Responsible Party (Guarantor) Info. Insurance Information

Transcription

1 Associates in Women s Health, P.C YOUNGFIELD STREET, SUITE 200 GOLDEN, CO P: F: Please Circle Your Doctor: ELLIS GANTER PYTHON SCHOEN WESSELL, WHNP PATIENT INFORMATION Account # Social Security #: Name: DOB: Address: City: State: Zip: Race: Ethnicity: (Please circle) Hispanic/Latino NOT Hispanic/Latino Marital Status: Spouse s Name: Please circle your preferred telephone number. Home Phone: Work Phone: Cell Phone: IF WE MAY LEAVE RESULTS ON YOUR PREFERRED NUMBER S VOIC , INITIAL HERE: PHARMACY PHONE #: Patient Employer/Occupation/Phone #: Responsible Party (Guarantor) Info Name: Billing Address: City: State: Zip: Phone: Primary Insurance Carrier: Insurance Information Insurance Claims Address: Insurance Claims Address Cont: Subscriber: Employer: Subscriber DOB: Employer Phone #: Subscriber Sex: Subsciber SSN: Relationship to Subscriber: ID #: Group # (if applicable): Revised 1/2017

2 Secondary Insurance Carrier: Insurance Claims Address: Insurance Claims Address Cont: Subscriber: Employer: Subscriber DOB: Employer Phone #: Subscriber Sex: Subsciber SSN: Relationship to Subscriber: ID #: Group # (if applicable): 1) CONSENT TO TREATMENT I consent to treatment by Associates in Women's Health, PC, provided by and under the care of the physician, her associates, partners, assistants, other staff and/or contracted providers. I consent to outpatient care which encompasses diagnostic examination and procedures including, but not limited to laboratory, medication, drug testing, removal and disposal of tissue, nursing or medical/surgical treatment that my physician, associates, partners, assistants may deem necessary or advisable, under the general and special instructions of the same. 2) NON-DISCRIMINATION POLICY Associates in Women's Health, PC, will admit and treat patients regardless of race, color, national origin, religion, sex, sexual orientation, marital status, age or disability. 3) ASSIGNMENT OF INSURANCE BENEFITS I hereby assign my right to and authorize Associates in Women s Health, PC to bill and receive payments directly from my insurance carrier for any benefits or series of benefits covered and payable by my insurance carrier, as well as proceeds of claims resulting from the liability of third party(ies) or organizations. I further understand that prior to receiving services I may choose to pay for services directly. If I do not want my health information for that service to be provided to my insurance carrier or other third party payer. 4) NO SHOW POLICY Please be courteous of your appointment time and allow 24 hour notice to cancel/reschedule your appointment. Failure to do so will result in a no show fee of $50. For one hour procedures, the no show fee is $100 without a 72 hour notice, 5) FINANCIAL AGREEMENT I the undersigned, individually obligate myself to the payment of my Associates in Women's Health, PC account incurred by the patient s service(s). I understand that I will be responsible for charges not covered by my health insurance carrier(s). I will be expected to pay my medical bill in full when I am discharged or at the time of provision of medical services, diagnostic services and/or procedures, unless I have made other arrangements with Associates in Women s Health, PC s financial department. Should these bills not be paid, I understand that my account and any of my healthcare information necessary for collection of the bill, will be referred to an attorney or collection agency. I will be responsible for paying all attorney s fees, court costs, and other legal fees and costs incurred in collecting my medical payment, together with late fees and interest at the maximum rate allowable by law. DISCLOSURE: I have read and understand these documents and accept and agree to follow the conditions contained therin. I also understand that certain health information may be released to state and/or other federal agencies for reporting purposes unless otherwise stated below. X Signature: Patient, Guardian, or Legal Representative* Print: Patient, Guardian, or Legal Representative / / Date Revised 1/2017

3 Date: Patient #: Health History for Patients Under Age 50 NAME: DOB: Who is your primary care physician? When was the 1 st day of your last menstrual period? Are you currently pregnant? YES NO Total number of pregnancies? Total number of births? Have you ever had a miscarriage? YES NO Have you ever had an abortion? YES NO What are you currently using for contraception? Are you experiencing any problems with it? If yes, explain: How old were you when you started your period? How often are your periods? less than 21 days every days greater than 34 days How long does your period last? Are you periods painful? YES NO If yes, explain: Do you take anything for the pain? Do you experience any bleeding between cycles? YES NO If yes, explain: Are you having any problems with sex? YES NO Pain with intercourse Difficulty with lubrication Decreased sex drive Have you ever had any of the following STD s? Chlamydia Herpes (genital) Gonorrhea HIV HPV (warts) Syphilis Trichomonas Do you have, or have you ever had any of the following medical problems: Anxiety Asthma Blood clots Cancer - Type: Dense breast tissue Depression Diabetes insulin non-insulin Frequent urinary tract infections Heart disease High blood pressure High cholesterol Liver disease (Hepatitis) Migraines Thyroid problems Seizure disorder Other Past surgical history: (Please include date of surgery) See other side>>>>>>

4 Medications you are currently taking: (Please include the dosage) Do you have any allergies to medications? If yes, please list: Do you have a Latex allergy: YES NO Do you have a family history of any of the following? (Please include relation, age when diagnosed & if on mother s or father s side) Ashkenazi Jewish Heritage Heart Disease Breast Cancer Diabetes Endometrial Cancer Colon Cancer Colorectal Polyps Genetic Mutations High Blood Pressure Ovarian Cancer Pancreatic Cancer Skin Cancer Other Race: Do you consider yourself to be: STRAIGHT GAY/LESBIAN BISEXUAL What do you do for a living? Marital Status: SINGLE MARRIED SEPARATED DIVORCED WIDOWED Sexually active: YES NO If yes, how long have you been with current partner? Tobacco use: CURRENT FORMER NEVER If current, how many cigarettes a day? Alcohol use: NONE RARLEY OCCASIONAL HEAVY How many drinks per day: or per week: Drug use: NONE MARIJUANA COCAINE HEROIN IV DRUGS Caffeine use: YES NO If yes, how may cups a day? If former, when did you quit? Have you ever had your Cholesterol checked? YES NO When? When was your last Pap smear: Have you ever had an abnormal pap smear? YES NO If yes, when? Have you ever had a Mammogram? YES NO When? NORMAL ABNORMAL Have you had the chicken pox? YES NO If yes, when? Have you received/completed the Gardasil (HPV) vaccinations? YES NO If yes when? Pharmacy Name: Address: Pharmacy Number:

5 Date: Patient #: NAME: Who is your primary care physician? DOB: Do you still have a period? YES NO If yes, are they: less than 21 days every days greater than 34 days Considerably heavier than before Total number of pregnancies? Health History for Patients Age 50 And Over Total number of births? Have you ever had a miscarriage? YES NO Have you ever had an abortion? YES NO What are you currently using for contraception? Are you having any problems with sex? YES NO Pain with intercourse Difficulty with lubrication Decreased sex drive Do you currently have any of the following problems? Difficulty sleeping Hot flashes Depression Irritability/Mood changes Frequent bladder infections Loss of bladder control Frequent vaginal infections Memory loss Osteopenia Osteoporosis Painful intercourse Vaginal burning Have you ever taken Estrogen? YES NO Are you currently taking Estrogen now? YES NO Any problems with Estrogen? YES NO Breast tenderness Bloating Headaches Irregular bleeding Weight gain Other Have you ever had any of the following STD s? Chlamydia Herpes (genital) Gonorrhea HIV HPV (warts) Syphilis Trichomonas Do you have, or have you ever had any of the following medical problems? Anxiety Asthma Blood clots Cancer - Type Dense breast Depression Diabetes insulin non-insulin Frequent urinary tract infections Heart disease High blood pressure High cholesterol Liver disease (Hepatitis) Migraines Thyroid problems Seizure disorder Other _ Past surgical history: (Please include date of surgery) See other side>>>>>>>>

6 Medications you are currently taking: (Please include the dosage) Do you have any allergies to medications? If yes, please list: Do you have a Latex allergy: YES NO Do you have a family history of any of the following? (Please include relation, age when diagnosed & if on mother s or father s side) Ashkenazi Jewish Heritage Heart Disease Breast Cancer Diabetes Endometrial Cancer Colon Cancer Colorectal Polyps Genetic Mutations Race: What do you do for a living? Do you consider yourself to be: STRAIGHT GAY/LESBIAN BISEXUAL High Blood Pressure Ovarian Cancer Pancreatic Cancer Skin Cancer Other Marital Status: SINGLE MARRIED SEPARATED DIVORCED WIDOWED Sexually active: YES NO If yes, how long have you been with current partner? Tobacco use: CURRENT FORMER NEVER If current, how many cigarettes a day? Alcohol use: NONE RARLEY OCCASIONAL HEAVY How many drinks per day: or per week: If former, when did you quit? Drug use: NONE MARIJUANA COCAINE HEROIN IV DRUGS Caffeine use: YES NO If yes, how may cups a day? Have you ever had your Cholesterol checked? YES NO When? When was your last Pap smear? Have you ever had an abnormal pap smear? YES NO If yes, when? When was your last Mammogram? Have you ever had an abnormal mammogram? YES NO If yes, when? When was your last Bone Density scan? When was your last Colonoscopy? Have you ever had an abnormal colonoscopy? YES NO If yes, when? Have you had the chicken pox? YES NO If yes, when? Pharmacy Name: Address: Pharmacy Number:

7 In an effort to provide the best experience during your office visit today and help us keep current on your health, please take a few minutes to complete the following questions. Thank you! Name Date of Birth _ CONTRACEPTION 1. What is your current form of birth control? _ 2. How long have you been using your current form of birth control? (please check one) Two years or less 3 to 5 years 6 to 10 years Over 10 years 3. When are you planning to have another child? (please check one) Within the next year Within the next 5 years Within the next 10 years My family is complete 4. Are you finished having children and would you like information on a gentle, hormone-free permanent birth control procedure performed in the comfort of our office? Yes No MENSTRUAL PERIODS 1. How long does your average monthly period last? days 2. Do you ever feel as though your periods impact the quality of your life? Yes No 3. Do you ever experience irregular or inconsistent bleeding patterns? Yes No 4. Are you finished having children and would you like information on a simple, safe procedure performed in our office that can significantly reduce or eliminate your monthly period? Yes No URINARY HEALTH 1. Do you ever leak urine when you cough, laugh or sneeze? Yes No 2. Do you ever feel as though you have to urinate urgently? Yes No 3. Do you feel like you have to urinate too frequently? Yes No 4. Do you ever experience painful urination? Yes No Are there any concerns/issues that you would like to discuss today? Please be aware, if you have a specific problem that you would like to discuss, it may require a copay or an additionally scheduled appointment Please note: If there is a medical concern that the provider feels further diagnostic/lab testing is recommended, this may not be covered under your well women exam. You are strongly advised to contact your insurance to verify plan coverage before having the testing performed. Sign Date

8 Health Care Consent Policy Due to the ever-changing nature of health insurers and insurance plans, I understand that it is my responsibility to contact my insurance carrier to confirm that Associates in Women s Health is in network with my plan. If Associates in Women s Health is NOT in network, I understand and agree that I am responsible for the entire balance for my care. Patient Signature: Patient name (print): Date: Insurance: Staff initials:

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10 HIPAA CONSENT FORM CONSENT FOR THE PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS I consent to the use/disclosure of my private health information (PHI) by Associates in Women's Health for the purposes of diagnosing, providing care and treatment to me, obtaining payment for my health care bills or conducting health care operations of Associates in Women's Health. I understand that diagnosis or treatment of me by Associates in Women's Health may be conditional upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my PHI is used or disclosed to carry out treatment, payment or healthcare operations of this practice. Associates in Women's Health, is not required to agree to the restrictions that I may request. However, if Associates in Women's Health agrees to a restriction that I request, the restriction is binding on Associates in Women's Health. I have the right to revoke this consent, in writing, at any time, except to the extent that Associates in Women's Health has taken action in reliance on this consent. My PHI means health information, including demographics, collected from me and created or received by my physician, another health provider, a health plan, my employer or a healthcare clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or other is a reasonable basis to believe the information may identify me. I understand I have a right to review Associates in Women's Health s Notice of Privacy Practices prior to signing this document. The Associates in Women's Health s Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my PHI that will occur in my treatment, payment of my bills or in the performance of health care operations of Associates in Women's Health. The Notice of Privacy Practices for Associates in Women's Health is also provided upon request and in the waiting room. This Notice of Privacy practice s also describes my rights and Associates in Women's Health s duties with respect to my PHI. Associates in Women's Health reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of the privacy practice by calling the office and requesting a revised copy be sent to me in the mail or by asking for one at the time of my next appointment. Associates in Women s Health endorses, supports, and participates in electronic Health Information Exchange (HIE) as a means to improve the quality of your health and healthcare experience. HIE provides us with a way to securely and efficiently share patients clinical information electronically with other physicians and health care providers that participate in the HIE network. Using HIE helps your health care providers to more effectively share information and provide you with better care. The HIE also enables emergency medical personnel and other providers who are treating you to have immediate access to your medical data that may be critical for your care. Making your health information available to your health care providers through the HIE can also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt-out of participation in the <CORHIO> HIE, or cancel an opt-out choice, at any time Signature of Patient or Personal Representative Printed Name of Patient or Personal Representative Description of Personal Representative s Authority Date

11 Your Health Maintenance Visit and Preventive Health Benefits Thank you for scheduling your health maintenance examination. At Associates in Women s Health, our physicians are serious about proactively keeping you healthy, and preventive medicine is the key to doing just that. Know your Preventive Benefits Depending on your health insurance plan, you may receive certain preventive benefits for a reduced copayment or no copayment. This is a quick reference designed to help you understand which services maybe covered under your prevention benefits and which services may not. Please be aware that if you receive care beyond what your preventive visit benefit covers, you may incur additional charges for the care provided. Services covered during your preventive visit* Age-focus exam Advice for disease prevention and healthy living Discussions about previously identified risk factors (i.e., smoking) Management of previously diagnosed chronic problems that are relatively stable Management of minor new problems that require no new lab testing, procedures, follow-up or prolonged treatment plans Services that may NOT be covered during your preventive visit* & are subject to additional charges New problems that require lab tests, ultrasounds, or other evaluation New problems that require prescription medication Certain Lab tests to screen for diseases for which you may be at risk due to age Age-based immunizations Chronic problems that are significantly uncontrolled and require evaluation, management strategies, and possibly changes in medications *Please note that this handout can not describe or define your particular preventive benefits. Please contact your insurance company for specific benefit information. Your insurance card should have a phone number or address for you to contact them. Acknowledged By: Date: