Willow Bend OB/GYN Obstetrics, Gynecology & Infertility

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1 Dear Patient, Welcome to our medical office. We look forward to meeting you soon. In order to provide you with the best possible care, please complete our registration forms prior to your first visit and arrive at least 15 minutes prior to your appointment. Most of your medical concerns can be evaluated and addressed in our office. We have state-of-the-art equipment for the diagnosis and treatment of abnormal pap smears and cervical abnormalities, as well as an ultrasound machine with the latest technology for diagnosing gynecological problems. The staff at our office respects your time and will always try to maintain an on-time schedule. However, there may be situations where your doctor is called away for an emergency. If this should occur, you will be notified as soon as possible so you can return later in the day or reschedule for another day. Please call our office at (972) or visit our website at should you have any questions or concerns. We are excited to have you as a new patient look forward to seeing you soon. Sincerely, The Doctors and Staff at Willow Bend OB/GYN Page 1 of 9

2 Patient Office Policy These policies are designed so we can provide to you and all our patients the quality of care expected from our office in a prompt and courteous manner. Should you at any time have a question about our policies, please do not hesitate to contact our office. Office hours. Our office hours are Monday through Friday, 8:30 am to 4:30 pm. We are closed between the hours of 12:00 pm and 1:00 pm for lunch. After hours, weekends and holidays. To contact the doctor on call, call our main office phone number (972) and the answering service will page the doctor on call. Payment for services. We collect co-payments, co-insurance and deductibles at the time of service. All obstetrical, gynecological, and/or surgical deductibles or co-insurance must be paid prior to the procedure. We charge you only the amounts your insurance company calculates is your financial responsibility to our office. These amounts will match exactly to the Explanation of Benefits (EOB) you receive from your insurance company. After each episode of care, we file a claim to your insurance company. If your insurance company determines there is a balance due to our office, we will mail you an invoice. Payment is due upon receipt of the invoice. As a courtesy, we mail account statements one time each month summarizing any outstanding balance(s) due to our office. Should your health insurance company deny coverage for services rendered by our office, you are still financially obligated to pay our office for services rendered. It is your responsibility to verify with your insurance company the service(s) we provide are covered by your health insurance policy. In the event your account becomes past due, we may assess a $25.00 late fee each month that your account is past due. There is a $25.00 fee for any returned checks. Should you need a form filled out by your physician, we will charge a $25.00 fee. We accept Master Card, Visa, Discover, personal checks and cash. Appointment cancellations. We request at least 24 hours notice if you need to cancel or reschedule your appointment. Punctuality. Unless your doctor is called away for an emergency, she generally starts and finishes on time. If you are late for your appointment, there will be less time available for your visit, or you may need to reschedule your appointment. Page 2 of 9

3 Medical forms. All medical, consent, and insurance forms should be filled out before your first appointment. In the event you do not have your forms filled out prior to your scheduled appointment, please arrive at least 30 minutes prior to your appointment. Medical records. We maintain your medical records at our office. If you would like us to release your records you must sign a written release. You may be assessed a fee for our office to forward medical records at your request. Laboratory tests. Our office is not responsible for the billing of any laboratory tests ordered by your doctor. Please contact your laboratory directly if you have insurance coverage questions. Treatment of minors. We require prior permission from the parent or legal guardian to treat any patient under the age of 18 years. Please make sure you sign the Consent for Examination of a Minor Child to give us permission to treat your minor. We will not be able to see any minors without this form completed. Patients under 18 years of age must be accompanied by an adult at all times. Children. Please do not bring children with you to your appointment. Our office is not equipped to safely monitor or care for children. We do not allow sick children in our office. Sonograms. From time-to-time, you will hear our office staff use the words ultrasound and sonogram interchangeably. A gynecologic ultrasound is the use of a real-time ultrasound machine scanner which captures pictures of your uterus and ovaries. The woman conducting your sonogram is a Registered Diagnostic Medical Sonographer (RDMS). The medical sonographer uses the ultrasound machine for many different reasons. Gynecologic ultrasounds are used primarily to: Visualize the uterus and ovaries. Help explain findings from the manual exam or provide additional information. Common indications for a pelvic ultrasound examination include pelvic pain, abnormal vaginal bleeding and suspicion of an abnormality on a manual gynecologic examination. Page 3 of 9

4 Notice of Privacy Practices 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. This office may use and disclose medical and financial information related to your care that may be necessary now or in the future to facilitate payment by third parties for services rendered by us, or to assist with, aid in, or facilitate the collection of data for purposes of utilization review, quality assurance, or medical outcomes evaluation purposes. Such information may be released to insurance companies, HMO s and PPO s, managed care organizations, IPA s, Medicare/Medicaid, or other governmental or third party payors, or any organizations contracting with any of the above entities to perform such functions. Medical records may be delivered to a primary care physician or any other physician who is directly or indirectly responsible for your medical care or the payment thereof. This office will not use or disclose any of your information for any purpose not stated above without your specific authorization. You may revoke your authorization at any time. You may request restrictions on certain uses and disclosures. This office is not required to agree to a requested restriction. You have the right to receive confidential communications of your protected health information. You have the right to inspect, copy and amend your protected health information. You may also request an accounting of disclosures of your protected health information from this office. We are legally obligated to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices and to abide by its terms. We reserve the right to change our privacy practices and apply revised privacy practices to protected health information. You may register a complaint with this office if you suspect that your privacy rights have been violated. We will investigate the complaint and inform you of the findings. No retaliation will be made against you by this office because you registered a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services. You may speak with the Office Manager to obtain additional information regarding any questions you may have concerning this Notice or to receive a printed copy of the Notice. This Notice of Privacy Practices is effective as of the appointment date. By signing this document, I am stating that I have read and have a copy of the Notice of Privacy Practices. Date: / / Printed Name of the Patient mm dd yyyy Signature of Patient Page 4 of 9

5 Patient Information type or print Name: Address: Today s Date: Last First MI mm / dd / yyyy Street Apt # City, State Zip Code Date of Birth: Single Married Separated Divorced Widowed mm / dd / yyyy Phone: Phone: Phone: Home Work Mobile Primary Insurance Policy Holder: DOB Last Fist MI mm / dd / yyyy Relationship to patient: Address (if different from patient): Street Apt # City, State Zip Code Insurance Company Name: ID Number: Group Number: Secondary Insurance Is the patient covered by secondary insurance? Yes No Policy Holder: Last First MI Phone: Relationship to patient DOB mm/dd/yyyy Address (if different from patient): Steet Apt # City, Sate Zip Code Insurance Company Name: ID Number: Plan Group Number: Assignment, Release and HIPPA Acknowledgement I,(insert full name of insurance policy holder), the undersigned certify I have insurance coverage with Name of Insurance Company and assign all insurance benefits to Willow Bend OB/GYN, PLLC if any, and otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Willow Bend OB/GYN, PLLC to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all insurance submissions. Policy Holder s Signature Relationship to Patient Page 5 of 9

6 How were you referred to our office? New Patient Medical History Name: Date: Last First MI mm / dd / yyyy Date of Birth: mm / dd / yyyy Ethnicity: Married Single Separated Divorced Widowed Drug Allergies: Last Menstrual Period: Cycles: Regular Irregular mm / dd / yyyy Have you had any abnormal pap smears in the past? Yes No Surgeries: Hospitalizations (other than surgeries): Medications: Dose: Dose: Dose: Dose: Contraception: Cigarettes # per day Alcohol: # drinks per day Illicit Drug Use? Pregnancy # 1 Year: Hospital: City, State: Gender: Weight: Vaginal or Section: Newborn Complications: Page 6 of 9

7 Pregnancy # 2 Year: Hospital: City, State: Gender: Weight: Vaginal or Section: Newborn Complications: Pregnancy # 3 Year: Hospital: City, State: Gender: Weight: Vaginal or Section: Newborn Complications: Pregnancy # 4 Year: Hospital: City, State: Gender: Weight: Vaginal or Section: Newborn Complications: Family History: Father Mother Sibling Brother: Sister: Sibling Brother: Sister: Sibling Brother: Sister: Page 7 of 9

8 Has Any Relative Had: Birth defects Chromosomal abnormalities Defects of spine (Spina Bifida) Diabetes Down Syndrome Heart disease Hemophilia High blood pressure Hydrocephalus (Water on the brain) Kidney disease Mental disorder Mental retardation Muscular Dystrophy Polycystic kidney Seizures Sickle Cell Stillborn birth Tay Sachs Tuberculosis Tumors Have You Had: Arthritis Asthma Blood Disorder Blood Transfusion Breast Discharge or Mass Broken Bones Diabetes Heart Disease Heart Murmur Hepatitis High Blood Pressure Illegal Drugs Kidney Disease Kidney Infection Liver or Gall Bladder Disease Mental Disorder Migraine Headaches Pelvic Infection Phlebitis Pneumonia Rheumatic Fever Seizures Sexually Transmitted Disease Sinus Headaches Thyroid Disease Varicose Veins Other: Page 8 of 9

9 Patient Communication Permission Form Patient Name DOB Last First MI mm / dd / yyyy We may need to communicate with you when you are not in the office. To preserve your privacy, we would like you to indicate your preferred method for us to communicate information to you. Without specific permission, we will not release any of your medical information to another person. In some cases, you may wish another person to have access to your medical information. In the event that no one is available to answer your phone, we need your permission to leave certain types of information on your answering machine or with another person. Please indicate your preference by checking one or more of the boxes below. Do not leave any medical information on my answering machine or with another person. I give permission for this office to leave medical information pertaining to me, which may be sensitive in nature, at the number listed below: Telephone #: I give permission to Willow Bend OB/GYN personnel to give any and all medical information pertaining to myself (or my child), including appointment reminders, to the individual listed below. Name: Last First MI Telephone #: I will inform this office of changes to my phone number or preferences as to how I want medical information disclosed. Patient Signature Page 9 of 9