Tampa Cardiovascular Associates, P.A.
Asad Sawar, M.D., F.A.C.C.,   Victor Feliz, M.D., F.A.C.C.
Hadi Mahmaljy, M.D.,   Alaa Boulad, M.D., F.A.C.C.
4450 E Fletcher Avenue, Suite C, Tampa, Florida 33613
Phone: (813) 975-2800     Fax: (813) 977-7924
Patient Information – Please Print
*PLEASE GIVE YOUR INSURANCE CARD AND DRIVERS LICENSE TO THE RECEPTIONIST
Last Name:     First Name:     Middle Initial:  
Date of Birth:     SS#:      ___M   ___F
Home Address:  
City:     State:     Zip Code:  
Home #:     Cell #:     Work #:  
Email Address:  
Primary Care/Family Doctor:  
Pharmacy Name/Phone Number:  
Employer Information:
Employer Name:  
Employer Phone:     Occupation:  
Emergency Contact Information:
Last Name:     First Name:  
Address:  
City/State:     Zip Code:     Relationship:  
Home #:     Cell #:     Work #:  
It is the policy of the office of Tampa Cardiovascular Associates, P.A. to release information to your immediate family and/or leave messages with them or on your answering machine regarding appointments, lab/test results, billing or any other information we feel is necessary to provide quality care for you. You must specify in writing if you do not agree with this policy. I have read the above statement and the Notice of Privacy Practices and understand my rights.
 
 
Signature of Patient
Date
AUTHORIZED REPRESENTATIVE (Title):  
Financial Responsibility:
I understand that insurance billing is a service provided as a courtesy and that I am at all times finally responsible to Tampa Cardiovascular Associates for any charges not covered by healthcare benefits, including but not limited to co-insurance, co-pays, and deductible. It is my responsibility to call the insurance company to determine benefits. It is my responsibility to notify Tampa Cardiovascular Associates of any changes in my healthcare coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by Tampa Cardiovascular Associates and/or my healthcare insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form that I am accepting financial responsibility as explained above for all payment for medical services and/or supplies received.
 
 
Signature of Patient
Date
AUTHORIZED REPRESENTATIVE (Title):  
Consent for Treatment and Assignment of Benefits:
I hereby give consent to Tampa Cardiovascular Associates, P.A., and the staff to provide whatever treatment they may deem necessary to the patient above. I understand that I am responsible for charges incurred for services. I understand I am responsible for charges not covered by the insurance policy or Medicare including but not limited to co-insurance, co-pays, and deductible. Should it become necessary to collect these charges through an attorney or other collection process, I shall be responsible for all court costs, interest, collection costs, and attorney's fees.

I hereby request payment of authorized Medicare benefits and/or any other including supplemental insurance benefits for me to be paid directly to Tampa Cardiovascular Associates, P.A./Vasco M. Marques, M.D., P.A. for any services furnished me. I authorize Tampa Cardiovascular Associates, P.A., and staff to release to my insurance carrier and its agents any information concerning healthcare, advice, treatment or supplies provided me needed to determine these benefits payable for related services. I understand this is a lifetime authorization.
 
 
Signature of Patient
Date
AUTHORIZED REPRESENTATIVE (Title):  
Acknowledgement of Receipt of Notice of Privacy Practices & Permission to Share Health Information:
I have received a copy of the Notice of Privacy Practices of Tampa Cardiovascular Associates, P.A. this date.   ____Yes    ___No
 
 
Signature of Patient
Date
AUTHORIZED REPRESENTATIVE (Title):  
_____Received but refused to sign:  
STAFF SIGNATURE:     Date:  
Notification of Family and Friends
I hereby authorize Tampa Cardiovascular Associates, P.A. and staff to disclose my health information to the following persons (name, relationship, telephone number):
 
 
 
 
 
Signature of Patient
Date
AUTHORIZED REPRESENTATIVE (Title):  
Please check One:   ____American Indian or Alaska Native   ____Asian   ____Native Hawaiian or other Pacific Island   ____African American   ____Caucasian   ____Two or more races   ____Other Race   ____Prefer not to answer
Please check one:   _____Hispanic or Latino   _____Not Hispanic or Latino   _____Prefer not to answer
Preferred Language:  
Updated 1/28/22