Lexington OB/GYN DEMOGRAPHICS

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Regina Simon
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1 Lexington OB/GYN DEMOGRAPHICS Patient Information: Title: First name: MI: Last name: Marital status: Single Married Separated Divorced Widowed Live w/ partner Date of birth: Social security #: Street Address: Apartment #: City: State: Zip: Phone: Work Cell Home address: How would you like to be contacted? Employer: Emergency contact: Relationship: Phone #s: How did you find us? another patient physician zoc docs insurance other Name of referring patient/physician: Primary care physician: Pharmacy name: Address: Phone#: Insurance Information: Primary Insurance Company: Claims address: Policy #: Group #: Patient s relationship to insured: Policy holder s name (if not self): DOB: Policy holder Social Security #: Address: Phone: Secondary Insurance Company: Claims address: Policy #: Group #: Patient s relationship to insured: Policy holder s name (if not self): DOB: Policy holder Social Security #: Address: Phone: (rev 5/14)

2 Lexington OB/GYN FINANCIAL POLICY To find out if we participate with your insurance plan, check our website or call the office. Whether or not we accept your insurance, your specific plan is an agreement between you and the insurance carrier and/or your employer. While our staff is available to advise and assist you in understanding your financial responsibility for the services we provide to you, it is your obligation to learn the rules of your plan. Co-payment, deductible, and coinsurance amounts vary among different plans offered by the same company. There might also be requirements for pre-authorizations and referrals, and limits on coverage. For plans with which we participate, we will bill the insurance company directly. Please be sure we have your most current demographic and insurance information. We keep your credit card number and authorization on file; it will be used only in the event that a claim for coverage is denied by your insurer. Well Woman (Preventive) vs. Illness (Problem focused) Visits: A Well Woman visit is when a patient with no complaints or symptoms is seen for a checkup or preventive exam; most plans cover only 1 per year (some use the calendar year, some use a 12 month cycle). An Illness visit is when you have a specific problem or complaint. We are required to submit claims based on the services you receive. We will not change billing codes to circumvent co-pays, deductibles, or uncovered visits, as this could constitute insurance fraud. If we provide both well woman and problem focused services during the same visit, both will be billed. Payment Policy Schedule: Co-payments Non-covered services Out-of-network services Deductibles and coinsurance Denied services Full payment due at time of visit. Full payment due at time of visit. Full payment due at time of visit. Full payment due within 30 days of insurance processing. Full payment due within 30 days of insurance processing. Other charges (subject to change): Appointment cancellation fee (unless 24 hrs notice given): $50 for routine appointment $100 for extended appointment (new GYN or new pregnancy visit, procedure) Form completion fee $25+, depending on complexity of filing. Returned check fee $35 Lost prescription/requisition $25 Medical records $0.75 per page Late (Rebilling) fee $10 per month for overdue payments Lab Bills: Pap smears, blood tests, and other samples are sent to an outside laboratory for analysis. We will use a lab which participates with your insurance, but cannot make guarantees regarding coverage; there will often be a co-pay for which you will receive a separate bill from the lab. Any questions about lab bills must be directed to the lab facility and/or your insurance company. If you have questions about our financial policy or concerns about paying for medical services, or wish to discuss a payment arrangement, please contact our office. I have read this policy and understand my financial responsibilities. I agree to the terms and conditions stated. I authorize payment of my medical insurance benefits directly to Lexington Ob/Gyn. I understand and agree that, regardless of my insurance status, I am responsible for the balance of my account for any professional services rendered, including co-pays and deductibles and non-covered services. Signature: Date: 2014 Lexington OB/GYN (rev 5/14) 145 East 32 nd Street 11 th Floor New York, NY Tel Fax

3 Lexington OB/GYN ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES We are required by law to provide you with a notice that tells you how we may use and share your health information and how you can exercise your health privacy rights. You can view and receive a copy of this notice from our website ( see Resources section), from the patient portal of the electronic medical record, or in the office. The law also requires that we ask you to state in writing that you received the notice. Signing does not mean you have agreed to any special uses or disclosures of your health information. You are not required to sign the acknowledgement. Refusing to sign does not prevent us from using or disclosing your health information as the law allows. If you refuse to sign, we must keep a record that we failed to obtain your acknowledgement. I acknowledge that I was provided with the Lexington OB/GYN Notice of Privacy Practices. Signature: Date: For office use only I made a good faith effort to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but could not do so because: patient refused to sign. it was not possible due to an emergency situation. we could not communicate with patient. other Employee signature: Date: (rev 5/14)

4 COMPREHENSIVE HISTORY Name: DOB: Date: MEDICATIONS (including birth control pills, over the counter medications, vitamins, herbs): MEDICINE DOSE MEDICINE DOSE ALLERGIES (to medications): MEDICINE REACTION MEDICINE REACTION GYN HISTORY: Age periods began: # of days from start of one period to next: # of days of bleeding: Flow: NONE LIGHT MODERATE HEAVY HEAVY W/ CLOTS Age at menopause: History of HPV? HPV vaccine received? History of abnormal pap? Y N Past contraception: NA CONDOM PILL RING IUD DIAPHRAGM TUBAL STERILIZATION OTHER Current contraception: NA CONDOM PILL RING IUD DIAPHRAGM TUBAL STERILIZATION OTHER Have you ever had: Y N PAINFUL PERIODS MILD MODERATE SEVERE UTERINE FIBROIDS OVARIAN CYSTS HERPES BREAST PROBLEMS UTERINE POLYPS CERVICAL POLYPS SYPHILIS GONORRHEA CHLAMYDIA INFERTILITY OTHER GYN PROBLEM OB HISTORY: # TOTAL PREGNANCIES: # FULL TERM: # PRETERM: # MISCARRIAGES: # ABORTIONS: # ECTOPICS: #LIVING: DATE WEEKS TYPE OF DELIVERY WEIGHT SEX COMPLICATIONS 2014 Lexington OB/GYN (rev 5/14) COMPREHENSIVE HISTORY page 1

5 Name: DOB: MEDICAL HISTORY: Y N Y N HIGH BLOOD PRESSURE THYROID DISORDER HIGH CHOLESTEROL IRREGULAR/RAPID HEART BEAT HEART ATTACK STROKE ASTHMA TUBERCULOSIS REFLUX ULCER BOWEL DISORDER GALL BLADDER DISEASE/STONES HEPATITIS/LIVER DISEASE KIDNEY DISEASE/STONES DIABETES SURGICAL HISTORY: MIGRAINES SEIZURES/EPILEPSY BLOOD DISORDER BLOOD CLOTS IN LEGS/LUNGS ARTHRITIS/JOINT DISEASE AUTOIMMUNE DISEASE OSTEOPENIA /OSTEOPOROSIS SKIN DISEASE EYE DISEASE CANCER DEPRESSION/ANXIETY/OTHER PSYCH PROB INJURIES/FRACTURES OTHER MEDICAL PROBLEM HOSPITALIZATIONS: YEAR TYPE OF OPERATION YEAR REASON FAMILY HISTORY: MOTHER FATHER SISTERS #: BROTHERS #: Any blood relatives with: Y N HEREDITARY PROBLEMS BLEEDING DISORDER CLOTS IN LEGS/LUNGS BREAST CANCER OVARIAN CANCER COLON CANCER MEDICAL PROBLEMS IF DECEASED, AGE & CAUSE SOCIAL HISTORY: Y N Do you currently smoke? Have you ever smoked? # packs per day: # of years: Do you drink alcohol? # drinks per week: Do you use recreational drugs? Are you currently sexually active? Have you had sex with: MEN WOMEN BOTH NEITHER Have you ever been abused? PHYSICALLY SEXUALLY EMOTIONALLY Marital status: SINGLE LIVE W/PARTNER ENGAGED MARRIED WIDOWED DIVORCED Occupation: Highest level of school completed: HIGH SCHOOL COLLEGE POSTGRADUATE Do you exercise? # of times/week: 2014 Lexington OB/GYN (rev 5/14) COMPREHENSIVE HISTORY page 2

6 VISIT HISTORY Name: DOB: Date: REASON FOR VISIT: 1 st day of last period: REVIEW OF SYSTEMS: Do you currently have: Y N Y N ABNORMAL BLEEDING NAUSEA SEXUAL PROBLEMS BLOOD IN URINE LOSS OF URINE BREAST LUMPS BREAST DISCHARGE LARGE WEIGHT GAIN LARGE WEIGHT LOSS UNUSUAL FATIGUE CHEST PAIN PALPITATIONS DIFFICULTY BREATHING W/ EXERTION WHEEZING SHORTNESS OF BREATH PERSISTENT COUGH CHANGE IN BOWEL MOVEMENTS BLOODY STOOL JOINT PAIN MUSCLE WEAKNESS NUMBNESS DIZZINESS SEVERE HEADACHE SEVERE ANXIETY DEPRESSION COARSE FACIAL HAIR UNUSUAL TEMPERATURE SENSITIVITY PROLONGED BLEEDING FROM CUTS ENLARGED GLANDS (LYMPH NODES) MD NOTES HPI: New: 1-3, 1-3, 4+*, 4+*, 4+* Estab: chief, 1-3, 1-3, 4+*, 4+* *or status of >3 chronic/inactive conditions ELEMENTS: Location Quality Severity Duration Timing Context Modifiers Assoc signs/sxs or CHRONIC/INACTIVE PROBLEMS 1. stable improving worsening 2. stable improving worsening 3. stable improving worsening LAST TEST DATE RESULT VACCINES Pap MMR Mammo Varicella Breast US Hepatitis Pelvic US HPV Colonoscopy other BMD 2014 Lexington OB/GYN (rev 5/14)

Nadine Antonelli, MD 1500 Medical Center Drive Wilmington, NC Phone: Fax:

Nadine Antonelli, MD 1500 Medical Center Drive Wilmington, NC Phone: Fax: Add to Cancellation list Yes No Patient Information Patient Name: DOB: AGE: SS#: Primary Phone: Current Address: City: State: Zip: Email: Other Phone: Other Phone: Employer/School Name: Employment / School