ANNUAL EXAM WELCOME BACK Name: Date: An annual exam is preventative care consisting of a physical exam and possibly a Pap smear. If you have problems to discuss with the physician or nurse practitioner, you may have an additional charge for a problem visit or may be asked to return for a separate visit. If you are having a problem, briefly describe: First day of your last menstrual period: Menopausal? Are you experiencing any of the following: (please circle) Weight loss Violence in your home Skin problems Painful urination Cough or cold symptoms Nausea or vomiting Leakage of urine Change in bowel function Blood in the stool Abdominal bloating Shortness of breath Chest pain Depression Suicidal thoughts Are you allergic to any medications? No Yes If yes, please list. Who is your primary care physician? Current Medications (please include birth control):
ADVANCED ANNUAL NOTICE Dear Patient, You are scheduled for your annual Pap smear, breast and pelvic examination today. Our normal fee for this service is $120 for established patients and $160 for new patients. Any lab work (Pap smear, blood work) that may be associated with the exam will be billed by the laboratory directly. If you have health insurance that we will be billing for you today and you do not have a benefit for this exam, you will be responsible for this fee. The laboratory will bill you separately for those charges. If you have other medical concerns not related to your annual exam that you would like to discuss with the doctor at the same time and it meets necessity to bill additionally for this service, we will do so. By signing this form, you are confirming your agreement to assume financial responsibility for payment of these charges should your insurance find them not medically necessary or non-covered. Patient Signature: Date
Patient Registration and Insurance Information Name: D.O.B. Address: City: _ State: Zip: SS# Please circle the RACE and ETHNICITY that is best for you (required by law). RACE: American Indian, Alaskan Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, Other, Refused to report. ETHNICITY: Hispanic or Latino, Not Hispanic or Latino, Unreported or refused to report Primary phone # Secondary phone # Employer Work Phone # E-mail address: Alt. contract: Phone Relationship PLEASE COMPLETE ALL INSURANCE INFORMATION If you do NOT have insurance, check here Insurance Co. Name of Insured Policy holder s date of birth: _ Relationship ASSIGNMENT OF INSURANCE BENEFITS I hereby authorize direct payment of surgical or medical benefits to OBGYN ASSOCIATEDS for services rendered. I understand that I am financially responsible for any balance not covered by my insurance. I hereby authorize OBGYN ASSOCIATES to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I understand I may revoke this consent at any time by notifying OBGYN ASSOCIATES in writing. OBGYN ASSOCIATES has the right to refuse treatment should I revoke or refuse this consent. Patient Signature Date
Privacy Issues for Patients I have read and understand the laminated Notice of Privacy Practices which is posted near the front desk window. A printed copy is available upon request. Signature: You may give the following people detailed medical information about me (you may decide that no one should have medical information about you): Name: Relationship Name: Relationship Name: Relationship Signature: Office Policies 1. Your co-pay is due at the time of service. You are responsible for any deductible insurance amounts. 2. If your insurance requires a referral or authorization, it is your responsibility to get it. 3. Your insurance company has contracted with a lab for any blood work, Pap smears or biopsies. You should know which lab to visit for blood work. We will make every attempt to send any specimens to the correct lab. Our office does not bill for lab work; the lab company will bill you for any labs, Pap smears or biopsies. 4. If you do not call to cancel a scheduled appointment and to not show up for the appointment, we will charge you $25.00. Signature:
Susan Yarian, MD Eric Pulsfus, MD Thomas Searle, MD Kelly Jago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terine(endometrial) cancer before 50 Y N Colorectal cancer before age 50 Y N Two or more Lynch Syndrome cancers* in the same person or on the same side of the family EKD-'/,L-'641)&/#'/&4.'/:96&*M1:1'N@&/$#:N>$&4'&N=O#4#'NL$1)#/,NP#::3:#66&409/$N8'$&.$'#:N"#'/4&#.#'6 34#'G 6G&2F&AE7J&H&A9&A9G2G.;;&:H.I:G:6G&DG&FEH&DA72H2 Y N Breast cancer at age 50 or younger Y N Ovarian cancer Y N Two primary (unrelated) breast cancers in the same person or on the same side of the family Y N Male breast cancer Y N Triple negative breast cancer (ER-,PR-HER2-pathology) Y N Pancreatic cancer with breast or ovarian cancer in the same person or on the same side of the family Y N Ashkenazi Jewish ancestry with breast, ovarian or pancreatic cancer in the same person or on the same side of the family Y N Have you or any member of your family ever been tested for hereditary risk of cancer "#$&'$LJ'#$94&++++++++++++++++++++++++++++++++++++B//&<$+++++0&/:'&+++++5&.$'J