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1 Grand Rapids OB/GYN Dr Stephen C Dalm Nisha McKenzie PA-C Erin Walker PA-C 5060 Cascade Rd SE Ste C Grand Rapids, MI Phone (616) Fax (616) Welcome to Grand Rapids OB/GYN-the office of Dr Stephen Dalm and Physician Assistants Nisha McKenzie and Erin Walker. Thank you for choosing our office, we look forward to having you as a patient. Enclosed you will find paperwork that must be filled out and brought with you to your first appointment. If you take medications please list these medicines along with their dosages or bring them with you to the appointment. Due to federal regulations, you must be able to provide your current insurance card at every appointment, along with a photo ID. Without these cards we will not be able to see you and you may be responsible for payment at time of service. If you do not have a picture ID, or if your driver s license does not show your current address, you must also bring a utility bill showing your current address. If you are under 18 years old your parent/guardian must provide these items. Please call with any questions about insurance and we do not accept any new patients with Medicare or Medicaid coverage (or if your coverage changes to either if you are a new patient to us). You will also be expected to pay any co-pays that are required through your insurance. Please arrive at this appointment 15 minutes early so we can prepare all of your paper work. We do find it necessary to charge for no show appointments so please contact us at least 24 hours prior to your appointment time if it will not work for you. Dr Dalm uses Mercy Health Saint Mary s Hospital and Grand Valley Surgical Center for surgeries. If you have any questions feel free to call Your appointment with our office is scheduled on

2 PATIENT INFORMATION Today s Date Name Date of Birth Age Address Home Phone ( ) Work Phone ( ) Cell Phone ( ) May we correspond to you via ? Your address (When corresponding via please place your name in the subject line of each ). Marital Status SSN# (required) Employer Name Spouse/Guardian s name Employer & Daytime phone Drivers License # of patient or guardian (required) Race: Ethnicity: Choose One Hispanic Non Hispanic PRIMARY CARE PHYSICIAN PHONE # EMERGENCY CONTACTS Name: Relationship Phone #: Name: Relationship Phone #: EMPLOYMENT STATUS: Employed Unemployed Retired Self-Employed Student Employer Address of Employment Occupation INSURANCE INFORMATION PRIMARY SECONDARY Type/contract # Type/contract# Name of Insured Name of Insured SSN# Birth date SSN# Birth date RESPONSIBLE PARTY (If patient is a minor) Name Date of Birth Relationship to patient Address Home Phone ( ) Work Phone ( ) Cell Phone ( ) AUTHORIZATION I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician. Patient/Guardian Signature Date

3 NEW PATIENTS: WHOM MAY WE THANK FOR REFERRING YOU TO US? The following consent is required by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA). CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) Protected Health Information or PHI is any information that is unique to you. It includes any personal information about you and your health care. I authorize the use and disclosure of my PHI for purposes of treatment, payment, and daily healthcare operations which include but are not limited to: the coordination of healthcare services between providers of such services; services with insurance companies regarding payment, reimbursement, premiums, eligibility, coverage, and utilization review; third party collectors and consumer reporting agencies. I have been offered a copy of the Notice of Privacy Practices. I understand that I may review the office s Notice at any time. I understand the Notice may change and that I may request a revised Notice. I understand that I may request restrictions be placed on disclosure of my PHI, but that Grand Rapids OB/GYN is not obligated to comply with my requests, unless they agree to my restrictions in writing. I understand that I have a right to revoke the consent, in writing, to the extent that Grand Rapids OB/GYN has not yet taken any action in reliance upon the consent. Signature of patient or responsible party Date Grand Rapids OB/GYN has always protected your personal information and we will continue to do so. If for any reason you are not willing or able to sign the consent, then we will be unable to enter into a physician/patient relationship with you. Please list any persons whom you authorize us to discuss or release medical information and /or test results with: (Authorizations will remain in effect until removed) Date of Authorization In order to establish optimal relationship with our patients it is important for you to understand the financial policy of the office. Unless the patient is covered by an insurance plan with which we have a contract payment is required for all services at the time they are rendered. If you do not have the insurance card with you at the time of service you will be solely responsible for payment as we cannot submit the claim without complete insurance information. If determinable, applicable co-payments and deductibles will be collected at the time of service. It is your responsibility to know and understand your benefits. We will do our best to help you in this area. We will need your help in areas such as prior authorizations, referrals, and knowing which facilities and providers we can and cannot refer you to. All laboratories fees are billed independent of our office. If your insurance company requires a specific laboratory facility to be used for lab tests, x-rays, mammograms etc., it is YOUR responsibility to notify the receptionist and nurse. After receiving payment from your insurance company, a bill will be sent from our office for any remaining balance. Payment is required within 30 days. We accept payment in the form of cash, check or credit card. We find it necessary to charge fees for No Show Appointments. We will charge $45 for Appointment, $100 for Procedures and Surgery no shows may vary. 24 hours advance notice is expected. If your account is transferred to the Collection Agency for failure to pay your bill, these additional fees will be added to your balance. Your signature below signifies your understanding and willingness to comply with this policy. Patient/Guardian Signature Date

4 Today s Date / / Name Date of Birth / / Do you have any medication allergies? Y N If yes, please list: Please list any close relatives with a history of the following medical conditions: Relative Relative BREAST CANCER HIGH BLOOD PRESSURE OVARIAN CANCER DIABETES UTERINE CANCER HEART DISEASE (HEART ATTACK, STROKE, BYPASS) COLON CANCER OTHER Have you ever been diagnosed with any of the following illnesses? Please circle all that apply: Anemia Blood clots Chicken Pox High blood pressure Stroke Bleeding issues Bladder infection Pelvic infection Migraines Depression Anxiety Drug or alcohol abuse Diabetes Thyroid problem Genetic condition Cancer Blood Sickle Cell transfusion Fibrocystic breasts Endometriosis Ovarian cysts Uterine fibroids Abnormal pap Osteoporosis OB History Are you CURRENTLY pregnant? Please list all past pregnancies in order (please include miscarriages, premature, stillbirth, ectopic/tubal, and abortions) Year of birth M/F Weight of baby Delivery Type Length of Pregnancy Complications with pregnancy Name/Age

5 GYN History Age at 1 st period - Age at last period - Cycle length days - Cycles last days Are your periods: Regular Irregular Painful Not bothersome Is your flow: Light light to moderate moderate to heavy very heavy Are you currently sexually active? Yes No Virginal What is your sexual preference? Heterosexual Homosexual Bisexual Other: If applicable, what pronoun(s) do you prefer? She/her, he/him, they/them, other: Number of lifetime partners? What kind of birth control do you currently take/have? Have you ever been diagnosed with a Sexually Transmitted Infection? Yes No If you answered yes to the above question please list all infections you have been diagnosed with in your lifetime: Please list all surgeries: Date of last pap smear result Date of last Mammogram result Have you had the following vaccinations? If yes, what is the date of your most recent? TDaP Gardasil (HPV) series Flu shot Do you currently smoke cigarettes? How many per day? Are you a former smoker? How long ago did you quit? Do you chew tobacco? Do you currently drink alcohol? How much and how often?

6 Do you currently use any recreational drugs? Never used Used in the past but not anymore Check all that apply: o Marijuana o Amphetamines o Heroin o Barbiturates o Opiates o Cocaine o Others: o Do you currently exercise? How often? What type? Do you have a history of physical, sexual or emotional abuse? If yes, are you safe now? Did you attend counseling for the abuse? Please list ALL CURRENT medications, including vitamins/herbs: Please comment below any pertinent information you would like the provider to know regarding your visit today: