WOMEN S PREMIER OBGYN REGISTRATION FORM

WOMEN S PREMIER OBGYN REGISTRATION FORM Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: q Miss q Ms. Marital status (circle one) Single / Married / Divorced / Sep / Widow Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: q Yes q No / / q M q F Street address: Social Security no.: Home phone no.: ( ) P.O. box: City: State: ZIP Code: Occupation: Employer: Employer phone no.: ( ) Chose clinic because/referred to clinic by (please check one box): q Dr. q Insurance Plan q Hospital q Family q Friend q Close to home/work q Other Other family members seen here: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: Is this person a patient here? q Yes q No / / ( ) Occupation: Employer: Employer address: Employer phone no.: Is this patient covered by insurance? Please indicate primary insurance q Yes q No q [Insurance] q [Insurance] q [Insurance] ( ) q [Insurance] q [Insurance] q [Insurance] q [Insurance] q [Insurance] q Welfare (Please provide coupon) q Other Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: Patient s relationship to subscriber: q Self q Spouse q Child q Other / / $ Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: Patient s relationship to subscriber: q Self q Spouse q Child q Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Women s premier obgyn or insurance company to release any information required to process my claims. Patient/Guardian signature Date

Women s Premier OBGYN Notice of Privacy Practices Please initial on the lines below Our Obligations: We are required by law to: Maintain the privacy of protected health information, hereinafter designated PHI. Inform you of our legal duties and privacy practices regarding your PHI. Follow the terms of our notice that is currently in effect. How we may use and disclose health information: Except for the following, we will use and disclose health information only with your written permission: Treatment- We may use and disclose PHI for your treatment and to provide you with treatment- related services. For example, we may disclose PHI to doctors, nurses, technicians, pharmacists, including personal outside our office who are involved in your care and need to provide you with care. Payment - We may use and disclose PHI so that we or others may bill and receive payment from you, from an insurance company, or a third party for the treatment and services you received. Operations- We may use and disclose PHI for operational purposes. These uses and disclosure are necessary to make sure that all of our patients receive quality care, and to operate and manage our office. For example, your PHI may be shared with quality improvement personel or evaluate the performance of our staff. Individuals involved in your care or payment for your care- We may use and disclose PHI with a person involved in your care such as your family or a close friend. Appointment reminders- We may use and disclose PHU to contact you and remind you of your appointment with us. Your Rights You have the following rights regarding your PHI. Right to Inspect and Copy- Your medical and billing records except for psychotherapy notes. You must make this request in writing. The charges for copying are in accordance with the Texas Medical Practice Act. Right to Amend- You may ask to amend the information when the information is in our office. Right to accounting of Disclosures- You have the right to request a list of certain disclosures we made of your PHI other than for treatment, payment, operations, or to someone involved in your care or the payment of your care, like family member or friend. This request must be made in writing. We are not required to agree to your request

Women s Premier OBGYN Right to request confidential communications- You have the right to request that we communicate with you about medical matters in certain way or at certain locations. For example, you can ask that we contact you only by mail or at work. Your request must be in writing and must specify how or where you wish to be contacted. We will accommodate reasonable requests. Right to a paper copy of this Notice- You may ask us to provide you with a copy of this notice at any time. Changes to this Notice We reserve the right to change this notice and make the new notice apply to PHI we already have as well as any information we receive in the future. We will post a copy of our current notice in our office. This notice will contain the effective date on the top of the first page. Complaints If you believe your privacy rights have been violated, you may file a complaint to the Department of Health and Human Services. A complaint must be filed within 180 days of when the complainant knew or should have known that the act occurred. Filling a complaint will not interfere with your health care at this practice. Patient Name Patient Signature Date

Women s Premier OBGYN Acknowledgment of Receipt of Privacy Practices List of Contacts To whom Dr. Rachenetta V Stimage may release information I, have been provided and have reviewed the Notice of Privacy Practices of this office. I understand that my medical records are confidential and cannot be disclosed without my prior authorization, except as otherwise provided by law. I give my permission for Dr. Rachenetta V Stimage and her staff to contact me at the following numbers or email address. If necessary, messages can be left at the number(s) or email indicated by ( ) in box. Home phone #: Cell Phone#: Messages Messages No Messages No Messages Work Phone#: Messages No Messages Primary Email: Messages No Messages Dr. Rachenetta V Stimage and her staff have my permission to release medical and/ or financial information to the following individuals: Person: Home Phone #: Relationship: Mobile Phone #: I permit the release of the following information (indicated with ( ) in box): Medical Financial Dr. Rachenetta V Stimage and her staff have my permission to release medical and/ or financial information to the following individuals: Person: Home Phone #: Relationship: Mobile Phone #: I permit the release of the following information (indicated with ( ) in box): Medical Financial Dr. Rachenetta V Stimage and her staff have my permission to release medical and/ or financial information to the following individuals: Person: Relationship: Home Phone #: Mobile Phone #: I permit the release of the following information (indicated with ( ) in box): Medical Financial I understand that I have the right to revoke this authorization at any time and that my revocation must be in writing. I am aware my revocation is not effective to the extent that the persons I have authorized to use and/ or disclose my protected health information have already acted in reliance upon this authorization. Patient Name Patient Signature Date

Women s Premier OBGYN HIPAA Disclosure I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. Protected Health Insurance (PHI) may originate in your medical records at Women s Premier OBGYN, or may be received from outside health entities and filed in your medical record. I understand that this information can and will be used by Women s Premier OBYN to: A) Conduct, plan, and direct my treatment and follow- up among the multiple healthcare providers who may be involved in the treatment directly or indirectly. B) Obtain payment from third- party payers. C) Conduct normal healthcare operations such as quality through Women s Premier OBGYN or Network Organizations, and E) consent to property transfer of specimen (tissue obtained during medical testing) to Women s Premier OBGYN. I have been informed by you of your notice of privacy practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may obtain a current copy of the Notice of Privacy Practices from my office or by contacting them at 4325 N. Josey Ln. Suite 210, Carrollton, Texas 75010. I understand that I may request in writing that you restrict how my private information is used or disclosed for treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name (Please Print) / / Date of Birth in MM/DD/YYYY Signature of Patient/Guardian Date

Women s Premier OBGYN Financial Policy Please Initial on the Lines Below Our goal is to provide you with the best possible care available. In order to meet this goal, we ask for your assistance and understanding of our patient policies. Our financial policy is necessary part of assuring the financial resources needed to maintain this health care facility for our patients. Insurance Companies We are here to help answer any questions you may have regarding your insurance coverage and payments. However, your insurance is a contract between you, your employer, and the insurance company. We are not a party to the contract, unless we are a contracted provider with your plan. Insurance payments are based on a Usual and Customary Rate (UCR) by most companies. Our fees generally fall within the UCR range; unfortunately, some insurance companies reimburse on a fee schedule, which may beat no relationship to the current standard and cost of this area. Unless we are participants with your plan, you will be responsible for our charges regardless of the company s arbitrary determination of the UCR. If we are contracted with your insurance plan, we will file your claims directly to your insurance company. Note: The Office of the Inspector General strictly prohibits the waiving of copays and deductibles. It is considered fraudulent to accept insurance only. Office Visits Full payment of services is due at the time services are rendered. We accept cash, debit card, Visa, MasterCard, and American Express. Any required co- payment or deductible amounts will be collected at the time of visit. Surgical Procedures We will file insurance claims as a courtesy for patients requiring surgery. Surgery payments are to be made no later than one (1) week prior to your scheduled surgery date. Your insurance benefits will be verified for Dr. Stimage s fee only (Hospital Fees are billed separately by the Hospital.) Once your benefits have been verified you will be contacted by our office with the full amount due for your surgical procedure. Obstetrical Care Payment for Obstetrical care will be discussed with you during your first office visit with our office. Expected charges and payment procedures will be explained to you by one of the members of our staff.

Women s Premier OBGYN Unpaid Balance Balances that are due for greater that (90) days that have gone unpaid will result in termination of care. Fees for Business Services The fees for completion/preparation of the following forms/correspondence may not be covered under your insurance plan: Forms for school physicals, sport physicals, camp registration, disability, FMLA, LOA; written correspondence to employers, schools, and insurance companies; reissuing written prescriptions. Completion of some of these documents may require a fee which will be collected in advance. Thank you for choosing us as your OB/Gynecologist. We believe it is important that our patients fully understand our financial policy, so we may concentrate on you and your medical needs. It is your responsibility to notify us in writing of any changes in your account status (i.e. address, phone numbers, and insurance.) Our business office is available during regular business hours and we welcome any questions you may have regarding our policies. I have read the above and I understand and agree to this Financial Policy. Patient Name Patient Signature Date

Women's Premier OBGYN Consent for Care and Treatment Consent This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment by your health care provider, we encourage you to ask questions. I voluntarily request a physician, and or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing, and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). To the Patient: You have the right, as a patient to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may take the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/ or procedure for any identified condition(s). I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Signature of Patient or Personal Representative Date Printed Name of Patient or Personal Representative Relationship to Patient