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1 Doctor: Patient Name: Address: State: Date of Birth: Home Phone: Work Phone: Zip: Patient Demographics Maiden Name: City: Social Security Number: Cell Phone: Address: * Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable) Preferred Pharmacy: Primary Care Physician: Referred By: Emergency Contact Name: Emergency Contact Relationship: Location/Address: Insurance Information Primary Insurance Company: I have no insurance Subscribers Name: Subscribers Subscriber Date of Birth: / / Relationship to Subscriber: Self Spouse Parent Other Subscribers Employer: Financial Consent I authorize release of my medical records as required by my insurance company(s). I hereby authorize payment directly to Kansas City Ob Gyn P.A., of any insurance coverage for office procedures or hospital charges. I understand that I am fully responsible for all services and charges, including any balance due after payment of insurance and that insurance coverage does not necessarily pay all charges. I also understand that doctor and office fees are due and payable when services are rendered. I, the undersigned, authorize treatment by the doctor in this office. Signature How would you like to receive appointment reminders: Text Phone Call: Please select home / cell phone * reminders will automatically be sent (If patient is a minor, parent or guardian signature is required)

2 At Kansas City Ob Gyn, we are implementing Meaningful Use initiatives that are part of the HITECH provisions of the American Recovery and Reinvestment Act (ARRA) of 2009, also known as the Stimulus Plan. As a result, we are now required to collect government-requested data including information regarding the primary language, race and ethnicity of our patients. The purpose of Meaningful Use is to ultimately improve patient care and lower health care costs and we aim to fully comply with the initiative. The information you provide will be used for reporting purposes only. Please Answer the Following Questions: Your Name: Date of Birth: Race: White Black or African American Asian American Indian or Alaska Native Native Hawaiian or other Pacific Islander Declined Ethnicity: Hispanic or Latino NOT Hispanic or Latino Declined Preferred Language: English Spanish Indian Japanese Chinese Korean French German Russian Other Address (please provide): Thank You for Your Participation

3 In order to protect your confidentiality and to comply with government regulations (HIPAA), Kansas City Ob Gyn P.A. is required to obtain authorization from you in order to release messages and/or provide information regarding your care with any person(s) other than yourself. RELEASE OF MEDICAL INFORMATION: The physicians and staff at Kansas City Ob Gyn may discuss my medical information and/or care with the following. (Please check all that apply and list names.) My Spouse (name) Name Relationship Name Relationship MESSAGES: I give my consent to the physicians and staff of Kansas City Ob Gyn to leave or discuss treatment, surgery, lab, radiology results or other information regarding my care as follows. (Please check all that apply.) On answering machine or voice mail on cell phone. On answering machine or voice mail at home. On answering machine or voice mail at work. I do not consent to messages being left at home, work, or with any other person. Authorization to release information: I hereby authorize the release of any medical information necessary to process all claims for charges incurred at Kansas City Ob Gyn P.A. Authorization to pay benefits to physician: I assign payment directly to Kansas City Ob Gyn P.A. for the medical and/or surgical benefits, if any, otherwise payable to me for services as described above but not to exceed my indebtedness to Kansas City Ob Gyn P.A. for those services. I understand I am financially responsible for charges not covered by my insurance. Financial Agreement: I agree that I am financially responsible for all charges not covered by my insurance company, included but not limited to medical services deemed routine, elective or not medically necessary by my insurance company and/or any co-pays, deductibles, coinsurance amounts or non-covered items specified by my insurance company. Notice of Privacy Practices: I acknowledge that I have read and understand the content of the Notice of Privacy Practices (HIPAA). X Signature (Parent or Guardian if Patient is a minor) Date

4 Office Policy Item 1 Assignment of Insurance Benefits I hereby authorize and assign, my insurance carrier(s), to make payment directly to Kansas City Ob Gyn P.A., of insurance benefits for services herein specified and otherwise payable to the insured. Kansas City Ob Gyn files both primary and secondary insurance as a courtesy to patients. I understand and agree that I am financially responsible to Kansas City Ob Gyn for all charges incurred regardless of potential insurance benefits, including but not limited to Co-Payments, Co-Insurance, Deductibles, Pre-Existing and Non-Covered services. I understand Kansas City Ob Gyn will not become involved in disputes between the patient and the insurance company. I understand it is my responsibility to verify with my insurance company that the physician(s) treating me are covered under my insurance and to get referrals and/or authorization for services. Item 2 Insurance and Driver s License due at time of Service I understand insurance cards must be presented at time of service, or I will be self pay until cards are presented or if insurance changes within treatment, cards must be presented before Kansas City Ob Gyn will file claims to new insurance. Co-Payments, Co-Insurance, Deductibles and Non covered services are due at the time of service. I understand my insurance company may require a referral before being seen If not obtained I will be responsible for incurred charges until a referral is obtained. Item 3 Estimated Cost (Global Maternity, Surgery or Office Procedures) I understand that I am financially responsible for all charges arising for treatment of my dependents or myself by Kansas City Ob Gyn. I understand that I will be responsible for a down payment, deductible, co-insurance or co-pay for all services provided. I understand that if I am 2 months delinquent and default on the terms of this agreement then my account will be turned to a collection agency. I understand that if I am seen as an Ob patient, I will be provided an estimate for my care including delivery at the beginning of my pregnancy. This charge will be required to be paid prior to 28 weeks into my pregnancy. Once all claims have been processed and paid by my insurance company, if applicable, Kansas City Ob Gyn will issue a refund check to me and send it by mail. Item 4 Returned Check Fee I understand if Kansas City Ob Gyn receives a returned check, I will be charged an additional $25 above the amount on the check and will be on a cash only basis thereafter. Item 5 Appointments I understand Kansas City Ob Gyn will charge $25 if I do not show up to a routine appointment or $100 if I do not show up to an in-office procedure appointment. I understand that this charge is not covered by my insurance policy. I understand that if I arrive late for an appointment I may be asked to see another provider or reschedule my appointment. Kansas City Ob Gyn will provide all appointment reminders and office communication by , phone or text.

5 Item 6 Noncompliance I understand Kansas City Ob Gyn has the right to discharge any patient from this practice at any time due to non-compliance. If this occurs, records will be released to a physician of my choice only when a signed release of information is received in this office. Item 7 Collections I understand that if I am turned to a collection agency by Kansas City Ob Gyn it will be at management s discretion to accept me back into the practice. If accepted back, I know I am responsible to have my balance paid in full before having any future treatments with Kansas City Ob Gyn. I understand that there will be a minimum of a $25 charge for reinstatement applied to my account. The reinstatement fee and the full amount of the visit will be due at the time of service as a guarantee of payment. Kansas City Ob Gyn will submit my claim to my insurance company and I will be reimbursed once my claim is processed. Item 8 FMLA I understand that FMLA will take two weeks to process from the date provided to the office. I also understand there will be a $15 charge for all FMLA paperwork to be completed. Item 9 Phone Calls I understand that phone calls will be returned throughout the day, when the Nurses are able to complete calls. I also understand that any call received after 4 pm will be returned the following business day, unless in an emergency situation. Item 10 Prescriptions I understand that prescription refills need to go through the pharmacy. Please allow 24 hours for any prescription refill, Monday Thursday. Any prescriptions received on Fridays will not be filled until the following Monday. I understand that most prescriptions will be sent electronically to the pharmacy that I have requested. Name: Date: Signature:

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