Financial Policy

Thank you for choosing Cardiovascular Institute as your health care provider. With today's rising cost of health care, we are making every effort to keep increases to a minimum. In order to do this, we need your help. The following is a statement of our Financial Policy.

IF YOU HAVE HEALTH INSURANCE COVERAGE...

  • Please supply us with a current copy of your insurance card.
  • Please notify us of any changes in your address or telephone number.
  • All copays are due at the time of service.
  • All referrals are the responsibility of the member and must be current prior to your visit.
  • It is the patient's responsibility to confirm we are in network with your plan.
  • Patient balances are due within 60 days after the insurance notifies our office of your responsibility.
We will gladly assist you by filing your claim with your insurance carrier. Our business office is available from 8:30am – 4:30pm Monday through Friday to answer any questions or address any concerns you have. If you receive a statement from our office, then we expect payment from you. If you disagree with the balance for any reason please contact our business office immediately. The number is 281-357-5700.

I HAVE READ AND AGREE TO THIS FINANCIAL POLICY:

INFORMATION TO DESIGNATED REPRESNTATIVE(S)

I authorize Daljit S. Muttiana, M.D. FACC, FSCAI, dba Cardiovascular Institute PA (“the Practice”) to obtain any and all medical records concerning my care from any physician, hospital, or other health professionals that has provided medical care to me in the past. I also authorize the practice to release any and all medical records concerning my care to any physician, hospital or other health care professional providing care to me at the time. Additionally, I authorize the practice to release any and all medical records concerning my care to Medicare, Medicaid, and/or any insurance company, third-party administrator, or managed Care Company.
In accordance with the federal government privacy rules implemented through the Healthcare Portability Act of 1966 (HIPPA) in order for your physician or staff of the practice to discuss your condition or finances with members of your family or other individuals that you designate, we obtain your authorization prior to doing so. In the event of an official episode or if you are unable to give your authorization due to the severity of your medical condition, the law states that these rules may be waived.
As a patient, you have the right to revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization or if applicable, during a contestability period. In order for the revocation of this authorization to be effective CARIOVASCULAR INSTITUTE must receive in writing to the attention of CARIOVASCULAR INSTITUTE PRIVACY OFFICE at 355 School Street, Suite 101, Tomball, Texas 77375 or fax it to 281-357-8822, and will not be considered effective until received by the Privacy Officer.

Vein Screening Assessment

History

Signs and Symptoms

Do you experience any of the following in your legs or ankles?

Risk Factors

PATIENT RESPONSIBILITIES

1. Bring all medications with you to every appointment.

Please make sure when you come for your appointments, you always have your medication or a list of medications with you. Things happened between visits. You may run out of your medications, another doctor may change your medications, you may lose your medications or you may have been in the hospital. This is a very important part of your visit. It is also wise to keep an updated medication list with you at all times. You never know when an emergency may happen. If you forget them, please make a phone call while you wait, to your pharmacy or someone at home so that you can write them down before you are called to the exam room.

2. Bring lab work or test results from other physicians to every appointment.

If you have your lab work done at your primary doctor’s office or at another facility other than Quest with our lab order, please bring a copy of your blood work results with you when you come in for your doctor’s visit with us. If you choose to have your bloodwork done at Quest, we receive the results right to our office to upload into your chart. If you choose to have your blood work done at your primary care doctor’s office or another facility, we do not automatically receive a copy of these results. You may choose to call and remind the facility
or doctor’s office to fax the results to our office.

3. Bring Insurance cards and referrals to every appointment.

If you have new insurance, please notify our office prior to scheduling your appointment. If you have chosen an insurance that requires a referral from your primary care doctor, please bring your referral with you to every appointment. Your primary care doctor must request this through your insurance plan. Once it is approved, an authorization number is generated that we must have before we can make an appointment for you . You may always call your insurance company to see if they have a referral on file for you along with the expiration date of the referral. If they do not have one, you must request one from either your insurance company or your primary care physician. If a referral is not provided or is not on file in your chart by the day prior to your appointment, you may receive a call from our office to cancel or reschedule your existing appointment until one can be obtained. If you are without a referral and your insurance requires one, you will be responsible for the full cost of your visit.

4. Medicare Patients Only.

If you have Medicare and secondary insurance, you must call Medicare to update your coordination of benefits at 1-855-789-2627. Medicare needs to know all about your secondary insurance so, be sure to have your card ready when you call.

PAYMENT IS DUE AT TIME OF SERVICE

IMPORTANT NOTICE

NO SHOW AND CANCELLATION POLICY

Please note that all patients must inform the office of Cardiovascular Institute, P.A. at least 48 hours in advance when canceling any vein procedures, office visits, nuclear stress tests, ultrasound imaging, or other testing.

Failure to do so will result in the following fees:

  • Ultrasound imaging: $50.00
  • Echocardiogram: $100.00
  • Stress test: $150.00
  • Stress Cardiolite: $250.00
  • Vein procedures: $200.00
  • Holter Monitor: $50.00
  • Follow-up office visits: $50.00
All fees must be paid in full before the next appointment

Authorization Disclose Health Information

Download Form

Patient Consent for Use Email/Patient Portal Communications

Communication relating to diagnosis and treatment will be filed in your medical record.

Please remember however, that this form of communication is not appropriate for use in an emergency. The turnaround time for the routine patient communication is within 48 hours. The service provider may delay message delivery. Should you require urgent or immediate attention, this medium is not appropriate. When sending an email, please put the subject of your message in the subject line so we can process it more efficiently. Also, be sure to put your name, patient date of birth, and return telephone number in the body of the message. We also ask that you acknowledge receipts of emails coming from this office by using the auto reply feature. This office is dedicated to keeping your medical record information confidential. Despite our best efforts, due to the nature of email, third parties may have access to the message. When communicating from work, you should be aware that some companies consider email corporate property, and your messages may be monitored. Even when emailing from home, you may feel that access to your email is not well-controlled, so you should take that into consideration. In addition, you should be aware that although addressed to me, my staff and or colleagues would have access to this information. The patient portal gives you access to all your office notes, labs, prescribed medications, and radiology reports. Being active within our Patient Portal, gives you the opportunity to communicate with either Dr. Muttiana or the staff at Cardiovascular Institute, P.A.
I understand that this office will not be responsible for information loss, or delay, or breaches in confidentiality that are due to technical factors beyond this office’s control. I understand and agree to the above email and patient portal policy. By signing below, you are agreeing that we may send medical related correspondence to you via email and that we may respond to your email to us via email.
All article and any forms, checklist, guidelines and material are for generalized information only and should not be reviewed or referred to as primary legal source nor constructed as establishing medical standards of the care for the purpose of litigation, including expert testimony. They are intended as resource to be selectively used and always adapted with the advice of the distributed with the understanding that neither Texas Medical Liability Trust Nor Texas Medical Insurance Company is engaged in rendering legal services. @TMLT Revised 04/13/2016

PLEASE PROVIDE ALL OF YOUR INSURANCE CARD(S), PICTURE ID, AND ANY MEDICAL RECORDS.

PATIENT’S EMPLOYER:

INSURANCE INFORMATION:

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AGREEMENT AND RELEASE: I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED BY ME OR MY DEPENDENTS. ALL COPAYS ARE REQUIRED AT TIME OF SERVICE. I HEREBY GIVE LIFETIME AUTHORIZATION FOR PAYMENT OF INSURANCE BENEFITS TO THE PHYSICIAN FOR MEDICAL BENEFITS OTHERWISE PAID TO ME. I ALSO AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY TO PROCESS ANY CLAIMS. I REQUEST PAYMENT OF GOVERNMENT BENEFITS EITHER TO MYSELF, OR TO THE PARTY WHO ACCEPTS THE ASSIGNMENT.