All Women OB/GYN, P.S.C. 4010 Dupont Circle, Suite L-07 Louisville, KY 40207 (P) 502.895.6559 (F) 502.895.8994 Lisa Crawford, MD Amy Deeley, MD Elena Salerno, MD Aimee Paul, MD Tanika R. Taylor, MD Rachel Thompson, APRN New Patient History (Please complete both pages of form) Patient Acct#: Name: : of Birth: Marital Status: (Single, Married, Widowed, Divorced, Other) Patient s Employer: Occupation: Partner s Name: Occupation: Partner s Employer: Emergency Contact: Phone #: Relationship: Reason for visit:!preventative/well-women Exam Other: (Please explain) Who referred you? Name of Family Doctor: Medication History (List all medications that you currently take with the dose) Do you take hormone therapy or birth control pills?! Yes! No If YES, please list below Allergies (List all adverse reactions or allergies you have to medications and what happened) Are you allergic to Latex? Peanuts?: Eggs? Surgical History (List all surgeries you have had including breast biopsies, breast augmentation, tonsillectomy, appendectomy, tubal ligation, wisdom tooth extraction including dates) Page 1 102
Medical History (Please list any medical problems that you have) General Health Height: Weight: /place of last pap smear: /place of last mammogram: How much alcohol do you drink? None Avg. less than 1/day Avg. 1/day Avg. more Do you smoke? Yes No Amount/day How many years: If you quit smoking, when did you stop? Gynecologic History Age of first menstrual period: of last menstrual period: Menopausal Hysterectomy Length of cycle from 1 st day to 1 st day each month: days Regular Irregular Average length of each period: Heavy Moderate Light What do you use to keep from getting pregnant? Nothing Vasectomy Condom Rhythm Tubal ligation IUD Diaphragm Birth Control Pills Patch Abstinence Sexual History Are you sexually active Yes No Pregnancy History Age when you had your first child: Number of times pregnant Full term births Premature Births Elective termination Miscarriages Tubal pregnancies Adopted children Step children Twins Have you ever had a C-Section? With any of your pregnancies, did you have: Gestational Diabetes? Gestational Hypertension? Preeclampsia? Any Other complication? (please explain) Family History Adopted Does your mother(m), father(f), sister(s), brother(b), Grandmother(GM), and/or Grandfather(GF) have any of the following? Increased cholesterol Yes No who? Diabetes Yes No who? Increased blood pressure Yes No who? Heart attack before age 50 Yes No who? Breast cancer Yes No who? Colon cancer Yes No who? Page 2
All Women OB/GYN, P.S.C. Patient Demographics Form Please complete all information and sign below PATIENT INFORMATION: : Last Name: First Name: Middle Initial: Age: of Birth: Social Security#: Preferred Pharmacy: Zip: Do you authorize us to submit prescriptions electronically? Y N Race: Caucasion African American Native American Asian Other Decline Ethnicity: Hispanic/Latino Not Hispanic/Latino Decline Marital Status: Single Married Divorced Widowed Other Street Address: City: State: Zip: Home Phone #: Work Ph#: Cell Ph#: Email: Employer: INSURANCE POLICY HOLDER INFORMATION (If other than Self) First Name: Middle Initial: Last Name: of Birth: Social Security #: Employer: Work Ph#: ( ) INSURANCE INFORMATION: Name of PRIMARY Insurance Plan: Policyholder: Subscriber ID#: Group#: Claims Address: Patient Relationship to Subscriber: SELF SPOUSE CHILD OTHER Name of SECONDARY Insurance Plan: Policyholder: Subscriber ID#: Group#: Claims Address: Patient Relationship to Subscriber: SELF SPOUSE CHILD OTHER PATIENT S OR AUTHORIZED PERSON S SIGNATURE I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, including Medicare, Private Insurance, and any other Health Plan to: All Women OB/GYN, PSC This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment. SIGNED: DATE: 104 01/15/2016
4010 Dupont Circle, Suite L-07, Louisville, KY 40207 Phone: 502-895-6559 Fax: 502-895-8994 FINANCIAL POLICY Welcome to our practice. We want to provide the best care possible to you. A portion of that care involves payment for the services we give, and this statement explains our policies and procedures in that endeavor. Please return this form to the receptionist once you have reviewed and signed it. A copy will be provided to you upon request. We require the following before we can provide you care and treatment: Updated demographic and current insurance information Co-payment or payment for non-covered services Referral if required by your insurance plan Once you have seen the doctor and charges for your encounter have been posted, your insurance company will be billed. Following receipt of the explanation of benefits and payment, disallows, write-offs and discounts have been taken, or if there is a denial of the claim, you will be sent a statement for any balance due. We will gladly work with you on a payment plan for any unusual balances left unpaid. If you have a credit balance following final insurance payments, refunds are issued twice per month. Special circumstances to this policy are prepayments required for global OB care and elective surgery. If no payment is received with your statement, follow up collection letters may be sent. On balances less than $50, we will suspend the balance, which will become payable before you may resume care. Unpaid balances over $50 may be referred to a collection agency if there is no response to billings. In this event, you will be responsible for Collection, Court and/or Attorney costs. Failure to pay for services in a timely manner will result in termination of the physician-patient relationship. If you should desire to reestablish your patient-doctor relationship it will be necessary for you to completely pay your collections balance and reimburse the Doctors for any commission loss. Termination of care may also result from noncompliance of recommended care including missed or multiple rescheduled appointments. A service charge of $25 may be made on the following: Co-payment not received within 24 hours of services Re-filing of insurance if incomplete or incorrect info given a time of appointment Returned checks is a $29 fee. After the first disability or FMLA form is processed, there is a $10 fee for each additional one for the same incident of care. Appointments should be cancelled 48 hours in advance. A charge of $50 may be made for a no show or an appointment cancelled without 48 hours notice. We realize that there may be extenuating circumstances in your lives which may cause you to miss an appointment; we do request a phone call to inform us of your inability to keep your appointment. I acknowledge that I have read and understand this financial policy of All Women OB/GYN, PSC Patient or Responsible Party Signature Patient s Printed Name 105 3/3/15
No Show or Late Cancellation Charge It is the policy of this office to collect no show fees and late cancellation fees for office visits, DEXA scans and Ultrasound testing. If a patient should no show for an appointment there will be a $ 50.00 charge which will be the patient s responsibility. If a patient fails to cancel 48 hours prior to their appointment time, so that we may schedule another patient, they will be responsible for a $ 50.00 fee. This fee will be billed to the patient and must be paid before another appointment or test can be scheduled. I have read the above office policy and agree to pay the $ 50.00 charge if I should no show for my appointments or if I should fail to cancel my appointments 48 hours prior to its scheduled time and date. Patient Name Witness to signature *** The above information was conveyed by phone to the patient. Staff Member giving phone information given 106
NURSE PRACTITIONER WAIVER Notification that all insurance plans do not cover services with a Nurse Practitioner. Our Nurse Practitioner is currently credentialed to see patients for all insurances except Medicare and Medicaid. That means that services rendered to patients with coverage by these insurance companies are filed with specific provider numbers designating that the care given was by Rachel Thompson. These charges are paid at a lower value than services billed from a physician. (Usually 70 85% of the normal fee) Even though the company may require we file a claim with the Nurse Practitioner provider number, the particular plan s policy is based on the employer s criteria. Some of these plans DO NOT cover a Nurse Practitioner and will deny the claim with responsibility for payment due from the patient. Since this is an individual plan stipulation and we cannot know everyone s particular coverage, should a denial of payment be received for these services, you, the patient, will be billed for the full charge. By signing this waiver, you are agreeing to be responsible for knowing your policy and for the charges incurred. Patient 107
4010 Dupont Circle, Suite L-07, Louisville, KY 40207 Phone: 502-895-6559 Fax: 502-895-8994 COMMUNICATIONS RELEASE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY (HIPAA) CONSENT FOR USE OR DISCLOSURE OF PATIENT INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS Patient Name of Birth SSN Medical Record # CONSENT FOR LEAVING MEDICAL INFORMATION ON PERSONAL PHONE By signing this section, I am consenting to have personal medical information left on my phone. The phone number, which I feel is secure enough for this information, is. Patient Signature Witness Signed Witnessed COMMUNICATION WITH FAMILY AND OTHERS INVOLVED IN YOUR CARE This section allows you, as the patient, to choose those persons you want to include and allow access to your medical information. This communication can be changed or voided by you at any time; however, we cannot retrieve information that has already been shared. Please list any family members or others whom may be involved in coordinating your care. Also, please indicate what type of information may be shared with each person listed. If you are a dependent on your parents insurance, please be aware that you must list your parent before we can release any billing/medical information to them for payment purposes. Name (please print) Relation to Patient All Appointment Medical Billing When verifying identity over the phone it is our standard policy to ask questions regarding the patient s demographics (SS#, DOB, Address), or billing information. Please initial one of the following lines: q I approve of the standard identity verification process q I would like to use a password for identification purposes. Password: All Women OB/GYN PSC will continue to rely on the information on this form when communicating with family members or others unless you request a change. To alter or void the designation above, please send a written request to the address on the top of this form. Patient Signature Signed I hereby consent to All Women OB/GYN, PSC (the Practice ) using or disclosing my protected health information for the purpose of providing treatment to me, obtaining payment for health care services rendered to me or to carry out the Practice s healthcare operations. I also request payment of government benefits either to myself or to the party who accepts assignments for claims. Patient Signature Signed Printed Name of Patient/Representative Relationship to Patient