FOOS OB/GYN. A Woman for Woman Care STATE: ZIP CODE: STATE: ZIP CODE: PHONE: WORK: PHONE: WORK:

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1 FOOS OB/GYN A Woman for Woman Care PATIENT INFORMATION NAME: ADDRESS: CITY: SPOUSE/GUARDIAN INFORMATION NAME: ADDRESS: CITY: STATE: ZIP CODE: STATE: ZIP CODE: PHONE: WORK: PHONE: WORK: BIRTHDATE: AGE: BIRTHDATE: AGE: MARITAL STATUS: RACE: MARITAL STATUS: RACE: SOCIAL SECURITY #: SOCIAL SECURITY #: EMPLOYER: EMPLOYER: OCCUPATION: OCCUPATION: EMERGENCY CONTACT NAME: PHONE: PRIMARY CARE PHYSICIAN NAME: PHONE: RELATIONSHIP: HOW DID YOU CHOOSE OUR PRACTICE: I request payment of authorized medical benefits, including Medicare benefits, be made either to me or on my behalf for any services furnished to me. I authorize any holder of medical information about me to release to the Health are Financing Administration and its agents, Social Security Administration, my insurance company, it intermediates or carriers. This physician s office, my attorney, or other physicians offices may provide any information needed to determine these benefits payable for related services or as needed for medical care. I permit a copy of authorization to be used in place of the original. This agreement will remain in effect until revoked by me in writing. I understand I am financially responsible for all charges whether of not paid by said insurance. Signature of Patient, Guardian, or Responsible Party Date Medical Arts Building, Suite 108, 890 Poplar Church Road, Camp Hill, PA Office: Fax:

2 Health History The following information is very important to your health. Please take time to fully and completely fill in the information. / / First Name Last Name D.O.B ( ) - Primary Care Provider Phone Number Occupation Reason for Visit: Allergies to: (Circle Y or N) Medicines Y or N if yes Food Y or N if yes Seasonal Y or N if yes Latex Y or N History of Mensal Cycle (Circle Y or N) How old were you when you got your first period Date of last period / / Number of days between period Length of period Bleed between periods Y or N Flow is light moderate heavy Cramps Y or N PMS Y or N Past Medical History (Circle Y or N ) Measles Mumps Chickenpox Whooping Cough Scarlet Fever Rheumatic Fever Heart Disease Arthritis Sexually Transmitted Infections Thyroid Disease Anemia Bladder Infections Epilepsy Migraine Headaches Tuberculosis Diabetes Polio Hernia Bleeding Tendency Kidney Disease Vaginal Infection High Blood Pressure Hemorrhoids Asthma Hives/Eczema AIDS/HIV + Infectious Mono Mitral Valve Prolapse Hepatius Ulcer Other Disease (list) Previous Hospitalizations/Surgeries/Serious Illnesses/Dates Pregancy(ies) C-section # Dates Mis- Terminations # Dates Vaginal # Dates carriages # Dates Medications/Dose: (Include nonprescription & herbal supplements) Patient Social History: (please circle) Martial Status: Single Married Separated Divorced Widowed Alcohol Never Rarely Moderate Daily Tobacco Never Rarely Moderate Daily Drugs Never Rarely Moderate Daily Caffeine Never Rarely Moderate Daily Excerise Never Rarely Moderate Daily Do you feel safe in your current living situation? Have you ever felt threatened, physically hurt you, or forced you to have sexual intercourse against your will? How old were you when you first had intercourse? Are you satisfied with your current weight? Have you ever had an eating disorder? Y or N if yes, please describe

3 Family Medical History: AGE DISEASES Deceased, Cause of Death Father Mother Brothers Sisters Spouse/other Children Grandparents Review of Systems: Please indicate any personal history below: (circle ) GENERAL HEALTH GENITOURINARY MUSCLE/JOINT Good genera health lately Frequent Urination Pain Recent weight change Burning/painful urination Stiffness or swelling Fatigue Blood in urine Headaches Changes in force of strain SKIN when urinating Skin becomes dryer EYE/EAR/NOSE/THROAT Incontinence or dribbling Changes in moles Hearing loss or ringing Kidney stones Earaches or drainage PSYCHIATRIC Chronic sinus problems SEXUAL HISTORY Memory loss Nose Bleeds Do you have current partner Confusion Mouth sores Sexual concerns Depression Bleeding gums Pain with intercourse Insomnia Sore throat/voice change Do you use condoms Anxiety Swollen gland in neck Partners: male female both CARDIOVASULAR GYNECOLOGY ENDOCRINE Heart trouble Female problems Excessive thirst Chest pain/angina pectoris Vaginal discharge Excessive hunger Shortness of breath w/walking Breast Pain Heat/cold tolerance Or lying flat Breast lump Swelling of feet,ankles,hands Breast discharge HEMATOLOGIC/LYMPHATIC Do you do self breast exam slow heal after cuts Date last Pap smear Bleed/bruise easily RESPIRATORY Date last mammogram Anemia Chronic/frequent cough Have you ever had an abnormal Phlebitis Chronic/frequent wheezing Pap smear Past transfusion Enlarged glands GASTROINTESTINAL NEUROLOGICAL Loss of appetite Tremors Change bowel movements Head injury OTHER Nausea or vomiting Light headed or dizzy Varicose veins Rectal bleeding/blood in stool Convulsions or seizures Did you ever have a bone Abdominal pain bone density screen What questions do you have today? To the bet of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need. Signature of Patient, Parent/Guardian Date Signature of Provider Date

4 FOOS OB/GYN A Woman for Woman Care Patient Name: DOB: Annual Exam/Preventative Exam Policy An annual exam/ preventive care visit consist of the following: Breast Exam Pelvic Exam Collection of ThinPrep Pap Specimen Mammogram Order (if applicable) Bone Density Screening (if applicable) Women over 50 should have a stool screening Not all women require a Pap Smear every year. The Provider will determine the need for the Pap Smear. If you have other problems you wish to discuss, please let your provider know. We understand your time is valuable and we are happy to address your other concerns at the time of the Preventive Visit, so you do not have to schedule another visit. Please be aware if you address your other issues/ problems/ symptoms at the same time as the preventive visit, then your insurance will also be billed for a problem visit as well as the preventive visit and a co pay payment may also be incurred. If you prefer not to discuss your other problems today, we can schedule another appointment in the future for the Problem Visit. The following are some examples of issues/symptoms/complaints/problems that are NOT preventive care and will be billed as a Problem Visit to your insurance company: Understand this list does not include every possible problem. Abnormal bleeding Abnormalities found on exam Birth Control Refills/Contraception Breast Problems Hormone Replacement Therapy Menopause PMS/ Mood changes /Depression Pelvic Pain Prescription Refills Sexual Problems Urinary issues Vaginal Discharge/Odor/Itching *Attention Policy Holders* Geisinger and HealthAmerica You MUST make a SEPARATE APPOINTMENT to address any of these concerns or get refills. These insurance companies will NOT allow ANY other concerns to be managed at your preventative exam. I have read and understand the Annual Exam/ Preventive Exam Policy: Signature Date Foos OB/GYN, PC 890 Poplar Chruch Road, Suite 108, Camp Hill, PA (717) Fax (717)

5 FOOS OB/GYN A Woman for Woman Care Financial Policy FOOS OB/GYN, P.C. is dedicated to providing our patients with the best possible care and service. By signing this agreement, you are agreeing to follow our company policies. Please read the following: FINANCIAL OBLIGATIONS- All expected co-pays, deductibles and out of pocket portions are due at the time of service by payments of cash, check and credit cards. We offer a credit option through Care Credit. Please speak to the Office Manager, if you need help with financing your health care services. MONTHLY STATEMENTS- If a balance exists on your account, FOOS OB/GYN, P.C. will send monthly statements regarding the outstanding balance. Payment is expected on a monthly basis until the account is paid in full. If a payment is missed and you cannot make the payment, please contact the Office Manager at Failure to do so, may result in a warning letter followed by being turned over to our collection agency. CHARGES TO ACCOUNT- FOOS OB/GYN, P.C. retains the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service or you may not receive your scheduled services. PAST DUE ACCOUNTS- If an account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to our collection agency, you agree to pay all of the collection costs which have incurred which could result in your dismissal of care from our practice. RETURNED CHECKS- A fee of $30.00 will be charged to your account for ALL returned checks. MISSED APPOINTMENT FEE- Please give us 24 hour notice if you cannot keep your appointment. Failure to do so will result in a $50.00 fee charged to your account. TRANSFERRING OF RECORDS- If you request to have your records transferred to another facility, a fee of $25.00 will be charged to your account. Once we receive your payment, please allow our office 7 business days to have your records copied and transferred (if our physicians request you see another doctor for further treatment or a 2 nd opinion, this fee will be waived). EFFECTIVE DATE- Once this agreement is signed, you agree to all of the terms and conditions contained above, and the agreement will be in full force and effect. Patient s Name: Date: Signature: Responsible Party (if not the patient): Medical Arts Building, Suite 108, 890 Poplar Church Road, Camp Hill, PA Office: Fax:

6 FOOS OB/GYN A Woman for Woman Care CANCELLATION & NO-SHOW POLICY FOOS OB/GYN, will charge a no-show fee, if you do not show up for your appointment AND if you had not cancelled your appointment at least 24 hours in advance. The amount of the noshow fee will depend on the nature of your scheduled visit. For example, missed office visits or annuals will result in a $50.00 no-show fee and missed procedures will result in a no-show fee of $ A no-show fee is a separate charge that will not be covered by your insurance plan. Also, after three no-show appointments, you will be discharged from the practice. BEFORE CHARGING YOU A NO-SHOW FEE, WE MAY CONSIDER EXTENUATING CIRCUMSTANCE ON CASE-BY-CASE BASIS. You will need to pay the no-show fee in full before you schedule any future appointments. WHY WE CHARGE A NO-SHOW FEE: A patient who does not show up for their appointment and who had not cancelled their appointment with at least 24 hours advance notice affects the care we provide our other patients and the cost of care. First of all, each no-show represents a missed opportunity for another patient to see the doctor. Second, certain supplies and medications that we have ordered for you may be wasted if you do not show up. Every noshow costs Foos OB/GYN time and money. We understand the Foos OB/GYN no-show policy and agree to pay the Foos OB/GYN no-show fees above if I am a no-show and had not call the office at least 24 hours in advance of my appointment to cancel. Patient s name (Print) Patients signature Date Responsible person s name (Print) Responsible Person s signature Date

7 FOOS OB/GYN, P.C. AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION Read entire document before signing This authorization gives permission to use or disclose health information about you. Patient Name: Date of Birth: / / 1. Source: The following individual(s) or organization(s) are authorized to disclose the health information of the above named individual as described in this authorization: FOOS OB/GYN, PC, Suite 108, 890 Poplar Church Road, Camp Hill, PA User/Recipient: FOOS OB/GYN, P.C. may use and disclose your protected health information to other health care providers, medical facilities, pharmacies, insurance companies, laboratories or other entities involved in your health care. You may request a copy of our Privacy Policy at the office or view online at Also, you may request the covered health information may be used by or disclosed to other individual(s) or organization(s) by filling out a separate request form. 3. Covered health information: The following health information is covered by this authorization: Complete medical record, problem, medication list and/or history, list of allergies, immunization records, most recent history/diagnosis, discharge summaries, lab results, X-ray and imaging reports, consultation report, operative report, progress notes, and/or treatment plan. Psychotherapy notes will not be covered unless specifically covered in a separate authorization. Please note that other mental health and behavioral information included in any checked category will be covered by this authorization unless excluded on page Specially protected information: The following information is specially protected by state and/or federal law. Please indicate below whether you would like the following information to be released. Substance abuse records(drug or alcohol) Yes No Initials Mental health records protected by the Mental Yes No Initials Health Procedures Act HIV/AIDS related information Yes No Initials 5. Other restrictions: Please specify any other restrictions on the covered information: Purpose: I am requesting use or disclosure of the covered health information for the following purposes: personal use, further medical treatment, insurance eligibility or benefits, eligibility for disability benefits, legal investigation or action and/or electronic communication between myself, Foos Ob/Gyn, P.C. and other entities involved in my healthcare delivery.

8 6. My personal health information may be released at any time within the next calendar year to: (ie. family member, friend) a. Name: b. Phone Number: c. Today's Date: d. Exceptions: 7. I understand that I have the following rights: Right not to sign. You may refuse to sign this authorization. Refusal to sign will not affect your ability to obtain treatment by FOOS OB/GYN, P.C. except when health services are solely for the purpose of reporting to a third party. An example is a pre-employment physical. Right to revoke. You may revoke this authorization at any time. Your revocation will not apply to any actions that we have already taken in reliance on this authorization. To revoke this authorization, you must submit a written revocation to our privacy officer at the following address: FOOS OB/GYN, P.C. Attention: Privacy Officer Medical Arts Building, Suite Poplar Church Road Camp Hill, PA Re-disclosure. I understand that once the covered health information has been disclosed, it may be no longer protected by privacy laws and may be re-disclosed by the recipient. 8. Expiration. This authorization expires one year from today s date I have read and understand this authorization, and authorize the use or disclosure of the covered health information as described in this authorization. Signature of patient (or personal representative) Date Personal Representative Information (as applicable): Name of personal representative Relationship to patient