Patient Forms and Info

Patient Forms for Heartland Cardiology Associates LLC

feel free to download and print these patient forms to fill-out and bring with you for your appointment OR Fax to us at 812.482.9758

440 Scott Rolen Drive

Jasper, Indiana 47546

phone 812.482.5656 or toll free 800.797.7717

fax 812.482.9758

Please be sure and bring a list of your current medications, and your current insurance information to your appointment. Thank You!

PATIENT REGISTRATION FORM:
This is the general information form that is required by all new patients. Periodically, existing patients will be asked to complete an updated version of this form also.

PATIENT PERSONAL REPRESENTATIVE FORM:
This form is to authorize others (family members etc.) to recieve information regarding your confidential health records. It is required by HIPAA regulations if we are to release information to a personally designated representative on your behalf.

PATIENT BILLING/INSURANCE RELEASE FORM:
This form gives us permission to bill your insurance and also release any necessary additional information regarding your treatment and/or care.

Please note - to view/print these forms you will need the free Adobe Acrobat Reader. If you don't have it please click on the link below to download this free add-on now. Thanks!

Fees & Insurance

Be advised many insurance plans/providers require prior authorization or pre-certification before seeking specialty care. Please check with your insurance provider for any necessary prior approval for procedures and/or office visits. We accept payment from most major insurance plans but it is the patient responsibility to determine whether our physicians are participants in your insurance providers network.