Associates In Women s Healthcare PATIENT INFORMATION

Transcription

1 (please print blue or black ink only) Associates In Women s Healthcare PATIENT INFORMATION Today s Date: Chart #: Name: Age: Birth Date: Last First MI Address: City: State: Zip: Home Phone: Cell Phone: Address: Social Security Number: Primary Care Physician: Employed? (circle one) Yes No Retired Full-time Student? (circle one) Yes No Employer: Work Phone: Occupation: Work Address: City: State: Zip: Marital Status (circle one) Single Married Divorced Widowed Civil Union Race: (circle) Caucasion Black/African American Asian Pacific Islander American Indian or Alaskan Native More than one race Ethnicity: (circle) Latino/Hispanic Other Not Reported/Refused SPOUSE INFORMATION Name: Social Security Number: Birth Date: Employer: Work Phone: Cell Phone: Work Address: City: State: Zip: PERSON TO NOTIFY IN CASE OF EMERGENCY Name: Relation to Patient: (circle one) Self Spouse Mother Father Other Social Security Number: Work Phone: Cell Phone: INSURANCE INFORMATION Primary Insurance Co. Name: Group #: ID# Policy Holder s Name: Social Security Number: Address (if different from above) City: State: Zip: Date of Birth: Relation to Patient: (circle one) Self Spouse Mother Father Other Secondary Insurance Co. Name: Group #: ID# Policy Holder s Name: Social Security Number: Date of Birth: Relation to Patient: (circle one) Self Spouse Mother Father Other AUTHORIZATION FOR PAYMENT I authorize the release of medical information necessary to process the claims for medical benefits. I authorize and assign any payment of medical benefits to the Lifeline medical Associates, LLC, its successors and assigns, or any individual it may designate for services provided. I further agree to pay all costs of collection, including attorney s fees, associated with collection of any amount due to services rendered and performed, I will pay interest at the prevailing annual rate for all amounts 30 days past due. I understand that I am financially responsible to the Lifeline Medical Associates, LLC, its successor and assigns and any individual it may designate for any balance not covered by insurance. Signature of patient or parent of minor Date AUTHORIZATION FOR MEDICARE I request that payment of Authorized Medicare benefits be made either to me or on my behalf to Lifeline medical Associates, LLC, for any services furnished to me by the physicians or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for relates services. Patient s signature Date

2 MEDICAL HISTORY Name Date of Birth Date (please print) REASON FOR VISIT PAST MEDICAL & FAMILY HISTORY PLEASE MARK AN X IF YOU (PERS) OR ANY BLOOD RELATIVE (FAM) HAVE HAD ANY OF THE FOLLOWING CONDITIONS: Pers Fam Pers Fam WEIGHT LOSS-GAIN BLOOD TRANSFUSIONS HEADACHES / MIGRAINE ANEMIA / BLOOD DISORDER HEART DISEASE VARICOSE VEINS/ PHLEBITIS HYPERTENSION SKIN DISEASE RESPIRATORY DISEASE DIABETES BREAST DISEASE NIGHT SWEATS JAUNDICE/ HEPATITIS THYROID DISEASE GALL BLADDER DISEASE CANCER TYPE: H. HERNIA / PEPTIC ULCER EPILEPSY / NEUROLOGICAL BOWEL DISORDERS ARTHRITIS KIDNEY DISEASE OTHER URINARY INCONTINENCE URINARY INFECTIONS HOSPITAL ADMISIONS LIST THOSE OPERATIONS & SERIOUS ILLNESS WHICH REQUIRED HOSPITALIZATION (EXCLUDING PREGNANCY) YEAR REASON FOR ADMISSION / HOSPITAL YEAR REASON FOR ADMISSION / HOSPITAL MEDICATIONS - LIST ALL MEDICATIONS YOUR ARE CURRENTLY TAKING (DOSAGE-FREQUENCY) - INCLUDE OVER THE COUNTER DRUGS DRUG ALLERGIES MENSTRUAL HISTORY AGE AT FIRST PERIOD DATE OF LAST PERIOD (1 ST DAY) PERIOD INTERVAL - # DAYS DURATION OF BLEEDING CRAMPS Y N MILD MOD. SEVERE ALWAYS PRESENT CRAMPS START BEFORE DURING AFTER BLEEDING MEDICATIONS FOR CRAMPS Y N TYPE? HOW MANY PERIODS IN LAST YEAR? BLEEDING (SPOTTING) BETWEEN PERIODS? Y N VAGINAL INFECTIONS HISTORY OF YEAST TRICHOMONAS CHLAMYDIA HERPES GONORRHEA PAP TEST DATE OF LAST TEST: NORMAL ABNORMAL MAMMOGRAM DATE OF LAST TEST: NORMAL ABNORMAL CONTRACEPTIVE HISTORY CURRENT METHOD: IF PILL BRAND? PAST METHODS OBSTETRICAL HISTORY NUMBER OF TIMES PREGNANT PREMATURE BABIES MISCARRIAGES ABORTIONS LIVING CHILDREN BORN YR/MOS WEEKS PREG. WEIGHT SEX TYPE OF DELIVERY REMARKS BORN YR/MOS WEEKS PREG. WIEGHT SEX TYPE OF DELIVERY REMARKS MENOPAUSAL HISTORY IF APPLICABLE HOT FLASHES / SWEATS Y N TREATMENT SEXUAL HISTORY SATISFACTORY UNCOMFORTABLE WISH TO DISCUSS SOCIAL HISTORY SMOKING CIG PER DAY/YEARS ALCOHOL OZ WEEK COFFEE CUPS / DAY STREET DRUGS

3 PATIENT FINANCIAL POLICY Participating Insurance Associates In Women s Healthcare participates with most major insurance plans. Copays (if applicable) are payable at the time of the visit. A statement will be mailed to you for coinsurances or deductibles as deemed by the insurance plan. You are responsible to pay for services that your insurance plan does not cover or that they determine not medically necessary. We suggest you contact your plan directly with any questions. Non-Participating Insurance You will be responsible to pay for your visit in full at the time of service. The billing office will be more than happy to assist you with filing a claim to your insurance copay for any reimbursement that may be due to you. No Insurance Payment is due at the time of your visit. If you require payment arrangements, you must contact the Finance Manager in advance of your appointment. Outstanding Balances Patients with an outstanding balance will be expected to pay that balance or commit to a payment plan before additional appointments will be accepted. Balances over 90 days past due without prior payment arrangements will be forwarded to an outside collection agency and 40% will be added to your balance due. Payment will need to be made in full before future appointments will be accepted. No Show We ask you to show consideration by notifying our office with advanced notice if you are unable to keep your appointment. Failure to cancel your appointment at least a day in advance will result in a $50.00 fee applied to our account. This is not payable by your insurance company. Payment will be expected before future appointments will be accepted. Returned Checks: A fee of $20.00 will be applied to your account for any checks returned for non-sufficient funds. Medical Records There is a fee of $1.00 per page for copies of your medical records. Please see Authorization to Release Medical Records form in patient forms. I authorize the release of medical information necessary to process claims for medical benefits. I authorize payment of benefits to Associates In Women s Healthcare for services rendered. I understand that I am financially responsible for and hereby guarantee payment for all services rendered. PATIENT NAME: DATE OF BIRTH SIGNATURE: DATE: (If patient is a minor, parent or legal guardian must sign)

4 OFFICE POLICIES APPOINTMENTS: We recognize that your time is valuable, therefore we do our very best to honor the appointment time that has been reserved for you. However due to the nature of Obstetrics and Gynecology, emergencies or complications may cause us to run late. We appreciate your patience in these matters. Your appointment is very important. We will never rush through your appointment because we may be running behind schedule. We ask that you arrive on time for your appointment. Our office reserves the right to reschedule any patient who arrives more than 15 minutes late. Please download the correct patient forms and complete them prior to your visit. You will need to bring your insurance card and drivers license, or other form of ID. We ask that you arrive 15 minutes early for your appointment to allow time to update your patient information. Our office will contact you to confirm your annual exam appointment 48 hours in advance. Should you need reschedule any appointment we would appreciate 24 hour notice. This will allow us to offer that time to another patient who has been waiting for an appointment. We are very proud of our newly renovated 5000 square foot office. We ask that you do not bring any food into the waiting room. You are welcome to enjoy a cup of coffee from our coffee bar while you wait. Our medical and professional staff are here to give you their undivided attention. Therefore, we ask that you make sure your cell phone is turned off while in our exam rooms. PRESCRIPTION REFILLS: Requests for prescription refills will only be accepted during office hours so that your records are accessible to us. For your convenience a list of over-the-counter medications are available for obstetric patients. MEDICAL RECORDS: You may request a copy of your medical records at any time. Your request must be in writing and include your full name, date of birth, current phone number,and where your records should be sent with full forwarding information. Let us know if there are specific records you are requesting (For example, all records from 1998-present). HIPAA allows providers 30 days to respond to a request for medical. New Jersey state law allows providers to charge $1.00 per page or $ for the entire record, whichever is less. If the record is less than 10 pages, providers may charge $ I If you need your records by a specific date we will do our best to accommodate your request. Once your request is received our office will contact you with the cost for your medical records. Go to Patient Forms on our website for a Release of Medical Records form.

5 PATIENT S CONFIDENTIALITY INSTRUCTIONS Patient Name: Date of Birth: (Please Print) It is important for us to honor the confidentiality between patient and physician. PLEASE CHECK YOUR PREFERENCE BELOW. You may discuss my medical information ONLY with me. OR I give my permission to discuss my medical information with the following people: Relationship Relationship Relationship YES or NO: You may leave medical information (for example: test results) on my voice mail at: (circle one) Cell#: Home#: Signed Date

6 Receipt of Notice of Privacy Practices Written Acknowledgement Form I,, have received and/or reviewed a copy of the (please print) Associates In Women s Healthcare Notice of Privacy Practices. Signature of Patient Date

7 NOTICE OF PRIVACY PRACTICES Effective on and after April 14, 2003 and remains in effect until we replace it. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE REGARDING MEDICAL INFORMATION: The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at Associates in Women s Healthcare. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information. OUR LEGAL DUTY: The law requires us to: Keep your medical information private. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. We are required to comply with this notice. Obtain your written permission to use or disclose your information for reasons other than those listed here or permitted by law. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes different ways that we use and disclose medical information. We have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us. For Treatment: We will use and/or disclose your health information to provide you with medical treatment and related services, including coordination or management of your care with a third party that is also involved in your treatment. For example, we may disclose your health information to another health care provider, such as a specialist to whom you are referred to by your physician, or to a laboratory performing tests related to your medical care. For Payment: We will use and/or disclose your health information to others, as necessary; to obtain payment for the treatment or services you receive. For example, a bill, containing information that both identifies you and your diagnosis or treatment may be sent to you or directly to your insurance company, health plan, or other third-party payer. We may also use your health information for the purpose of determining your eligibility or coverage under a certain health plan. For Health Care Operations: We may also use and/or disclose your health information as necessary to run our business operations and to support the core functions of treatment and payment. These activities include: employee evaluation activities; conducting medical review; legal and auditing services; business planning and development activities; and business management and general administrative activities. We will share your health information, as necessary, with certain business associates that provide certain services on our behalf, such as billing, collection, or record storage services. Whenever we have an arrangement with a business associate involving your health information, we will have that party execute a written contract containing terms that will protect the privacy of your health information. ADDITIONAL USES AND DISCLOSURES In addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purpose. Notification: With your written permission, we may use and/or disclose your health information to a family member or your personal representative. We will share information about your general condition or specific outcomes, however you indicate. We will also give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care according to our professional judgment. We will also make use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, or medical information about you. As Required by Law: We may use and/or disclose your health information as and to the extent required to comply with applicable law. We may, for example, disclose information in the course of a judicial or administrative proceeding in response to a court order, subpoena or other lawful process, or may be required in certain instances to report certain information to law enforcement officials or other government authorities. Public Health Activities: We may use and/or disclose your health information for public health activity purposes to a public health agency that is permitted to collect such information for the purpose of controlling disease, injury, disability, or other health oversight activities. Workers Compensation/Medical Disability: We may use and/or disclose your health information, when authorized, in order to comply with applicable laws and regulations related to Workers Compensation or Medical Disability. Telephone Calls: We may call you to discuss your specific medical condition, either because you have requested the call or because we feel it is necessary to contact you. We ask for various means of contacting you. Please indicate to us if you do not wish to be contacted at a specific location. We will speak to you only unless you give us permission, in writing, to speak to another person. If we leave a message, it will only be to contact us with a return call.

8 Mail: We may send notice by mail of laboratory results, for example, Pap smear results. These results will be sent to the address that you indicate. We may send letters regarding your health conditions, as well, to the address that you have indicated. Mailings containing health information will be in sealed envelopes. Appointment Reminders: We will use your history of medical appointments to send you a reminder and that you are due for a specific type of examination. This will be sent to the address which you indicate and will be of a general nature. YOUR INDIVIDUAL RIGHTS You may request a copy of your medical information (records). You must make your request in writing. If the request is for the records of a minor, due to the fact that we are a reproductive health facility, we request that the minor s signature appear as well. You may request that your records be sent to another physician, health care facility or anyone of your choice. This request must be in writing on a special form provided by us or other means specifically stating the dates of service and records that you want to be released. You may request that certain records be omitted, if this is permissible. There may be a fee associated with record preparation. This fee falls within the guidelines set forth by the statutes of the State of New Jersey. You may request that we place additional restrictions on our use or disclosure of your medical information. We are not required to abide by this request but will make every attempt to fulfill your request within the parameters allowed. You have a right to revoke your authorization to use or disclose your health information except to the extent that action has already been taken. This request must be done in writing. You have the right to receive an accounting of certain disclosures of your health information that we have made. This pertains to disclosures made after April 14, 2003 and does not include disclosures made for treatment, payment, or operation purposes or other exceptions set forth in federal regulation. You have the right to request your physician to amend your health information. We will amend your health information if we have made an error or an omission. We cannot alter health records to the extent that they will not provide an accurate and legal accounting of your medical care. Any request for amendment must be made in writing. We will respond in writing, setting forth any reason for denial if it applies. You may respond to that as well, as will we. You have the right to request communication of your health information by alternative means or at an alternative location. We will accommodate reasonable requests, made in writing, to our office. QUESTIONS AND COMPLAINTS If you have any questions about this notice or if you think that your privacy rights have been violated, please contact our office manager who serves as our privacy officer. You may also submit a written complaint to the U.S. Dept. of Health and Human Services. We will not retaliate against you for filing a complaint. MODIFICATION OF PRIVACY POLICY We reserve the right to change information in this notice that falls within the confines of the law. Any modifications will apply to all health information of our patients but will become effective from the date of revision forward. Revised notices will be made available to all new patients and former recipients who have received copies of previous notices and have advised us in writing that they wish any revised copy of our privacy policy. Our privacy policy is posted in our reception/waiting room area. PUBLIC POSTING OF PRIVACY POLICY

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