Financial Policy: As a courtesy to you, The Heartbeat Clinic will file all insurance claims for you. It is your responsibility to present us with your most current insurance card and information. Failure to do so may cause you to be responsible for the entire bill, if your failure to inform us of these changes causes your insurance company to deny payment. REMINDER: Check your individual benefit coverage! It is our policy to pre-authorize/notify your insurance company for all sleep studies, long term telemetry monitors, hospital procedures, video EEG, and nuclear studies. But pre-authorization/notification does not guarantee payment of benefits by your insurance company. It is your responsibility to check your benefits in your benefit booklet or by contacting your insurance company. All non-covered benefits for sleep studies, long term telemetry monitors, video EEG, nuclear studies, and hospital procedures will be the patient/members responsibility.

Appointment Cancellations: There is a $75.00 fee added to all accounts for any appointments that are cancelled, missed, or broken without 24-hour notice. If the office is closed, please leave a message with our answering service and we will return your call the next business day. You can also send a portal message or email us at [email protected]. If you do have any questions concerning this matter, please let us know.

Form Fee: There is a $15 fee for processing forms which require more than a physician signature. Some forms may have a higher fee. This is billable directly to you (not your insurance company) and should be paid prior to the completion of the forms.

Medical Records Request: At anytime you may request a copy of your records or request them to be sent to another facility. We will request that we have a release of information form on file to process your request. This form is on our website (thbc.us). You can fill it out electronically under patient forms or print the PDF and send it in to us by email at [email protected] or fax it to (214) 504-9940. Payment will be required up front for request by mail otherwise records are provided electronically through our third party company (Vital Records Control). If at any time you need to check the status on an records request you can contact Vital Records Control at (972) 399-0914 or our office at (214) 504-9942 ext 252.

Privacy Policy: You acknowledge you have had an opportunity to review our Notice of Privacy Practices prior to signing this consent. We encourage you to review our Notice of Privacy Practice carefully. It provides more detail on how The Heartbeat Clinic may use and disclose your information. The Notice of Privacy Practices may change. A current copy may be requested from The Heartbeat Clinic. If you would like to request a restriction, please do so in writing. However, The Heartbeat Clinic reserves the right to deny your request. If granted a request, we are bound by the terms of this agreement. You may also revoke this consent in writing. However, information on any treatment or service provided using this or prior consents may still be used or disclosed for purposes of treatment, payment, or health care options. Refer to the Notice of Privacy Practice for further information.

Disclosure & Consent for Testing: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether to undergo the procedure after knowing all the ricks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may consent to the procedure you so desire. Additionally, understand that these procedures may be compared to past or further procedures to help discover any changes in your condition that may occur. Every effort will be made to minimize the risks and the procedures will be monitored continually. The risk of death because of the planned procedure is approximately 1 in 10,000, which is less than the risk of death in any 24-hour period for a given person who undergoes such procedures. I understand that the procedure will be stopped at my request, the physician’s decision that it should be stopped, or upon the completion thereof. I have been given the opportunity to ask questions about the procedure and the risks and hazards involved, and I believe that I have sufficient information to give this informed consent.

Patient Portal: We are pleased to announce that we now have a patient portal available. Patients can enter medical history on-line, send messages to their doctor’s office, refill prescriptions, schedule appointments, receive reminder notices from the office and view patient consent forms. To be signed up for the services please add your email address here: