Forms

To welcome and introduce you to The Heart Attack and Stroke Prevention Center, please read the following documents. Then proceed below to download and complete the forms necessary to begin care at The HASPC.

The Heart Attack and Stroke Prevention Center Patient Forms (ALL FORMS INCLUDED)
Click to Download

 

You can also download the forms individually below:

General Information About The HASPC

Patient Understanding of Initial Risk Assessment Payment


To allow us to provide you with optimal care and thoroughly assess your risk for heart attack, stroke, and diabetes, the following forms must be completed by all new Heart Attack & Stroke Prevention Center patients.

Release of Medical Records – Form that authorizes release of your medical records by your physician(s).

It is important that you sign and provide this form to your physician(s) so that we may receive records that are important for us to understand your prior health care and history from your attending physician(s).  Please provide this signed form to your physician a minimum of two weeks prior to your initial consultation so that we have time to receive and review your records prior to your initial appointment at The Heart Attack and Stroke Prevention Center.


Required Forms to be Faxed to The HASPC Prior to Initial Consultation

Please download, complete, sign and fax the following forms back to the Heart Attack & Stroke Prevention Center as soon as your appointment has been scheduled. Our fax number is: (509) 747-8051.

Continuation of Care Pricing 2017 – Pricing and payment terms related to your initial consultation.

Patient Demographics – Basic information about you that is important to your care.

Patient Health History – Vital information about your health history that will help assess your risk.

Physician & Provider Info Form – Contact information for other healthcare practitioners who provide you care.

Notice of Privacy Practices – Your acknowledgement of the HASPC patient privacy practices.

Patient Record of Disclosures – Your choice of methods of contact for privacy purposes.


Other Forms

Universal Insurance Claim Form – Send to your insurance company for reimbursement of paid HASPC fees.

Private Medicare Contract – Required from patients who are eligible for Medicare benefits.