FAX TO: OR TO:

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Alicia Gallagher
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1 PATIENT REGISTRATION FORM Name (Last) (First) (MI) (Previous/Maiden) Social Security Number DOB Marital Status Address City State Zip Home# Work# Ext Cell# Address *CIRCLE THE PREFERRED WAY TO BE REACHED* Employer Occupation Race [ ] White [ ] Black or African American [ ] Hispanic [ ] Asian [ ] Other [ ] Decline Ethnicity [ ] Hispanic or Latino [ ] Not Hispanic or Latino [ ] Decline Language [ ] English [ ] Spanish [ ] Other ************************************************************************************************************************************ PRIMARY CARE PHYSICIAN/PRACTITIONER Phone# EMERGENCY CONTACT Relationship Home # Work# Cell# PHARMACY LOCATION PHONE ********************************************************************************************************************** SPOUSE / PARENT / GUARANTOR Name (Last) (First) (MI) DOB SS# Address City State Zip Address Home# Work# Cell# Employer _Employer Phone PRIMARY INSURANCE INFORMATION Insurance Company Phone# Name of Insured Patient Relationship to Insured DOB Insurance Address Employer Subscriber ID# Group ID# Co-Pay Amount SECONDARY INSURANCE INFORMATION Insurance Company Phone# Name of Insured Patient Relationship to Insured DOB Insurance Address Employer Subscriber ID# Group ID# Co-Pay Amount I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge. I also understand that I am responsible for contacting Annapolis Ob-Gyn Associates, in a timely manner, with any future changes in the above information, especially those that may affect the processing of my insurance claims. Patient Signature Date Parent or Guardian Relationship Date FAX TO: OR TO: preregistration@annapolisobgyn.com Office Use Only: FD CL UPDATED 4/26/13

2 ANNAPOLIS OB-GYN ASSOCIATES, P.A. DISCLOSURE AGREEMENT Patient s Name (Print) DOB Street Address City, State, Zip Copay/Balance Date of Visit Home Phone No. Work Phone No. Cell Phone No. Address Race: Ethnicity: Language: ( ) White ( ) Black or African American ( ) Hispanic ( ) Asian ( ) Other: ( ) Decline ( ) Hispanic or Latino ( ) Not Hispanic or Latino ( ) Decline ( ) English ( ) Spanish ( ) Other: REASON FOR TODAY S VISIT: Routine Preventive Exam My insurance plan covers Preventive Medical Services. My insurance plan does not cover Preventive Medical Services. I do not know. I have a problem/complaint that I wish to have evaluated/treated. NOTE: If you would like anyone else to have access to your patient information, (spouse, parent, partner, etc.) please complete the REQUEST FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO INDIVIDUALS OTHER THAN THE PATIENT form. I am here today for I agree to pay for any and all medical services I receive from Annapolis OB-GYN that are not covered services or payment is denied by my insurance company, for whatever reasons. I further agree and understand that this office can only code and file a claim for my visit with a diagnosis that was encountered and documented in my medical record. To prevent erroneous denials and to help us collect the correct insurance reimbursement for your visit, be sure that you clearly indicate above what you are being seen for today. At the time of discharge, please double check your diagnosis to make sure there is no miscommunication. WE CAN NOT CHANGE THE DIAGNOSIS AFTER IT HAS BEEN SUBMITTED TO YOUR INSURANCE _ Signature Date 8/23/12

3 HISTORY AND PHYSICAL RECORD Date: PATIENT NAME: DOB: SS#: FAMILY HISTORY: Alive Dead Cause of Death Age at Death Other Diseases (If cancer, list type) Mother Father Brother(s) Sister(s) CHECK BELOW ANY DISEASE A BLOOD RELATIVE OF YOURS MAY HAVE (HAD) (Please write maternal or paternal & include your children) Disease Type Relative Cause of Death Disease Type Relative Cause of Death Addiction Osteoporosis Blood Disorder Thyroid Disease Cancer Hypertension Colon/Rectal High Cholesterol Depression Heart Disease Diabetes Alzheimers Epilepsy Mental Illness Pulmonary Other: LIST YOUR PAST SURGICAL/INJURY HISTORY BELOW: (If you had a D&C due to a miscarriage, enter in Obstetrical History at bottom of page) Disease/Diagnosis/Injury Procedure or Surgery Date Physician/Surgeon Hospital LIST YOUR MOST RECENT SCREENINGS: Screening Date Result Screening Date Result Screening Date Result Bone Density Colonoscopy Pap Chest X-Ray Cholesterol Mammogram OBSTETRICAL HISTORY: Date of Delivery Wks Gest Type of Delivery Physician Sex Wt. Abortion (Elective) Miscarriage List other problems/complications and outcome TOTALS: Enter totals below: Total Pregnancies # of Full Term # of Premature Elective Abortions Miscarriages Ectopics Live Children YOUR MEDICAL HISTORY: (Check off if you have had this illness and write what type if applicable) Disease Type Disease Type Disease Type Asthma Kidney Dis/Infections Epilepsy/Seizures Tuberculosis Hypertension Hepatitis (list kind)/liver Dis. Diabetes (list kind) Gastrointestinal Prob. STD (list kind) Cancer (list kind) Mental Illness (list kind) Herpes ( list kind) Heart Disease Chronic Bladder Infec. Thyroid Disorder Hyperlipidemia Osteoporosis Blood Clotting Disorder Other:

4 GYN HISTORY Patient s Name: Age when period started? Periods come every days They last days. Flow: Light Moderate Heavy Pain with menstrual period? Bleeding between periods? Pain between cycles? Last Menstrual Period Are you having perimenopausal symptoms? Type? Are you post menopausal? At what age? Type of menopause: Natural Surgical Premature Chemo Other Vaginal discharge? Is this normal for you? Color and consistency Itching/odor? How often do you douche? Do you do self breast exams? Sexually active? Practice safe sex? Current sexual orientation Past orientation? # of partners Type of birth control Pain with intercourse? Vag. Dryness? Bleeding with intercourse? Marital status: S Sep M D W Previously divorced? Previously widowed? SOCIAL HISTORY: Do you smoke? How much do you smoke? Date quit? How many years did you smoke? Do you drink alcohol? Amount and frequency? Prior alcohol abuse? Caffeine use? Amount and frequency? Breast tenderness w/caffeine? Drug use? (Circle one) Yes No (Circle one) Past Present Date Stopped? Type? Frequency? LIFESTYLE: Level of activity: (Circle one) Above average Average Sedentary Type of exercise: Exercise frequency: Type of daily diet: Recent weight gain/loss? Amount: Place of birth: Advanced Directives: (Circle one) None DNR Living Will Do you use seat belts? CURRENT REVIEW OF SYSTEMS: Please check below if you are currently suffering from any of the symptoms listed. Fatigue Intestinal Problems (Name) Urinary Stress Incontinence Unusual Vag. Discharge Dizziness Varicose Veins Burning w/urination Other: (List) Blurred/Double Vision Phlebitis Blood in Urine Chest Pain Edema (swelling) Anxiety/Nervousness Chronic Cough Blood Transfusion (date) Insomnia Breathing Problems Reaction to transfusion Breast Lump Indigestion/GERD Poor Appetite Breast Tenderness Weight loss/gain (amt?) Food Intolerance Pelvic Pain or Pressure Migraines Eating Disorder (Name) Irregular Bleeding ALLERGIES: Allergy Reaction Allergy Reaction MEDICATIONS: (Include medications, vitamins & herbal supplements) Name Strength Dosage Reason Name Strength Dosage Reason 8/21/12

5 ANNAPOLIS OB-GYN ASSOCIATES PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Please read this form carefully. You will be asked to sign this form electronically upon arrival to your appointment. There is no need to bring this form to your visit. I hereby give my consent for Annapolis OB-GYN Associates to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Annapolis OB-GYN Associates Notice of Privacy Practices provides a more complete description of such disclosures) I have the right to review the Notice of Privacy Practices prior to signing this consent. Annapolis OB-GYN Associates reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Annapolis OB-GYN Associates Privacy Official at 2000 Medical Parkway Ste. 304, Annapolis, MD With this consent, Annapolis OB-GYN Associates may call my home or other alternative location and leave a message on voic or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent, Annapolis OB-GYN Associates may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Annapolis OB-GYN Associates restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Annapolis OB-GYN Associates use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Annapolis OB-GYN Associates may decline to provide treatment to me. NOTE: If you would like anyone else (spouse, partner, parent, etc.) to have access to your health information please ask for the appropriate form. Updated 12/22/11

6 ANNAPOLIS OB-GYN ASSOCIATES REQUEST FOR DISCLOSURE AND/OR MODIFICATION OF PROTECTED HEALTH INFORMATION TO INDIVIDUALS OTHER THAN THE PATIENT PATIENT PLEASE NOTE: The Practice is not required to agree to your request. Please see our Notice of Privacy Practices for more information regarding such requests. Patient Name (Print) DOB SS# Address City State Zip Type of Protected Health Information (PHI) to be released: I authorize the following individuals to have access to my PHI: (PLEASE PRINT) 1. Name: Relationship to patient: All information Limited to the following information 2. Name: Relationship to patient: All information Limited to the following information 3. Name: Relationship to patient: All information Limited to the following information AMENDMENT TO PREVIOUS PHI AUTHORIZATION Add or remove the following person(s) to/from my existing authorization: 1. Name:Relationship to patient: Add Remove 2. Name:Relationship to patient: Add Remove _ Signature of Patient Date PHI Disclosure Updated 02/18/14 FOR INTERNAL PURPOSES ONLY:

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email