Patient Forms

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Peter J.Chung Cardiology / 심장 내과

Peter J.Chung Cardiology / 심장 내과

Home Address (집주소)
Street Address
Apt, Suite, Unit

Emergency Contact (응급시 연락처)

Patient Health Questionnaire


Alcoholic Beverage


Please list current medications in the table below (현재 복용중인 약을 아래 표에 적어주세요)


Family History

Any family history of heart disease or cardiovascular disease? (심장질환 또는 심혈관 질환에 대한 가족력이 있으십니까?)


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Patient Agreement

Patient Agreement

I understand that

1. Authorization to release medical information: I hereby authorize Dr. Peter Chung to release any information necessary for I understand that my course of treatment.
본인은 Dr. Peter Chung 이 치료에 필요한 의료 정보와 개인정보를 공개하는 것을 허락합니다.

2. Authorization to pay benefits to physician: I authorize the release of medical or other information necessary to process health insurance claims.
본인은 의료보험 청구에 필요한 의료 정보와 개인정보를 공개하는 것을 허락합니다.

3. If I change my insurance plan, I am responsible for informing the clinic. If my insurance plan is deemed ineligible, I am responsible for the full amount of the service rendered.
본인은 의료보험이 변경될 경우, 병원 측에 새로운 보험 정보를 제공해야 할 의무가 있음을 숙지합니다. 만약 변경된 보험 정보를 제공하지 않아 보험 혜택이 적용되지 않을 경우, 의료 서비스 비용을 액 지불할 것을 동의합니다.

4. I am responsible for providing payments on the day of service to cover my co-payment and/or deductible for the visit. If overpayments occur, we promise to return your fees. Fees may be subject to adjustments based on annual insurance fee schedules.
본인은 진료일에 발생한 Co-Payment 및 Deductible 을 진료 당일 모두 지급할 것에 동의합니다. 진료 비용은 연간 보험료 책정 금액에 따라 달라질 수 있습니다. 만약 환자분께 청구한 비용이 초과 발생하였을 경우, 저희 병원에서는 보험료 지급내역서가 온 후에 초과 발생한 금액 만큼 되돌려 드릴 것을 약속합니다.

5. If check payment is returned for insufficient funds, a stop payment, or any other reason, a returned check of $35 will be assessed.
본인은 지불한 Check (수표) 가 잔고 부족, 지급 정지, 혹은 다른 이유들로 반송될 경우 (bounce 발생) $35 의 비용이 추가되는 것에 동의합니다.

6. Patient responsibility that is quoted on the date of service is a best estimate and not a guaranteed amount. I agree to pay the difference between the estimate and the actual patient responsibility which iwill be on the Explanation of Benefits with your current insurance company.
본인은 진료 당일 청구된 금액이 오피스에서 예상된 진료 비용임을 숙지하였으며, 보험 청구서 내역을 받고난 후, 차액이 있을 경우 지불할 것에 동의합니다.

I certify that the above information is correct as of the date signed.
본인은 위의 내용에 동의하였으며 아래 서명한 날로부터 유효함을 숙지하였습니다.

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Medicare Only

Medicare Only

1. Do you or your spouse work for a company that provides you with health insurance?
(선생님 혹은 선생님의 배우자께서는 건강보험을 제공하는 회사를 다시고 계십니까?)

2. Are you entitled to Medicare before of End Stage Renal Disease?
(선생님께서는 End Stage Renal Disease 전의 메디케어를 받으실 수 있으십니까?)

3. Is the illness or injury the result of an accident or illness that occurred at work?
(이 질병 또는 부상은 선생님의 직장에서 일어난 사고에 의한 것입니까?)

4. Is this illness or injury the result of an accident or other injury?
(이 질병 또는 부상은 다른 사고에 의한 것입니까?)

5. Has the treatment for this accident or illness been authorized by the Veteran’s Administration?
(이 사고 또한 질병에 대한 치료는 Veteran’s Administration 에서 허가한것입니까?)

6. Are you entitled to any benefits under the Federal Black Lung Program?
(선생님께서는 Federal Black Lung Program을 통한 혜택을 받으실 수 있으십니까?)

7. Do you have a Medicare Medigap Policy?

8. Do you have a medicare supplement policy (Policy provided by employer you retired from)?
(선생님께서는 medicare supplement policy를 가지고 계십니까?)

I authorize the release of any medical or other information necessary to process my insurance claim. This is to serve as a long-term authorization card. Also, I have read and understood the policies on the Payment policy information and health information consent forms. I have received copies of these forms.
(본인은 보험 청구에 필요한 의료정보와 개인정보를 공개할 것을 허락합니다. 본인은 모든 약관을 읽고 이해하였으며 사본을 가지고 있습니다.)

I authorize payment of medical benefit to Peter J. Chung Cardiology for the services described on the insurance form. This authorization is to apply to all occasions of service until it is revoked in writing. I agree to pay for services not covered by insurance and understand that I am ultimately responsible for payment in full at this office.
(본인은 보험 기재서에 설명되어 있는 진료에 대한 진료비를 Peter J. Chung Cardiology 에서 청구하는 것을 허락합니다. 이 것은 공식적인 글로 폐지 되지 않는 이상 모든 진료에 대하여 적용됩니다. 본인은 보험이 적용되지 않는 진료를 낼 것을 보장하고 결국 이 클리닉에서 청구한 진료비에 대한 책임은 자신에게 있음을 이해합니다.)

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HIPAA Privacy Authorization Form

HIPAA Privacy Authorization Form

Authorization for Use of Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

1. Authorization

2. Effective Period

3. Extent of Authorization

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing, or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until the date below, at which time this authorzation expires.

6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.


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