Women s Specialty Care, P.C 682 Hemlock Street Suite 300 Macon GA WELCOME

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1 Women s Specialty Care, P.C 682 Hemlock Street Suite 3 Macon GA WELCOME Thank you for choosing Women s Specialty Care, P.C. for your OB/GYN needs. We ask that you complete all of the forms attached and bring them with you to your scheduled appointment. This will make your wait time less and will make your visit as quick as possible. In order to file your insurance claims timely, please bring your insurance card with you. If your card does not contain the address and telephone number of your carrier, please obtain that information and bring it with you. If you have secondary insurance, we will also need that information in order to coordinate your benefits. Failure to bring insurance information will result in your paying for your visit and being reimbursed after we obtain and verify your insurance information. Due to HIPPA regulations, our office can no longer look up your insurance information online. All co-pays and unmet deductibles are due and payable when services are rendered. If you do NOT have insurance OR if we do not participate with your insurance company, you will be responsible for your entire bill at the time of services unless financial arrangements are made prior to your visit. If you have any questions or concerns, please contact our office prior to your appointment. If you need to cancel your appointment, we ask that you give us at least a 24 hour notice. We are located one block down from the Medical Center of Central Georgia between First and Second Street on Hemlock Street. Our building is a four story brown building with green x s on the side. You will need to park in the parking deck that is attached to this building and is labeled Blue Parking Deck. Your parking ticket will be validated at check-out. We look forward to seeing you soon! Visit us at:

2 W O M E N S S P E C I A L T Y C A R E OBSTETRICS & GYNECOLOGY Paul E Evans, M.D. A Kenneth Harper, M.D. John T Slocumb, M.D. Ernest H Carlton, M.D. PATIENT INFORMATION Patient Name Home Address Address City State Zip Home Phone Number Cell Phone Work Phone Employer Social Security Number Date of Birth Age Race Ethnicity Language EMERGENCY INFORMATION Husband/Significant Other Social Security Number Employer Phone Number Emergency Contact (other than person listed above) Relationship to Patient Phone Number INSURANCE INFORMATION Primary Carrier s Name Policy Holder Name Policy Holder Date of Birth Relationship Contract/Policy ID Number Group Number Secondary Carrier s Name Policy Holder Name Policy Holder Date of Birth Relationship Contract/Policy ID Number Group Number AUTHORIZATIONS I authorize Women s Specialty Care, P.C. to provide medical and/or surgical treatment as necessary during my care. I authorize payment directly to Women s Specialty Care, P.C. for any surgical and/or medical benefits. I further authorize release of any information acquired in the course of my examination and/or treatments to be released to my insurance company if necessary. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED I permit a copy of this authorization to be used in place of the original. Signature of Patient Date Signature of Responsible Party Relationship Date Who may we thank for your referral to Women s Specialty Care?

3 Name PERSONAL HISTORY Age B Latex Allergy ONoOYes Date MEDICAL HISTORY Rheumatic Fever... Kidney/Bladder Disease... STDs... Herpes... Gallbladder Disease.... Anemia... Liver Disease... Asthma/Lung Disease... Epilepsy:,... Migraine Headaches... Diabetes... High/low 8 Pressure... Col~is!Bowel Disease... Hemorrhoids/Rectal Disease.. Heart Disease... Thyroid Disease... Blood/Plasma Transfusion Other: CANCER Breast..... Patient c-j:cl Patient Family N/A Family Relationship (Specific Please) N/A Relationship (Specific Please) MEDICATIONS Birth Control SOCIAL HISTORY Alcohol Use.... Tobacco Use... Street Drugs... Exercise.... Dosage MENSTRUAL HISTORY Age of Onset Days of Cycle (Start to Finish).... Days of Duration.... Flow.... DPads OTampona Used Per Period.... Clots Passed.... Pains or Cramps... ~ Discharge from Vagina.... lives.... ltchingnrritation of Vaginal Area.... Date of Last Pelvic Exam..... Date of Last Pap Test Results of Last Pap Test Frequency Day Week Month PRN How Often Day Week Month Date of Last Period Light Medium Heavy ONo DYes ONo DYes ONo DYes Color Odor N/A ONo DYes Negative Positive Colon.... Cervical..... Ovarian.... Uterine.... Other: SURGERY Tubal Ligation..... Hysterectomy..... Appendectomy.... D&C.... Other: Other: Have you ever been advised to have a surgical operation which was not done?..... Broken back or pelvis?.... HOSPITALIZED FOR ANY ILLNESS Year Year Comments Diagnosis SEXUAL HISTORY Have you ever had intercourse... Are you sexually active... Partners last 2 years... More than 4 sexual partners... Sexual partner who used drugs.. Had a homosexual relationship... Sexual partner who had a homosexual relationship... Sex problems you wish to discuss... PREGNANCIES Total Pregnancies... How many children born alive... H9w many.still births... How many miscarriages/abortions. How many premature births... How many Cesarean Sections... Any complications with pregnancy.. N/A Comments N/A (No Pregnancies) N/A N/A N/A NIA N/A N/A. List any problems or concerns you would like to discuss ALLERGIES Reactions NOTE: This is a confidential record of your medical history and will be kept in this office. Information contained here will not be released to anyone except when you have authorized us to do so.

4 CENTRAL GEORGIA HEALTH EXCHANGE The next generation of patient information Permission to Create a Health Exchange record and Share My Medical Information with my Healthcare Providers We are taking part in an exciting program to improve your healthcare and make office visits easier and more convenient. To do this, all of your doctors participating in the Central Georgia Health Network (CGHN) would like your permission to share your Health Information (as defined below) through the Central Georgia Health Exchange electronic medical record program (Health Exchange). This will authorize your CGHN-participating doctors to disclose your Health Information so that it can be shared electronically with other providers of healthcare to you. I acknowledge that I have read the information set forth below and understand the permission I am giving in this document, and have had the opportunity to have my questions answered about the Health Exchange and this permission form. Yes. I agree to participate in the Central Georgia Health Exchange electronic medical record No, I do not agree to participate in the Central Georgia Health Exchange electronic medical record Printed Name of Patient Signature of Patient or Representative AUTHORITY OF REPRESENTAT/VE: Patients Date of Birth Date Printed Name of Representative I,, do hereby state that I am authorized to sign this permission on behalf of the patient on the following basis (Relationship to Patient): [A signed copy of this permission will be provided to the patient/representative] This authorization will allow your CGHN-participating doctors to disclose your demographic, insurance, and medical information so that it can be shared with other providers of healthcare to you (including doctors, nurses, and other health professionals, as well as hospitals and other healthcare facilities) and CGHN, through the Health Exchange electronic medical record system. Only authorized healthcare providers and their contractors, and others whose job it is to maintain, secure, monitor and evaluate the operation of the information system and quality of care, would be able to access your information. The Health Exchange will allow your providers access to your health information more quickly and accurately than with paper charts. By signing this authorization, I authorize all of my doctors who participate in CGHN to use and disclose my Health Information and to make such Health Information available through the Health Exchange to other healthcare providers who need access to my Health Information for the purposes described in this document. The Health Information may include, but is not limited to the following: Information contained in medical records; physicians' records; surgeons' records; x-rays, CAT scans, MRI films, photographs, or other radiological, nuclear medicine or radiation therapy films; pathology materials, slides or tissues; laboratory reports; genetic testing results; discharge summaries; progress notes; consultations; prescriptions; records of child abuse, spousal abuse. drug abuse and alcohol abuse; HJV/AIDS and sexually transmitted diseases diagnosis or treatment; physicals and histories; nurses' notes; patient intake forms; correspondence; social workers' records; insurance records; consents for treatment; and any other documents concerning any treatment, examination, periods of hospitalization, confinement, diagnosis or other information concerning my physical or mental condition. Information disclosed pursuant to this permission may no longer be protected by federal health information privacy laws and may be subject to redisclosure. However, the Health Exchange system incorporates access controls, encryption technology and other security features designed to protect the privacy and security of your Health Information. In addition, access to the Health Exchange will be limited to only those users who have agreed to use the Health Exchange consistent with your permission. Information shared through the Health Exchange will be used and disclosed for the following purposes and disclosures: clinical care; obtaining reimbursement for health care services; ; for administrative functions related to the provision of and payment for care; quality monitoring and improvement; and administrative management of the Health Exchange and CGHN. You can learn more about the Central Georgia Health Exchange by reading the information booklet, "A Guide To The Central Georgia Health Exchange" that is available at the CGHE website ( or on request from your doctor's office. I understand that I may withdraw this permission by giving written notice to Administrator, Central Georgia Heath Exchange, 777 Hemlock Street, Hospital Box 98, Macon, GA Any withdrawal of permission will be effective except to the extent action already has been taken in reliance on this permission. This permission will expire automatically if the Central Georgia Health Exchange program is discontinued. I understand that my eligibility for treatment or any healthcare benefits cannot be conditioned on whether I sign this permission. However, to the extent I have refused permission, I understand that my Health Information will not be available to other providers (including The Medical Center of Central Georgia) through the Central Georgia Health Exchange. 6251

5 FINANCIAL AGREEMENT Payment is expected at the time services are rendered unless other arrangements have been made BEFORE your visit. We do ask for your insurance card at each visit in an effort to maintain current and updated information on each patient. We only file benefits for those carriers with whom we have a signed participation agreement. Please inquire with the receptionist as to the status of your insurance carrier. PATHOLOGY BILLING Most pap smears and biopsy samples obtained during your examination are sent to an outside pathology lab for testing. Those charges are billed separately by the pathologist and all questions concerning these bills should be directed to that office. The charge of OBTAINING a pap smear is included in your office visit. The charge for OBTAINING biopsy samples are billed as a separate procedure by our office according to site and size of the biopsy. I understand the above billing practices. Patient s Signature Date OTHER IMPORTANT INFORMATION Due to the ever increasing changes regarding insurance, WSC will NOT be responsible for lab charges when patients do not furnish current insurance information. Labs will be sent to MCCG and billed to the patient if the patient does not have any insurance or there is no insurance information reported to WSC at the time of service. Lab requests CANNOT be changed after the patient leaves the office. Failure to provide WSC with the necessary information may result in a denial by your insurance company. I understand the above and agree to accept responsibility for any ancillary charges incurred as a result of my care from Women s Specialty Care, P.C. Patient s Signature Date

6 Women s Specialty Care P.C. O B S T E T R I C S & G Y N E C O L O G Y PATIENT CONFIDENTIALITY RELEASE CUMENT Name Phone Work Phone Address City State Zip Address I,, Date of Birth, give my permission for the following person(s) listed below to have access to my medical records, including test results, appointment information, information regarding my care and other types of records. This includes billing and insurance documentation. Relationship to patient Relationship to patient Relationship to patient I,, give permission to Women s Specialty Care P.C. to leave confidential messages regarding my health information at: My home number: My work/cell number: THIS RELEASE IS VALID UNLESS REVOKED Signature Date Paul E Evans, M.D. John T Slocumb M.D. Ernest H Carlton M.D. Aubrey K Harper M.D

7 Women s Specialty Care, P.C 682 Hemlock Street Suite 3 Macon GA CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS I,, understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plan for future care of treatment. I also understand the practice utilizes electronic prescribing technology and may obtain information regarding my medication history from SureScripts, which is a national provider of electronic prescribing services connecting physicians and hospitals with pharmacies. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care. A source of information for applying my diagnosis and surgical information to my bill. A means by which a third-party payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing the consent. I understand that the organization reserves the right to change its notice and practices and, prior to implementation, will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I fully understand and accept/decline the terms of this consent. Patient Signature Date Revised 11/215

8 W O M E N S S P E C I A L T Y C A R E ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I, acknowledge that I have received a copy of Women s Specialty Care, P.C. s Notice of Privacy Practices. This notice describes how Women s Specialty Care, P.C. may use and disclose my protected health care information, certain restrictions on the use and disclosure of my health care information and rights I may have regarding my protected health information. Signature of Patient or Personal Representative Date Relationship to Patient

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