V. B. SHENOY, M.D. P.A. NORTHWEST CARDIOLOGY CLINIC 7333

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V. B. SHENOY, M.D. P.A. NORTHWEST CARDIOLOGY CLINIC 7333 Powered By Docstoc
					                                    V. B. SHENOY, M.D. P.A.
                             NORTHWEST CARDIOLOGY CLINIC
                                  7333 North Freeway, Suite 100
                                       Houston, Texas 77076
                            Phone: (713) 691-3649 Fax: (713) 697-4006

Patient’s Name: ________________________________                 D.O.B.______/______/_______

SS#:_________-_________-_________              Home Phone: (______) _______-____________

Work Phone: (______) _______-________            Cell Phone: (______) _______-____________

Address: ____________________________________________________________________

City: _______________________ State: ________________ Zip: ______________________

      HMO           PPO           MEDICARE            COMMERCIAL                 MEDICAID

Insurance Carrier: _____________________________ Phone: (_____) _______-___________

Address: ________________________________ Policy#:_____________ Group#:_________

City: ______________________ State: ________________ Zip: ________________________

Employer: _______________________________________ Phone: (_____) ______-_________

 □ Consult and Treat               □ Arterial Imaging Study       □ Pacemaker Evaluation
 □ Echocardiogram                        □ Upper/ Arms            □ 24 hour Holter Monitoring
 □ Ultrasound of Carotids                □ Lower/ Legs            □ Stress Myoview Spect
 □ External Counter Pulsation      □ Venous Doppler               □ Adenosine Myoview Spect
 □ Thoracic Impedence Study              □ Upper/ Arms            □ Dobutamine Myoview Spect
 □ Cardiac Event Monitor                 □ Lower/ Legs            □ Resting Myoview Spect
Referring Doctor: ___________________________________ Contact: ___________________

Address: _____________________________________________________________________

Phone: (______) _______-___________                           Fax: (______) _______-___________

Referring Doctor’s Signature: ____________________________________________________

**PLEASE SEND A COPY OF THE PATIENT’S INSURANCE CARD(S). THANK YOU.**
HMO/PPO PLANS ACCEPTED:

      Aetna (PPO/POS/HMO)                              Champva
      Amerivantage (Medicare Replacement)              Unicare (PPO/HMO)
      Americaid                                        Medicare
      Americaid Star Plus                              Select Care of Texas (Texan Plus)
      Blue Cross Blue Shield (PPO/POS/HMO)             Heritage IPA
      Beech Street (PPO)                               Integranet IPA
      Cigna (PPO/POS/HMO)                              Accountable Health Plan
      Community Health Choice Star                     Amerihealth
      Evercare Star Plus                               Bakery/Confectionary Union
      ElderHealth (Medicare Replacement)               APWU
      Fiesta Mart                                      Conseco Health
      Great West                                       GBA Palmetto (RR Medicare)
      Humana (PPO/POS/HMO)                             Mega Life
      Humana (Medicare Replacement: PPO/HMO)           Performax
      Pacificare (PPO/HMO)                             Boon-Chapman
      Multi-Plan                                       UFCW
      PCCM(Medicaid/THMP:                              United HealthCare (PPO/POS/HMO/STAR)
      Tradition/Star/StarPlus)
      PHCS                                             The J P Farley Co.
      Texas Childrens (Star/StarPlus)                  Tricare/Champus
      Texas True Choice                                Molina Healthcare: COMING SOON




DIRECTIONS:

Northwest Cardiology Clinic is located in Suite 100 (on the first floor) of the Triumph Medical
Plaza, which is just south of Triumph Hospital North along the feeder road of IH-45 between
West Little York and West Parker Road.
              If driving northbound on IH-45, exit West Little York, make a U-turn at Little
              York, and stay on the feeder.
              If driving southbound on IH-45, exit North Shepherd/West Little York and stay on
              the feeder.
Please visit our website, www.nwcclinic.com, for maps and more information. Thank you.

				
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