, FL 33607, FL 33635 Patient General Information Name Birth date Age Social Security # Drivers License Home # Cell # Work # Street Address City State Zip Code Email Address Occupation Employer Spouse s Name Spouse s Phone Emergency Contact Phone # Primary Care Physician Phone # Pharmacy Name Pharmacy # Primary Insurance Policy Holder Policy Holder Date of Birth Policy Holder Social Security # Secondary Insurance Policy Holder Policy Holder Date of Birth Policy Holder Social Security # Patient or Guardian Signature Date Rev 8/14
, FL 33607, FL 33635 Office Policy Welcome to our office. Please read this policy carefully and feel free to ask questions regarding any part of this document. We believe that a clear definition of our office and financial policies will allow us to concentrate on the primary goal of restoring or maintaining your health. Our practice will strive to provide you with the finest quality obstetrics and gynecology care. If you have any questions regarding your treatment, please do not hesitate to ask. We welcome referrals and look forward to establishing an excellent doctor- patient relationship with you. Appointments If you are unable to keep an appointment, please call the office to reschedule at least 24 hours in advance. Patients with three missed appointments or three cancelled appointments may be asked to transfer their records to another doctor. Patients who are more than 15 minutes late may be asked to reschedule their appointment. Patients who are not compliant will be discharged from the office. Leaving Messages Our office policy is to leave generic information on answering machines. Please initial next to your preference: Please leave very little information. Please call number and leave specific details. Please leave as much information as possible on the machine or with anyone who answers my phone. Rev 8/14
, FL 33607, FL 33635 In order to be in compliance with all HIPAA regulations, we ask that you update the following information. Please sign the necessary authorizations and assignments which will allow the Premier physicians to provide your medical care. Name Date of birth Social Security Number Address City State Zip Code Email Address Home Phone Cell Phone Work Phone Insurance Company Telephone Number ID/Policy Number Group Number I hereby authorize Premier Ob/Gyn of, LLP to release my records to other healthcare professionals as well as to any corporation, person or agency that may be responsible for payment of outstanding charges. The following persons are authorized to have access to my personal medical and financial records: Name Relationship Name Relationship I hereby assign all benefits from all payers to Premiere Ob/Gyn of, LLP. This assignment shall remain in effect until revoked by me in writing. Initial Rev 8/14
, FL 33607, FL 33635 Assignment of Benefits Policy Number: Group Number: I hereby assign all medical and/or surgical benefits to which I am entitled including Medicare and other government sponsored programs, private insurance and other health plans to Premier Ob/Gyn. This assignment will remain in effect until revoked by me in writing. I hereby authorize said assignee to release all information necessary to secure the payment directly to the above doctor for their services as described herein. I understand that I am financially responsible for all charges whether or not paid by such insurance. Name (print): Name (signature): Date: Rev8/14
, FL 33607, FL 33635 Financial Responsibility I understand that I am financially responsible for all charges. By signing below I am authorizing treatment by Premier Ob/Gyn of, LLP physicians and staff. I acknowledge that information has been provided to me regarding the HIPAA laws. Name (print): Name (signature): Date: Rev 8/14
, FL 33607, FL 33635, Verification of Benefits We may assist you at our discretion in verifying your insurance coverage in an effort to verify exactly what ObGyn coverage is available on your policy. This can only be done on the day of your appointment if time permits. You as the policy holder are primarily responsible to verify benefits. We cannot guarantee payment of the benefits and subsequently you may be responsible for any coinsurance, deductibles or fees for non-covered services that may result. Referrals If your insurance company requires a referral and/or preauthorization and/or precertification, you are responsible for obtaining it. We most likely will not be able to obtain a referral on the date of service. Options at that point will be to reschedule your appointment or to pay at the time of service. We suggest you call your primary doctor at least 48 hours in advance to confirm that your referral has been generated and faxed to our office. The most reliable method is to obtain the referral yourself. Paperwork Disability forms and/or other types of forms to be completed and signed by the doctor will have a charge associated with them of $25.00. Forms will not be faxed or returned to the patient until they are paid in full. Please allow 2 to 3 weeks for completion. Outside Testing Facilities Please be advised that this office maintains no financial relationship with any laboratory or radiology centers. All bills generated by those facilities are the sole responsibility of the patient. Name (print): Name (signature): Date: Rev 8/14
, FL 33607, FL 33635 Informed Consent/Decline for Cystic Fibrosis You must be certain you understand the seven items listed below. If you are not certain about any of them please ask for a further explanation before either signing this form regarding cystic fibrosis carrier testing. - I understand that the decision to be carrier tested for CF carrier status is completely mine. - I understand that the test does NOT detect all CF carriers. - I understand that if I am a carrier, testing the baby s father will help me learn more about the chance that my baby could have CF. - I understand that if one parent is a carrier and the other is not, it is still possible that the baby will have CF but the chance is small.. - I understand that if both parents are carriers, additional testing can be done in order to know whether or not the baby will have CF. - I understand that if the baby has inherited a changed CF gene from each parent, the only way to avoid the birth of a baby with CF is by terminating the pregnancy. - I understand that the risk that an individual is a carrier of CF is as follows: Chance of Being a Chance Both Carriers CF Carrier of CF Carriers Incidence of CF - for European Caucasians 1 in 29 1 in 841 1 in 3,300 - for Hispanic Americans 1 in 46 1 in 2,116 1 in 8-9,000 - for African Americans 1 in 62 1 in 4,225 1 in 15,300 - for Asian Americans 1 in 90 1 in 8,100 1 in 32,100 I have read and understand the information above and: I do NOT want CF testing. I DO want CF carrier testing. Print Name: Signature: Date: Rev 8/14
, FL 33607, FL 33635 Referral and Authorizations Office Policy Any and all private or Medicaid HMO s (ex. Medipass, Molina, Prestige, Sunshine, Universal) will require a referral prior to all ob/gyn procedures. A referral will also be required prior to performing sonograms if you have any of these insurance companies: Humana, Blue Cross, Blue Shield or AvMed. If your insurance carrier requires a referral, pre- authorization or pre- certification, it is your responsibility to obtain the referral by the time of your appointment. We will NOT be able to obtain it for you and you will need to reschedule your appointment. We suggest you call your primary care doctor at least 48 hours in advance to confirm that your referral has been generated and faxed to our office. Patient or Guardian Signature: Date: Rev 8/14
, FL 33607, FL 33635 Transferring Records If you wish to have copies of your records you must authorize us to include all relevant information including your payment history upon request. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information including your payment history. A fee of $1.00 per page will be charged. Please allow 3 to 6 weeks for copies of records. Financial Policy This is an agreement between Premier Ob/Gyn, LLP as creditor and the patient/doctor named on this form. In this agreement the words you, your and yours means the the patient/debtor. The word account means the account that has been established in your name to which charges are made and payments credited. The words we, us and ours refers to the office of Premier Ob/Gyn. By executing this agreement you are agreeing to pay all services rendered. Insurance Insurance is a contract between you and your insurance company. We are not a party to this contract in most cases. We will bill your primary insurance company only if we are a contracted participating provider. We will accept secondary insurances for Medicare only as long as it is medigapped (automatic crossover). Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. Rev 8/14
, FL 33607, FL 33635 I,, hereby acknowledge that virus HIV or AIDS test, its purpose, potential uses, limitations and the meaning of its results. I authorize and consent to the taking of blood from me for the purpose of conducting an HIV test. I understand that a second or confirmatory test may be necessary before any test results are released (whether positive or negative). I will be provided with an opportunity for a face-to-face counseling. Name: Date: Witness: Patient REFUSED to sign. Witness: Date: Rev 8/14
, FL 33607, FL 33635 Florida Birth Related Neurological Injury Compensation Association I have been furnished information by Premier ObGyn prepared by the Florida Birth Related Neurological Injury Compensation Association (NICA) and have been advised that Premier ObGyn is a participating physician group in that program, wherein certain limited compensation is available in the event certain neurological injury may occur during labor, delivery or resuscitation. For specifics on the program, I understand I can contact the Florida Birth Related Neurological Injury Compensation Association, P.O Box 14567, Tallahassee, Florida, 32317-4567 or phone 1-800- 398-2129. I further acknowledge that I have received a copy of the brochure prepared by NICA. Name (print): Name (signature): Social Security Number: Date: Witness: Rev 8/14
, FL 33607, FL 33635 Ultrasound Consent I understand that I will be having sonogram examinations performed by Premier ObGyn physicians and their employees during my pregnancy. I further understand that these sonograms are considered Level I exams as compared to the hospital sonograms which are much more detailed examinations. This essentially means that your office sonograms are performed primarily to determine fetal growth, assess the expected due date and to scan for any major fetal defects. Consequently it is important that you recognize and acknowledge that an office sonogram reported as normal will NOT guarantee your baby will be free of anomalies. Name (print): Name (signature): Date: Witness: Rev 8/14