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Bookmark or Share- Government Required Information - Atlanta Heart AssociatesPlease list any persons that Atlanta Heart Associates, P.C. is allowed to discuss your protected health information with. This includes, but is not limited to your treatment, health care options, test results, appointment reminders, and medical bills. Please include your Emergency Contact listed on the first page.
- FORMS COMPLETION - Atlanta Heart AssociatesFORMS COMPLETION To better serve you, this questionnaire must be filled out in its entirety to have forms completed. Patient Name: _____ DOB: _____
- Atlanta Heart AssociatesAtlanta Heart Associates reserves the right to refuse service, terminate accounts, remove or edit content. Logging into this patient portal serves as your agreement to the terms of use for this patient portal.
- Medical History for Cardiology Services Please Complete and Bring to ...congestive heart failure congenital heart disease hyperlipidemia hypertension hypotension mitral valve disease murmur (cardiac) palpitations pericarditis percardial effusion renal artery stenosis rheumatic heart disease myocardial infarction valvular heart disease abdominal ulcer disease black tarry stools psychiactric
- AUTHORIZATION FOR RELEASE OF HEALTH INFORMATIONRE-DISCLOSURE: Notice is hereby given to the patient of legal representative signing this Authorization that Atlanta Heart Associates, P.C. cannot guarantee that the Recipient receiving the requested health information will not re-disclose any or all of it to others. Notice is hereby given to the Recipient that law prohibits the re-disclosure ...
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