17183 I-45 S, Suite 410 The Woodlands, TX (281) / (281) Fax PATIENT INFORMATION
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1 17183 I-45 S, Suite 410 The Wdlands, TX (281) / (281) Fax PATIENT INFORMATION Date: Name: DOB: Scial Security #: Address: City/State/Zip: Hm # Wrk # Cell # Emplyer: Hw did yu hear abut us? Primary Care Physician: Preferred Pharmacy: Pharm# SPOUSE INFORMATION Name: DOB: SS # Cntact Phne #: EMERGENCY INFO Name: Phne #: INSURANCE INFORMATION Insurance Cmpany: Member ID: Grup #: Mailing Address fr Claims: INSURED/RESPONSIBLE PARTY Name: DOB: SS # Address (if different): City/Zip: Hm # Wrk # Cell # Emplyer: Relatinship t Patient: Spuse Significant Other Parent PICTURE ID & INSURANCE CARD REQUIRED
2 Medical Histry Frm Patient Name: DOB: Gyneclgic Histry What was the first day f yur last perid? Are yu currently sexually active? If n, have yu ever had sex? At what age did yur perids start? Any abnrmal vaginal discharge? Hw ften d yu have a perid? Every days Have yu ever been treated fr a pelvic infectin? Hw many days des yur perid last? days Any pain with sex? Any pain with yur perids? Have yu ever been treated fr infertility? Any changes in yur perids? Have yu ever had herpes? When was yur last pap test? Yur present methd f birth cntrl is Have yu ever had an abnrmal pap? If yes, when... If yes, explain Are yu trying t get pregnant?
3 Obstetrical Histry Number Number Number Ttal Pregnancies Abrtins Miscarriages Preterm Births (<37 wks) Term Births Living Children N. Birth Date Weight Baby s Sex Gestatinal Delivery Vaginal r C-Sectin Cmplicatins Any histry f diabetes, high bld pressure r pre-eclampsia with yur pregnancies? Any histry f depressin? Histry f chicken px r chicken px vaccinatin? Histry f rheumatic fever r heart disease? Medical Histry Are yu allergic t any medicatins? If s, please prvide name and list reactin Any Histry f. Asthma Heart Failure Diabetes Heart Attack Eating Disrder High Bld Pressure Bwel Prblems Abnrmal Heart Rhythm Ulcer r Gastritis Bld Clts Liver Prblems Lupus Thyrid Prblems Sexually Transmitted Disease Bld Prblems Cancer Kidney Prblems If s, where?
4 Serius Illness? If yes, explain Hspitalizatin? If yes, explain Bld Transfusin? If yes, explain Surgeries? If yes, list alng with date Recent Immunizatins: Hepatitis B? Tetanus? Scial Histry Marital Status: Single Married Partner Widwed Divrced Tbacc: Never smked Quit Smker ( years smked, packs per day) Alchl: Never <1 week 1-5 per week Other Drug Use: Yes N Seat belt use: Yes N Regular exercise: Yes N D yu take calcium r dairy prducts: Yes N Have yu been hurt by anyne: Yes N D yu have an advance directive (living will): Yes N Family Histry Any histry f these in a parent, sibling, child, grandparent r ther relative? Strke Osteprsis Diabetes Bleeding Tendencies Heart Prblems Sickle Cell r Thalassemia Heart Attack Hereditary Defects High Bld Pressure Cystic Fibrsis Abnrmal Heart Rhythm Arthritis r Gut Bld Clts in legs r lung Mental Illness High Chlesterl Cancer Tuberculsis If s, where?
5 Medicatins (include ver the cunter medicatins, herbal remedies and vitamins) Name Dse Times per day Why d yu take it? Preferred Pharmacy Preferred Pharmacy Name: Preferred Pharmacy Address: City/State/Zip: Pharmacy Phne Number: Pharmacy Fax Number: Signature f Patient/Legal Guardian: Date:
6 Patient Cnsent fr Use f Disclsure f Prtected Health Infrmatin I hereby give my cnsent fr All Abut Wmen Obstetrics and Gyneclgy t use and disclse Prtected Heath Infrmatin (PHI) abut me t carry ut Treatment, Payment and health care Operatins (TPO). I have the right t review the Ntice f Privacy Practices prir t signing this cnsent. All Abut Wmen Obstetrics and Gyneclgy reserves the right t revise its Ntice f Privacy Practices at any time. A revised Ntice f Privacy may be btained by frwarding a written request t I-45 S, Suite 410, The Wdlands, TX With this cnsent, All Abut Wmen Obstetrics and Gyneclgy may call, mail, , leave a message n vic r in persn, t my hme r ther alternative lcatin in reference t any items that assist the practice in carrying ut TPO. Such items include: appintment reminder calls and cards, patient statements, insurance items and any calls pertaining t my clinical care, including labratry test results. I have the right t request that All Abut Wmen Obstetrics and Gyneclgy restrict hw it uses r disclses my PHI t carry ut TPO. The practice is nt required t agree t my requested restrictins, but if it des, it is bund by this agreement. I authrize my insurance carrier t release infrmatin regarding my cverage t All Abut Wmen Obstetrics and Gyneclgy. I als authrize agents f any hspital, treatment center r previus physicians t furnish All Abut Wmen Obstetrics and Gyneclgy cpies f any recrds f my medical histry, services r treatments. I als authrize the release f any medical infrmatin and/r reprts related t my treatment t any federal, state r accreditatin agency, r any physician r insurance carrier as needed. I als agree t a review f my recrds fr purpses f internal audits, research and quality assurance reviews with in this ffice. By signing this frm, I am cnsenting t allw All Abut Wmen Obstetrics and Gyneclgy t use and disclse my PHI t carry ur TPO. I may revke my cnsent in writing except t the extent that the practice has already made disclsures in reliance upn my prir cnsent. If I d nt sign this cnsent, r later revke it, All Abut Wmen Obstetrics and Gyneclgy may decline t prvide treatment t me. Signature f Parent r Legal Guardian Relatinship t Patient Print Patient s Name Print Name f Legal Guardian (if applicable) Date
7 RELEASE OF MEDICAL INFORMATION By signing the fllwing I, allw the fllwing persn, (name f relative r spuse wh yu wuld like infrmatin released t) t have access t my medical infrmatin assciated with All Abut Wmen Obstetrics and Gyneclgy. This includes any persnal infrmatin that shuld be dcumented in the chart, results f any lab wrk and phne calls. If yu want t release infrmatin t mre than ne persn, please list the names and relatinships belw Patient Signature/Legal Guardian Date If yu DO NOT want any access r infrmatin t be released t anyne please mark the fllwing: NO ONE TO HAVE ACCESS TO MY RECORDS OR ACCOUNT. Patient Signature/Legal Guardian Date THIS AGREEMENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING
8 FINANCIAL POLICY AND PROCEDURES All Abut Wmen Obstetrics and Gyneclgy believes all patients deserve the best medical care that can be prvided. In rder t prvide the highest quality medical care and current technlgy, we must ensure we are able t meet the expenses necessary t perate this facility. T ensure these expenses are met, we prvide yu with this agreement t acquaint yu with ur financial plicy. Payment At Time f Service As a curtesy, we will bill yur insurance fr all ffice visits, prcedures, surgeries and bstetrical care and delivery. We ask that yu pay any prtin nt cvered by yur insurance due t deductibles r cpayments n the day f service. Appintment Plicy Due t the nature f ur busy bstetric practice, if yu are mre than 15 minutes late yu will be asked t reschedule. Shuld yu need t cancel yur appintment, please give 24-hur prir ntice in cnsideratin t ther patients. Failure f 24-hur ntificatin will result in a $25.00 fee. Insurance Claims We will submit yur insurance claims t yur insurance cmpany. Hwever, it is imprtant t remember yur insurance is a cntract between yu and yur insurer. Althugh we file insurance claims as a curtesy t yu, yu are still respnsible fr payment f services regardless f the amunt yur insurance pays. Balances Due After Insurance Pays Any remaining balance after yur insurance carrier pays is due in 30 days. We attempt t cllect these balances prir t any services, but this is an estimate. Yu will receive a statement frm ur ffice regarding any balance due. Outstanding Balances We encurage yu t keep yur accunt current. Outstanding balances will need t be cleared befre appintments can be made. Accunt balances past due will be sent t an utside agency fr cllectins. At this pint the accunt is ut f ur hands. T make appintments after accunts have been sent t an utside agency, yu will need t clear yur accunt with the cllectin agency. Yu will be respnsible fr the full amunt f ur accunt balance and any charges incurred with the agency. It is yur respnsibility t cntact ur business ffice if there are special circumstances regarding yur accunt befre yur accunt is turned ver t an utside agency. Payment Optins Our ffice accepts VISA, MasterCard, Discver, American Express, cash r check. A $35.00 fee is charged fr returned checks. I have read the abve statements and accept the terms. Patient s Signature Date Respnsible Party s Signature Date Relatinship t patient
9 What is an Annual Well-Wman Exam? With the new health care laws regarding the cverage f preventive screening, we feel it is imprtant t keep rutine preventive screening separate frm all ther visits. This helps t ensure that accurate prcessing and payment frm yur insurance cmpany fr yur rutine well-wman visit is btained and that yu receive the full benefit f yur plan allwances. An annual well-wman exam is a rutine examinatin f a patient, wh is in general, nt having any current health issues. These well-wman visits are scheduled separately frm ther visits which address specific prblem health issues. A rutine, annual well-wman exam cnsists f the fllwing. All items are recrded in the visit ntes: *Recrd vital signs *Update persnal and family medical histry *Update surgical histry *Update current medicatins and medicatin histry *Update allergies *Update reprductive histry *Update scial histry *Physical exam *General discussin regarding findings during exam *General cunseling abut health and well-being *Pap smear (if needed) *HPV testing (if applicable) *Breast cancer screening *Ordering f rutine bld wrk (if applicable) *Ordering f ther rutine testing such as management bne density study (if needed) *Refill f maintenance medicatins pertinent t gyneclgical care and/r change in medicatins r dsage We ask that yu schedule any visit fr a specific health-related prblem separately frm yur visit fr an annual exam. There are times when a general prblem that yu might be having can bscure sme f the testing dne at yur annual well wman exam, s it is always better t schedule these visits separately, t ptentially avid having t repeat tests. If a specific health-related prblem is addressed at yur annual exam, please be aware yu may be charged an additinal cpay and visit. I have read and understd the abve infrmatin. Patient Signature Printed Name Date
10 17183 I-45 S, Suite 410 The Wdlands, TX (281) / (281) Fax E-Prescribing PBM Cnsent Frm eprescribing is defined as a physician s ability t electrnically send an accurate errr free and understandable prescriptin directly t a pharmacy. Cngress has determined that the ability t electrnically send prescriptins is an imprtant element in imprving the quality f patient care. We are pleased t ffer a new feature t ur patients. We can nw autmatically btain yur prescriptin histry frm Pharmacy Benefits Managers (PBM) via Surescript and dwnlad the prescriptin infrmatin int yur electrnic medical chart. It will make it easier fr yu t share yur medical histry with us and give us the ability t prvide yu with better, mre efficient quality care. In rder t take advantage f this prgram, we will require yur permissin. Please circle as indicated belw and return the frm t the receptinist. I GIVE permissin t All Abut Wmen OB/GYN t btain my prescriptin histry directly t PBM. I DO NOT GIVE permissin t All Abut Wmen OB/GYN t btain my prescriptin histry frm PBM. Signed: Date: Printed Name:
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