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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 Keepintouch!Please“Like”ourFacebookpage:LouisianaPediatricCardiologyFoundation.