Download Student Athlete Heart Screen Consent Forms

StudentAthleteHeartScreenConsentForms
Part1.StudentInformation(tobecompletedbystudentorparent)
Student’sName(First&Last):______________________________________________DateofBirth:_________________
StreetAddress:______________________________________________________________________________________
City:__________________________________________________State:______________Zip:_______________________
Phone:(home)_________________________(work)________________________(cell)____________________________
EmailAddress:_________________________________________________
Gender:MaleFemaleAge:_________School:___________________Sport(s):____________________________
Height:____________Weight:____________Grade________
Incaseofemergency,contact:
NameofParent/Guardian:____________________________________________________________________________
RelationshiptoStudent:_____________________________________Phone:___________________________________
Part2.InformedConsent(tobecompletedbystudentandparent)
LouisianaPediatricCardiologyFoundation(LPCF),inpartnershipwithPediatricCardiologyAssociates(PCA),offersFREE
heartscreensasourcommitmenttoservingthepreventivehealthneedsofourcommunity.Thisconsentformismeant
toinformthescreeningparticipantaboutthescreeningandtodocumenttheparticipant’sconsenttothescreening.The
formismeanttoinformtheparticipantoftheimportanceoftakingpersonalresponsibilityforhealthcareneedsandasks
for a personal commitment from the participant to obtain appropriate follow-up care and treatment in the event the
screeningisabnormal.InordertoparticipateandbescreenedthroughLPCF’s“Save-A-Heart” ScreeningProgram,every
participantmustreadandsignthisNotice,InformedConsentandRelease.
ABOUTTHESCREENING:LPCFscreensyoungadultsforageneticheartconditioncalledHypertrophicCardiomyopathy
(HCM).Thiscondition,whichcausesathickeningoftheheartwall,typicallydoesnotpresentanysymptomsandcanlead
totheobstructionofbloodflowandanerraticheartbeat.Itistheleadingcauseofsuddencardiacdeathinyoungpeople.
Suddencardiacdeath(alsocalledsuddenarrest)isdeathresultingfromanabruptlossofheartfunction(cardiacarrest).
Thevictimmayormaynothavediagnosedheartdisease.Thetimeandmodeofdeathareunexpected.Itoccurswithin
minutesaftersymptomsappear.Whensuddendeathoccursinyoungadults,otherheartabnormalitiesaremorelikely
causes.Adrenalinereleaseduringintensephysicalorathleticactivityoftenactsasatriggerforsuddendeathwhenthese
abnormalitiesarepresent.
Anechocardiogram,alsoreferredtoasan“ECHO”,isatechniquethatsendssoundwaves(likesonar)intothechestto
reboundfromtheheart’swallsandvalves.Therecordedwavesshowtheshape,texture,andmovementofthevalveson
anechocardiogram.Theyalsoshowthesizeoftheheartchambersandhowwelltheyareworking.
Anelectrocardiogram,alsocalledan“EKG”,isatestthatmeasurestheelectricalactivityoftheheartbeat.Witheachbeat,
anelectricalimpulse(or“wave”)travelsthroughtheheart.Thiswavecausesthemuscletosqueezeandpumpbloodfrom
the heart. An EKG gives two major kinds of information. First, by measuring time intervals on the EKG, a doctor can
determinehowlongtheelectricalwavetakestopassthroughtheheart.Findingouthowlongawavetakestotravelfrom
onepartofthehearttothenextshowsiftheelectricalactivityisnormalorslow,fastorirregular.Second,bymeasuring
theamountofelectricalactivitypassingthroughtheheartmuscle,acardiologistmaybeabletofindoutifthepartsofthe
heartaretoolargeorareoverworked.
RISKS:Thisscreeningdoesnothurtandisnon-invasive.Noneedlesorsedationisused.However,shouldtheparticipant
experience chest pain, difficulty breathing, discomfort radiating into the neck or arm, or discomfort combined with
lightheadedness,sweating,faintingornausea,theparticipantshouldseekpromptmedicalattention.
PARTICIPATION:ByvoluntarilyparticipatinginthisscreenprogramandbyreceivingascreeningIrecognize,understand,
andacceptallrisksandresponsibilitiesassociatedwithandresultingfromit.Thisscreeningprogramwillonlyscreenfor
abnormalitiesintheheartusingtheelectrocardiogramandechocardiogram,anddoesnotconstituteacompletemedical
examinationordiagnosis.TestresultsdonotrepresentorimplythatIMAYorMAYNOTbeatriskforsuddencardiac
death.Althoughanechocardiogramcannotdefinitelydiagnosehypertrophiccardiomyopathy,itmayindicatelevelsof
probabilityofhavingornothavinghypertrophiccardiomyopathy.
CONFIDENTIALITY:Aspartofthisscreening,Iagreetoallowphysicians,medicalpersonnel,andstaffofbothLPCF/PCAto
haveaccesstomymedicalrecordsfromthisscreening.IallowLPCF/PCAanditsphysicians,medicalpersonnel,andstaff
tocontactmeinregardstomyparticipationinthisscreeningprogram.IalsoauthorizeLPCF/PCAtousethisinformation,
includingtheresultsofthisscreeningtestforstatisticalevaluation;however,IunderstandthatIwillnotbeindividually
identifiedinanyrecognizableway.Theresultsofthescreenwillbereleasedtome,andtheconfidentialityofmymedical
recordswillbemaintained.
TESTRESULTNOTIFICATION:ApediatriccardiologistatPCAwillreadeverytesttheweekfollowingthescreens.Ifthere
are any results other than normal, LPCF will contact the parent of the student directly. Finally, LPCF will mail a letter
indicatinganormaltesttotheremainingstudents’parents.Pleaseallow2-3weeksfortestresults.
IrecognizeandacknowledgethatIampersonallyresponsiblefortakingappropriatefollow-upactionuponreceiptoftest
results. I understand and acknowledge that it is my responsibility to decide whether to take this action and pursue
medicallyindicatedcareandtreatment.Itismyresponsibilitytodiscusstheresultsofthescreeningwithmyprimarycare
physicianand,ifindicated,beginamedicallyapprovedmodificationprogrambasedonthefindingsandrecommendations
ofmyprimarycarephysician.
IfIdonothaveaprimarycarephysician,IunderstandthatIamstronglyencouragedtoengagetheservicesofaprimary
care physician to review the results of an abnormal screen and to determine my follow-up healthcare needs. The
physiciansofPCAarenotprimarycarephysiciansand,thereforeassumenoresponsibilityorliabilityrelativetomyfollowup care. Should I receive notice of an abnormal screen, I understand that any delay on my part to follow-up with my
primarycarephysicianinatimelymannercouldresultinadversehealthconsequences.
IherebyauthorizePCAtoreleasetheresultsofmyscreeningtesttotheprimarycarephysicianindicatedonthehistory
formcontainedinPart3below.ThisauthorizationmayberevokedatanytimebysubmittingawrittennoticetoPCA,
7777HennessyBlvd.,Suite103,BatonRouge,Louisiana70808.ThereleaseofmyProtectedHealthInformationbyPCA
shallatalltimesbegovernedbyPCA’sNoticeofPrivacyPractices,whichIhavereceivedacopyofasPart4ofthisform.
CONSENT,AGREEMENT,ANDWAIVER:Ihaveread,understand,andacceptthisNotice,informedConsentandRelease.I
havehadtheopportunitytoaskquestionsandmyquestionshavebeenansweredinasatisfactorymanner.Ihavebeen
informedastothepurposeofthisscreeningandIfreelyconsenttobeaparticipantinthescreen.Iunderstandandassume
allrisksassociatedwithmyparticipationinthisscreenprogram.Iunderstandthatthescreeningprogramwillonlyscreen
for abnormalities in my heart for genetic heart condition, and does not constitute a complete medical exam or
diagnosis.IunderstandabnormaltestresultsdonotrepresentorimplythatIDOorDONOThaveaheartcondition.By
signing this consent and waiver, I hereby agree to waive any legal claim against LPCF and their directors, officers,
employees and agents (collectively “Indemnified Parties”), and I further agree to indemnify and hold harmless the
Indemnified Parties from and against any claim, loss, damage, cost, expense (including reasonable attorney’s fees) or
liabilityarisingoutoforrelatedtothefailureofthescreeningand/orthecorrespondinginterpretationoftheresultsto
detectheartdisease,abnormalitiesoranyotherillness.
Foradiagnosisofamedicalproblem,IacknowledgethatImustseeaphysicianforacompletemedicalexamination.I
understandthatIamresponsibleformyownhealth.IunderstandthatIamresponsibleforallfollow-upexaminations
to check abnormalities found during this screening. I am financially responsible for the cost of any follow-up care,
treatment, and/or procedures whether or not covered by my insurance. I received a copy of this Notice, Informed
Consent and Release prior to treatment by Pediatric Cardiology Associates. I understand and agree to the use of
informationfrommedicalrecordsinaccordancewiththelimitationssetforthinthisconsentformandtheNoticeof
PrivacyPracticesattachedasPart4ofthisform.
HavingreadthisNotice,InformedConsentandRelease,andinconsiderationofLPCFacceptingmeforparticipationinthis
screenprogram,I,formyselfandforanyoneonwhosebehalfIamentitledtoact,releaseLPCF/PCA,itsphysicians,medical
personnel,agents,andsponsorsformallclaimsofanykindarisingoutofmyparticipationinthisscreeningprogram.
_________________________________________
_____________________________________________
SignatureofStudent/ParticipantDateSignatureofParent/GuardianDate
Part3.MedicalHistory(tobecompletedbystudentorparent)
Explain“yes”answersbelow.Circleanyquestionsthatyoudonotknowtheanswerto.
Student’sName(First&Last):____________________________________________DateofBirth:_________________
NameofPrimaryCarePhysician:___________________________________________Phone#:_____________________
1. Hasitbeenmorethantwoyearssinceyouhadaphysicalexamthatincludedablood
pressurereadingandlisteningtoyourheart?
YES
NO
2. Haveyourparentsorhasaphysicianevertoldyouthatyouhaveaheartmurmur?
YES
NO
3. Hasaphysicianeversuggestedthatyounotparticipateinathleticcompetition?
YES
NO
4. Haveyouhadachestpain/pressure,dizziness,orracingor“skippedbeats”atrestorwith
exercise?
YES
NO
5. Haveyoueverfaintedorpassedoutduringexerciseorafterhavingbeenstartled?
YES
NO
6. Haveyoueverfaintedorpassedoutafterexercise?
YES
NO
7. Haveyoueverbeentoldthatyouhavehighbloodpressure,highcholesterol,or
diabetes?
YES
NO
8. Haveyoueverbeendiagnosedwithunexplainedseizuresorexerciseinducedasthma?
YES
NO
9. Doyouuseorhaveyoueverusedcocaineoranabolicsteroids,ordoyousmoke?
YES
NO
10. Hasanyoneinyourfamilyhadsudden,unexpecteddeathbefore45?
YES
NO
11. Hasanyoneinyourimmediatefamilyhadunexplainedfaintingorseizures?
YES
NO
12. Hasaphysiciandiagnosedanyoneinyourfamilywithanabnormallythickenedheart,
weakenedheart,orMarfansyndrome?
YES
NO
Iftheanswertoanyoftheabovequestionsis“yes”,pleasegivemoredetails:__________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Answeredby:
SignatureofStudent:_______________________________________________Date:___________________________
SignatureofParent/Guardian:________________________________________Date:___________________________
PART4:NoticeofPrivacyPractices(PAGES5-8FORYOUTOKEEPFORYOURRECORDS)
THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHIS
INFORMATION.PLEASEREVIEWITCAREFULLY.ThisNoticeofPrivacyPracticesisadoptedtoensurethatPEDIATRICCARDIOLOGYASSOCIATESOFLOUISIANA,INC.
(“PCA”)fullycomplieswithallfederalandstateprivacyprotectionlawsandregulations,inparticular,theHealthInsurancePortabilityandAccountabilityActof1996
(HIPAA).PCAisrequiredbylawtoprovideitspatientswithacopyofthisNoticeofPrivacyPractices.ThisNoticeofPrivacyPracticesshallbecomeeffectiveasofMay
1,2013,andshallremainineffectuntilitiseitheramendedorcancelled.
Ifyouhaveanyquestionsorcommentsconcerningthisnotice,youshouldcontacttheChiefPrivacyOfficer,c/oPCA,7777HennessyBlvd.,Suite103,Baton
Rouge,Louisiana70808,bymailorbytelephoneat225-767-6700.Forthepurposesofthisnotice,“HHS”shallmeantheUnitedStatesDepartmentofHealthand
HumanServicesand“HealthInformation”,“ProtectedHealthInformation”or“PHI”,shallmean,certainIndividuallyIdentifiableHealthInformation,asdefinedin45
C.F.R.§164.501ofthePrivacyStandards.
InformationCollected.Intheordinarycourseofbusiness,PCAmayreceivecertainpersonalinformationaboutapatientandwewillcreatearecordofthecareand/or
servicesprovidedtothepatientbyPCA.Someoftheinformationalsomaybeprovidedtousbyotherindividualsororganizationsthatarepartofthepatient’s“circle
ofcare”,suchasapatient’sreferringphysician,otherdoctors,healthplan,familymembers,hospitalsorotherhealthcareproviders.
HowPCAMayUseorDiscloseaPatient’sPHI.PCAcollectsPHIfromthepatientandstoresitinanaccountfile.Thisisthepatient’smedicalrecord.Themedicalrecord
isthepropertyofPCA,buttheinformationinthemedicalrecordbelongstothepatient.IntheeventthatPCAissoldormergeswithanotherorganization,thepatient’s
PHIwillbecomethepropertyofthenewowner.PCAprotectstheprivacyofthepatient’sPHI.ItisthepolicyofPCAthatPHImaynotbeusedordisclosedunlessit
meetsoneofthefollowingconditions:
Treatment.PHImaybetransmittedtovariousdepartmentswithinourorganization,thepatient’sreferringphysicianandotherentitiesassociatedor
involvedinthepatient’streatment.Thisinformationmayalsobedisclosedtothepatient’sphysiciansinassociationwiththepatient’streatmentincludingbutnot
limitedtoanyphysicaltherapyorhomehealthentities.
Payment.PCAwillcollectbillinginformationfromthepatientsuchasthepatient’spresentaddress,socialsecuritynumber,dateofbirth,healthinsurance
carrier,policynumberandanyotherrelatedbillinginformation.PCAmaydisclosetothepatient’shealthinsuranceprovider,Medicare,Medicaid,orotherpayerof
healthcareclaimstheminimumamountnecessaryofthepatient’sPHIinordertoprocessthepatient’shealthinsuranceclaim.
HealthCareOperations.PCAmaydisclosethepatient’shealthcareinformationtophysicians,medicalassistants,nurses,nursepractitioners,andphysician
assistants,radiologypersonnel,MRItechnologists,billingclerks,administrativestaffandotheremployeesinvolvedinthepatient’shealthcaretreatment.
Authorization. PCA may disclose the patient’s healthcare information if the patient, who is the subject of the information, through a written authorization, has
authorizedtheuseordisclosureoftheinformation.ThisauthorizationmayberevokedbythepatientprovidingPCAwithawrittenrevocationofsaidauthorization.
Withoutthepatient’sauthorization,PCAmaynotdisclosethepatient’spsychotherapynotes.PCAmayalsonotuseordisclosethepatient’sPHIformarketingandmay
notsellthepatient’sPHI.PCAmaydisclosethepatient’shealthcareinformationifpatient,whoisthesubjectoftheinformation,doesnotobjecttothedisclosureof
theirPHItopersonsinvolvedinthehealthcareoftheindividualorforfacilitydirectorypurposes.
Notificationandcommunicationwithfamily.Wemaydisclosethepatient’sPHItonotifyorassistinnotifyingafamilymember,thepatient’spersonalrepresentative
oranotherpersonresponsibleforthepatient’scareaboutthepatient’slocation,theirgeneralcondition,orintheeventofthepatient’sdeath.Ifthepatientisable
andavailabletoagreeorobject,wewillgivethepatienttheopportunitytoobjectpriortomakingthisnotification.Ifthepatientisunableorunavailabletoagreeor
object,ourhealthprofessionalswillusetheirbestjudgmentincommunicationwiththepatient’sfamilyandothers.ItisthepolicyofPCAthatavoicemailoranswering
machinemessagemaybeleftatapatient’shomeorothernumberthepatientprovidestoPCAregardingappointments,billingorpaymentissues,orotherPHI,related
totreatment,paymentorhealthcareoperations.
AsRequiredbyLaw.ItisthepolicyofPCAthatwemayuseanddiscloseapatient’sPHIasrequiredbyapplicablelawincludingtopublichealthauthoritiesforpublic
safetypurposessuchaspreventingorcontrollingdisease,injuryordisability;reportingchildabuseorneglect;reportingdomesticviolence;reportingtotheFoodand
DrugAdministrationproblemswithproductsandreactionstomedications;andreportingdiseaseorinfectionexposure.Wemaydiscloseapatient’sPHIasrequiredby
lawtohealthagenciesduringthecourseofaudits,investigations,inspections,licensure,andinthecourseofanyadministrativeorjudicialproceedingandtolaw
enforcementofficialsfornationalsecurity,identifyingorlocatingasuspect,fugitive,materialwitnessormissingperson,complyingwithacourtorderorsubpoena,
and/orforotherlawenforcementpurposes.Wemayalsodiscloseapatient’sPHItocoroners,medicalexaminersandfuneraldirectorsandtoorganizationsinvolved
inprocuring,bankingortransplantingorgansandtissues.Wemaydiscloseapatient’sPHItoresearchersconductingresearchthathasbeenapprovedbyanInstitutional
ReviewBoardorPCA’sBoardofDirectors.Wemaydiscloseapatient’sPHIasnecessarytocomplywithworker’scompensationlaws.ItisthepolicyofPCAthatoversight
agenciessuchastheOfficeforCivilRightsoftheDepartmentofHealthandHumanServicesbegivenfullsupportandcooperationintheireffortstoensuretheprotection
ofPHIwithinthisorganization.ItisalsothepolicyofPCAthatallpersonnelcooperatefullywithallprivacycompliancereviewandinvestigations.
Fundraising.Wemayusecertaininformation(name,address,telephonenumberoremailinformation,age,dateofbirth,healthinsurancestatus,datesofservice,
departmentofserviceinformation,treatingphysicianinformationoroutcomeinformation)tocontactyouforfundraisingpurposesandyouwillhavetherighttoopt
out of receiving such communications with each solicitation. The money raised will be used to expand and improve the services and programs we provide the
community.Youarefreetooptoutoffundraisingsolicitation,andyourdecisionwillhavenoimpactonyourtreatmentorpaymentforservicesatPCA.
NoticeofPrivacyPracticesandBreachNotification.ItisthepolicyofPCAthatprivacypracticesmustbepublishedandthatallusesanddisclosuresofPHIaredonein
accordancewithPCA’sprivacypolicy.PCAisrequiredbylawtoabidebythetermsofitsNoticeofPrivacyPractices.ItisthepolicyofPCAthatprivacyprotections
extendtoinformationconcerningdeceasedindividuals.Ifthereisabreach(aninappropriateuseordisclosureofthepatient’sPHIthatthelawrequirestobereported)
PCAmustnotifythepatientofsaidbreach.
RestrictionRequests.ThepatienthastherighttorequestrestrictionsoncertainusesanddisclosuresoftheirPHI.ThepatientmaydosobycompletingPCA’sform
entitled“Restrictions”.PCAisnotrequiredtoagreetotherestrictionthatthepatientrequests.Ifaparticularrestrictionisagreedto,PCAisboundbythatrestriction.
Ifapatientpaysforaspecifichealthproductorserviceoutofpocket,thepatienthastherighttorequestthatPCAnotdisclosetheirinformationtotheirinsurer.Such
arequestcanalsobemadeinwritingbycompletingPCA’sformentitled“Restriction”andcheckingtheparticularboxindicatingthattheserviceorproductwaspaid
forbythepatient.IfsucharequestismadePCAmustagreewithyourrequest.
MinimumNecessaryDisclosure.ItisthepolicyofPCAthatitshallmakereasonableeffortstolimitthedisclosuretotheminimumamountofinformationneededto
accomplishthepurposeofthedisclosure.ItisalsothepolicyofPCAthatallrequestsforPHImustbelimitedtotheminimumamountofinformationneededto
accomplishthepurposeoftherequest.AnyunauthorizeduseordisclosureofPHIbemitigated(todecreasethedamagecausedbytheaction)totheextentpossible.
AccesstoInformation.ItisthepolicyofPCAthatthepatienthastherighttoinspectandcopytheirPHI.ItisPCA’spolicythataccesstoPHImustbegrantedtoapatient
whensuchaccessisrequested.SuchrequestshallbesubmittedinwritingbycompletingPCA’srequestformentitled“RequestforInspectionand/orCopyofProtected
HealthInformation”.PatientshavetherighttoreceivetheirPHIthroughareasonablealternativemeansoratanalternativelocation.Confidentialcommunication
channelscanbeusedwithinthereasonablecapabilityofPCA,(i.e.donotcallmeatwork,callmeathome)asrequestedbythepatient.Suchrequestshallbemadein
writingbycompletingPCA’sformentitled“ConfidentialChannelCommunicationRequest.”CostsassociatedwiththecopyingofanyPHIshallbeinaccordancewith
applicablestateandfederallaw.ItisthepolicyofPCAthataccesstoPHImustbegrantedtoapatient’sdesignatedpersonalrepresentativeasspecifiedbythepatient
whensuchaccessisrequestedandauthorizedbythepatient.ThisdesignationofapersonalrepresentativemustbemadeinwritingbycompletingPCA’sformentitled
“DesignationofPersonalRepresentative.”
AmendmentofIncompleteorIncorrectProtectedHealthInformation.ItisthepolicyofPCAthatapatienthasarighttorequestthatPCAamendtheirPHIthatis
incorrectorincomplete.PCAisnotrequiredtochangeapatient’sPHIandwillprovidethepatientwithinformationaboutPCA’sdenialandhowthepatientcandisagree
withthedenial.Arequesttoamendapatient’sPHIshallbemadeinwritingbycompletingPCA’sformentitled“RequestforAmendmentofHealth
Information.”
AccountingofDisclosures.ItisthepolicyofPCAthatanaccountingofdisclosuresofPHImadebyPCAisgiventothepatientwheneversuchanaccountingisrequested
inwriting.ThepatienthasarighttoreceiveanaccountingofdisclosuresoftheirPHImadebyPCA.Suchwrittenrequestforanaccountingshallbemadebycompleting
PCA’sformentitled“RequestforAccountingofDisclosures”.
ProhibitedActivitiesPCAisprohibitedfromusingordisclosingapatient’sPHIthatisgeneticinformation(informationaboutgenetictestsorgeneticillnessesofthe
patient or their family members) for the purposes of eligibility, continued eligibility, enrollment, determination of benefits, computing premium or contribution
amounts,pre-existingconditionexclusion,orotheractivitiesrelatedtothecreation,renewal,orreplacementofacontractofhealthinsuranceorhealthbenefits.Itis
thepolicyofPCAthatnoemployeemayengageinanyintimidatingorretaliatoryactsoractionsagainstanypersonwhofilesacomplaintorotherwiseexercisestheir
rightsunderHIPAAregulations.ItisalsothepolicyofPCAthatnodisclosureofPHIwillbewithheldasaconditionforpaymentforservicesfromthepatientorfroman
entity.
Complaints.ItisthepolicyofPCAthatallcomplaintsbyemployees,patients,providersorotherentitiesrelatingtoPHIbeinvestigatedandresolvedinatimelyfashion.
ComplaintsaboutthisNoticeofPrivacyPracticesorhowPCAhandlesapatient’sPHIshouldbedirectedto:ChiefPrivacyOfficer,PCA,7777HennessyBlvd.,Suite103,
BatonRouge,Louisiana,70808.Ifapatientisnotsatisfiedwiththemannerinwhichthisofficehandlesacomplaint,thepatientmaysubmitaformalcomplaintto:
DepartmentofHealthandHumanServices,OfficeofCivilRights,HubertH.HumphreyBldg.,200IndependenceAvenue,S.W.,Room509FHHHBuilding,Washington,
DC,20201.
ChangestothisNotice.PCAreservestherighttoamendthisNoticeofPrivacyPracticesatanytimeinthefuture.Untilsuchamendmentismade,PCAisrequiredbylaw
tocomplywiththisnotice.Ifyouwouldliketohaveamoredetailedexplanationoftheserightsorifyouwouldliketoexerciseoneormoreoftheserights,contactthe
ChiefPrivacyOfficerofPCA.
FrequentlyAskedQuestions
1. Whenandwherewillthescreeningtakeplace?
Large-groupscreeningscantakeplaceonyourschool’scampuswhenorganizedbytheathleticdirectorortrainerorata
communityscreeningevent.Otherwiseaparentcancallourclinicofficeat225-768-2590toscheduleanindividual,in-office
screeningatyourconvenience.Asktoschedulea“FreeLPCFheartscreen.”Ourclinicofficeislocatedatthefollowingaddress:
LPCFOffice
3084WestforkDrive,SuiteB
BatonRouge,LA70816
2. WhatdoIneedtodotohavemychildscreened?
A parent/guardian of the student will sign an “Informed Consent and Release” form, along with some demographic
informationandashortmedicalhistoryquestionnairethatwewillprovideforyou(includedinthispacketoravailablefor
downloadonourwebsite-www.lpcf.com).Ifpossible,pleasehavetheformfilledoutpriortoyourarrivalinordertoexpedite
thecheck-inprocess.
3. Whattestswillberun?
- 12leadelectrocardiogram(EKG)
- Limitedechocardiogram(ECHO)toassessheartsizeandstructure
***Therewillbenoneedles,bloodwork,radiationexposure,orsedation.
4. Howlongwillthescreentake?
Thescreeningtakesapproximately15-20minutes.However,oftentimes,wearescreeningalargenumberofathletesand
theremaybeabriefwait-time.Unforeseenproblemsmayoccur,sopleasebepatientifthescreeningprocessrunslonger
thantheestimatedtime.
5. Whatisthecost?
Thereisnocostandwewillnotobtainorbillyourinsurance.Thevalueofthisfreetestisapproximately$150-$200/student.
LPCFisa501(c)(3)nonprofitandprovidesthisservicefreeofchargetothecommunity.Donationsofanyamountarewelcome
butnotrequired.
6. HowcanImakeadonationtoLPCFtohelpdefercosts?
YoucanmakeataxdeductibledonationtoLouisianaPediatricCardiologyFoundationonthedayofthescreenoronlineat
www.lpcf.com.WeacceptcashorchecksmadepayabletoLPCF.
7. WhatisHypertrophicCardiomyopathy(HCM)?
HypertrophicCardiomyopathy(HCM)isageneticheartconditionthatcausesathickeningoftheheartwall,leadingtothe
obstructionofbloodflowanderraticheartbeat.Itistheleadingcauseofsuddendeathinyoungpeople.Onein500people
haveHCM.
8. WhatarecommonsymptomsofHypertrophicCardiomyopathy(HCM)?
NotallpatientswillnecessarilyexperiencesymptomsofHCM.However,someofthesymptomsassociatedwithHCMmay
includechestpain,fatigue,dizziness,heartpalpitations,lightheadedness,fainting(especiallyafterexercise),orshortnessof
breath.
9. HowcanHypertrophicCardiomyopathybedetected?
Initial signs of HCM can be detected through an electrocardiogram (EKG). The diagnosis can also be made by utilizing an
echocardiogram(ECHO),whichisanultrasoundoftheheart.
10. Whatisanelectrocardiogram(EKG)?
AnEKGisatestthatmeasurestheelectricalactivityoftheheartbeat.Witheachbeat,anelectricalimpulse(or“wave”)travels
throughtheheart,causingthemuscletosqueezeandpumpbloodfromtheheart.TheEKGdisplaystheamountoftimeit
takesthewavetotravelfromonepartofthehearttothenext,showingiftheelectricalactivityisnormalorslow,fastor
irregular.TheEKGcanalsodetermineifpartsoftheheartaretoolargeorarebeingoverworked.
11. Whatisanechocardiogram(ECHO)?
AnECHOisatechniquethatsendssoundwaves(likesonar)intothechesttoreboundfromtheheart’swallsandvalves.The
recordedwavesshowtheshape,texture,andmovementofthevalves.TheECHOalsoshowsthesizeoftheheartchambers
andhowwelltheyareworking.
12. WhenwillIreceivetheresults?
A pediatric cardiologist will read every test the week following the screens. All normal test results will be mailed to the
patient’sfamily.Ifthetestresultshappentobeabnormal,wewillcommunicatetheresultstothestudent’sparent/guardian
byphonetodiscussnecessaryfollow-up.Pleaseallow2-3weekstoreceivethetestresults.
13. Mychildhasreceivedbothanelectrocardiogram(EKG)andechocardiogram(ECHO)inthepastbysomeoneotherthan
LPCF.Doeshe/sheneedtobescreenedagain?
LPCFrecommendsthathighschoolathletesbescreenedeveryotheryear.Ifyourchildhasreceivedascreenwithinthepast
twoyears,pleasegiveusacallat225-768-2590.IfthescreenwasperformedbysomeoneotherthanLPCF,wewillneedto
know the doctor/organization who conducted the screen and when the screen was done in order for you to gain sports
clearance.(NOTE:RoutinebloodpressureandcheckupdoesnotconstituteaHeartScreen.EKGandECHOmustbeincluded.)
14. Whatisthelikelihoodthatmychildhasthemostcommoncauseofsuddencardiacdeath?
ThefrequencyofHypertrophicCardiomyopathyrangesfrom1:500toasrareas1:5000.Weexpecttoidentifyonechildper
1000screenedhavingHCM.However,manyothercardiacabnormalitiesareidentifiedthroughourscreenings.
15. Willmychild’sschoolorcoachgetacopyoftheresults?
No.Yourprivacyisprotectedinthesamewayasifyouwereseeingaphysicianforatypicalappointment.
16. WhatdoesitmeantohaveanABNORMALscreen?
IfyourchildhasanABNORMALscreen,youwillworkwithyourprimarycarephysicianonafollow-upplanofcare.Many
studentsultimatelyarecleared.
17. WhatdoesaNORMALscreenmean?Doesitmeanmychildhasnoriskforanycardiacissues?
ANORMALscreenrulesoutover65%ofthecardiaccausesofsuddencardiacdeath.Thescreendoesnotcompletelyrule
outallcauses,butdoesfocusonthemostcommon.
18. WhodoIcontactifIhaveadditionalquestionsorwanttoparticipateasahealthcareprovider?
Ifyouhaveanyfurtherquestions,pleasefeelfreetocontactKeleeKing,LPCFHeartScreenCoordinator,at225-768-2590or
[email protected]:
LouisianaPediatricCardiologyFoundation
3084WestforkDr.,SuiteB
BatonRouge,LA70816
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