To welcome and introduce you to The Heart Attack and Stroke Prevention Center, please read the following two documents. The proceed below to download and complete the forms necessary to begin care at The HASPC.
General Information About The HASPC
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 at least two weeks prior to your initial consultation. Our fax number is: (509) 747-8051.
Initial Consultation Pricing Form – Pricing and payment terms related to your initial consultation.
Continuation of Care Pricing & Payment for 2012 – Provide billing preferences and payment details for 2012 care.
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.
Private Medicare Contract – Required from patients who are eligible for Medicare benefits.
Universal Insurance Claim Form – Send to your insurance company for reimbursement of paid HASPC fees.
Other Forms
Release of HASPC Medical Records to Another Health Practitioner – Use this form to release HASPC medical information to another healthcare provider.
