Information for Patients
Forms for New Patients
New patients, please print and complete forms. Bring them to the office with you. This will speed up the process of getting you in and seen by the doctor! The Forms are in PDF file format.
For new patient information form Click Here.
For the Patient information authorization form Click Here.
For the Patient Prescription information form Click Here.
Patient Rights and Responsibilities
NorthWest Heart Center believes in the importance of patients and families taking an active part in their health care. That is why we are providing you with this list of Patient Rights and Responsibilities. By becoming familiar with these points, you will be prepared to participate in your care as a vital part of the health care team. Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility’s right to expect certain behavior on the part of the patients. You may request a copy of the full text of this law from your health care provider or health care facility.
Patient Rights
As a patient you have the right to:
- Be treated with courtesy and respect for your cultural, psychosocial, spiritual and personal values, beliefs and preferences, as well as with appreciation of individual dignity, positive self image and protection of privacy and informational confidentiality within the law;
- Have a family member or representative of your choice and your physician notified promptly of your admission to the hospital;
- A prompt and reasonable response to questions and requests;
- Know who is providing medical services and who is responsible for your care;
- Know what patient support services are available, including access to phone for private telephone conversations, interpreters, translators and resources for the disabled;
- Impartial access to medical treatment or accommodation regardless of race, national origin, religion, physical handicaps or sources of payment;
- Treatment for any emergency medical condition that will deteriorate from failure to provide treatment;
- Know what rules and regulations apply to your conduct;
- Be given information concerning the diagnosis, progrnosis, planned course of treatment, benefit, risks and alternatives;
- To have your family involved in decision-making with permission from you or your surrogate;
- Appropriate assessment and management of your pain and to be involved in decisions about managing pain;
- Initiate or amend an advance health care directive and have hospital staff comply with those directives;
- Participate in decisions about your care at the end of life with attention to your physical, psychosocial, spiritual and cultural needs;
- Refuse any treatment, except as otherwise provided by law;
- Know if medical treatment is for a clinical trial and to give your informed consent or refusal to participate in experimental research;
- Information about accessing protective services if you feel you are in physical danger, have been abused, harassed, neglected or exploited by anyone;
- Be free from sexual, verbal, physical or mental abuse and corporal punishment and free from restraint when used as coercion, discipline, convenien or retaliation;
- Receive, upon request, information and counseling on the availability of known financial resources for your care;
- Know, upon request, in advance of treatment, whether the health care provider or facility accepts the Medicare assignment rate if you are eligible for Medicare;
- Receive, upon request, a copy of a reasonably clear and understandable itemized bill and to have the charges explained;
- Access to the Ethics Committee and the option to participate in the process to resolve ethical issues. Contact the Ethics Committee by contacting the Nurse Manager or Nursing Supervisor;
- Expect reasonable safety insofar as the hospital practices and environment permit;
- Consult with a specialist, at your request and expense;
- Express complaints or grievances through the hospital Patient Relations department by calling
Patient Responsibilities:
As a patient you are responsible for:
- Providing accurate and complete information about present physical complaints, past illnesses, hospitalizations, medications and other matters relating to your health;
- Reporting unexpected changes in your condition to your doctors and nurses;
- Reporting your pain and working with the staff to manage your pain;
- Asking questions if you do not understand your treatment or what is expected of you;
- Following the treatment plan recommended by the hospital staff and/or physicians;
- Your actions if you refuse treatment or do not follow the health care providers instructions;
- Thoughtful consideration of your wishes about end-of-life care and for communicating those wishes through advance directives;
- Keeping appointments and, when you are unable to do so for any reason, for notifying the health care provider or health care facility;
- Assuring that the financial obligations of your health care are fulfilled as promptly as possible;
- Providing accurate insurance and payment information to the hospital and physicians at the time of registration or service;
- Complying with the hospital’s rules and regulations affecting patient care and conduct;
- Being considerate of the rights of other patients and hospital personnel and for assisting in the control of noise and the number of visitors;
- Being respectful of the property of other persons and the hospital;
- Safeguarding your belongings (valuables should be sent home or places in the hospital safe).
Admission Information
Pre-Admission Testing
Your physician, in most cases, has scheduled you for various tests like MRI, CT scans or lab work before you are admitted. This series of tests allows your physician to have results completed prior to your admission.
What to Bring and What Not to Bring
For your comfort, our staff suggests you bring a bathrobe, slippers and any personal grooming items. In some cases you may want to bring a small amount of money to purchase newspapers, magazines or any other comfort items during your stay.
NWHC is not responsible for patient belongings. If you must carry items of value, contact your nurse to ensure items are placed in the hospital safe upon being admitted.
Do not bring any medications from home as all forms of medication will be monitored for interaction and will be ordered from our hospital pharmacy.
Identification Bracelet
For your safety an identification bracelet will be provided and must be worn throughout your stay at NWHC. This allows our staff to confirm your name, date of birth and other important information.
Billing & Financial Information
You may ask your banking institution to transfer funds directly to our bank account. The main cashier’s office can be contacted for all pertinent information related to such a transaction.
Financial Responsibilities
Initially, you will receive a summary statement of services rendered. This is not a bill if you are covered under Medicare, Medicaid, other third-party insurance or have made prior payment arrangements.
The charges for your room include nursing, food, telephone, room service, linen and maintenance. The private room rate is charged when you have requested to be in a private or upgraded room. Other hospital charges that may appear on your bill are for supplies, special equipment, laboratory tests, therapeutic treatment, personal items, pharmacy, operating room time, x-rays and intravenous solutions. Please remember that services performed at the hospital during the course of your care have been ordered by your physician. If you have any questions regarding these services, please contact your doctor.
Physician Charges
Your physician fees and any other services or physician consultations are settled separately by each party. This includes services in radiology, emergency department, EKG, pathology and anesthesia.
Self-Pay Patients
If you are a patient with no insurance coverage, please be aware that payment in full is due at time of discharge. If you do not have sufficient personal funds available to pay for your hospitalization, the business office can assist you. There are a variety of options available, based upon your circumstances. We can detail these options for you to help determine which one best suits your needs. We also have programs available that can assist medically indigent patients with their bills, based upon specific eligibility criteria.
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