments of co-pays, co-insurance, deductibles and all other procedures or treatments not covered by your insurance plan.
• Charge of $50 for missed appointments without 24 hour notice.

Pacific Endovascular Vein Procedures ONLY

By signing below, I acknowledge that I have been advised by my provider of the potential high co-payment incurred by the outpatient procedure. I understand the financial responsibility associated with the recommended procedure and will contact my insurance plan prior to my procedure to confirm my estimated co-payment.