Patient Registration

Transcription

1 Date: Patient Registration PATIENT INFORMATION Social Security # Home Address First Name Middle P.O. Box Last Name City State Zip Sex Date of Birth / / Referring Physician Marital Status Married Single Home Phone ( ) Divorced Widowed Work Phone ( ) Cell Phone ( ) (Check one) Employed Retired Full Time Student Employer Address Employer City State Zip Emergency Contact First Name Int. Sex Relationship Last Name Home Phone ( ) Work Phone ( ) Cell Phone ( ) Spouse / Guarantor / Responsible Party Social Security # Sex Date of Birth / / First Name Int. Last Name Employer Work Phone ( ) Employer Address City State Zip Authorization to pay benefits to physician: I hereby authorize payment directly To the Physician of the surgical and/ Medical Benefits. If any otherwise payable To me for his/her services as described, realizing I am responsible to pay non- Covered services. Signature (Patient or Parent if Minor) Date Authorization to release information: I hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process Insurance claims. Signature Date

2 INSURANCE INFORMATION INSURANCE (9(Circle One) Commercial Medicaid Medicare Other None - THIS SECTION MUST BE FILLED OUT COMPLETELY OR INSURANCE CANNOT BE BILLED Insurance Company Plan Name Primary Secondary Policy Holder Relationship Social Security # Date of Birth / / Spouse / / Parent / / Self / / Other ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I.D. Number Group No. Co-Pay Insured s Employer ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Insurance Company Plan Name Primary Secondary Policy Holder Relationship Social Security # Date of Birth / / Spouse / / Parent / / Self / / Other ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I.D. Number Group No. Co-Pay Insured s Employer ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ INSURANCE AUTHORIZATION AND ASSIGNMENT I hereby authorize ALPINE WOMENS HEALTH to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to the physician(s) all payments for medical services rendered to myself or my dependents, I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. Date Signature Print Name

3 Date: Alpine Women s Health 645 N. Arlington Ave., Ste. 340 Reno, NV Phone: Fax: Financial Agreement This is a formal agreement between the patient and Alpine Women s Health for the payment of Gynecological or Obstetrical care. I understand that it is my responsibility to know and understand my insurance coverage and to pay my co-payments at the time of service. I certify that the insurance presented today is in effect and that I am in good standing with them. Int: I understand that I will not be seen if I do not pay my co-payment at the time of service. Int: I will inform the office staff of any changes in my insurance or demographics. Int: FEES FOR LAB WORK, HOSPITAL STAYS, ASSISTANT SURGEONS AND SOME RADIOLOGY SERVICES ARE BILLED BY THEM AND ARE NOT THE RESPONSIBILITY OF THE PHYSICIAN. IT IS YOUR RESPONSIBILITY TO INFORM US WHAT HOSPITAL, LAB AND RADIOLOGY GROUP IS CONTRACTED WITH YOUR INSURANCE. The office policy has been explained to me, and I understand and acknowledge that I am responsible for all fees whether or not they are paid by my insurance company. Patient s Signature: Date: ************************************************************************ ****IF YOU ARE UNABLE TO MAKE YOUR PAYMENT, WE WILL WITHDRAW YOU FROM FURTHER PROFESSIONAL SERVICES. I owe Alpine Women s Health $ I would like to set up a monthly installment of $ to be applied to a deposit of $ which is to be paid in full by. Patient s Signature: Date: Office Signature: Date:

4 Alpine Women's Health 645 N. Arlington, Ste. 340 Reno, NV Phone: Fax: Informed Consent Regarding PAP and HPV Testing Routine PAP tests are performed annually. The PAP test is a procedure in which the doctor collects cells from the cervix and sends the sample to either LabCorp or Quest. If the PAP results are inconclusive meaning they don t look clearly abnormal, but they aren t clearly normal either the doctor will automatically ask the lab to test the cervical cells for high-risk HPV. Women over the age of 30 will automatically be tested for HPV in compliance with the American College of Obstetricians and Gynecologist s protocol. HPV, also called Human Papillomavirus, is a sexually transmitted virus which can lead to cervical cancer. A persistent HPV infection places the patient at an increased risk for cervical disease or cancer. Knowing the HPV status of a patient can help the doctor (1) determine when additional tests or procedures are needed or (2) ensure that treatment is initiated before cancer can develop. Test results remain confidential. No disclosure of a positive test will be made to anyone except you. Be aware that your insurance company MAY NOT pay for the additional HPV test. You would then be responsible for that charge payable to the lab. I understand that a HPV test may be run automatically if my PAP result is inconclusive. Patient s Signature Date Print Name Person Obtaining Consent Date

5 Alpine Women s Health 645 N. Arlington, Ste. 340 Reno, NV Phone: Fax: Informed consent regarding HIV (AIDS) test Your doctor has requested that you have a screening test for AIDS in preparation for your delivery or surgery. This office is now performing this test routinely on ALL Obstetrical patients. It s important that your physician knows whether this is a risk for you. Exposure to your surgeon and other health care workers is also a concern. I have been informed that in some patients with AIDS, pregnancy or surgery can make the disease worse. Initials The serologic test performed is one of the most accurate scientific tests available in medicine today, but there can be false-positives. All positive serologic tests (Elisa) for the HIV virus (AIDS) are confirmed by a different more involved test called a Western Blot Test. Since it requires 3-6 months for a person to convert to a positive after exposure to the AIDS virus, there can also be false-negatives during that period of time. The test you are going to have is confidential. No disclosure of a positive test will be made to anyone except you. Therefore, the information cannot be used to discriminate against you in your employment, housing, or insurability. I hereby consent, of my own free will, to undergo the serologic test. Patient s Signature Date Print Name Person Obtaining consent Date File: My Documents/Consent/HIV

6 Consent to Release Medical Information to Family or Others Each person must be listed separately Print: Patient Name: Date of Birth: Date: Acct. #: I hereby authorize you to release, disclose and deliver medical information of the diagnoses, treatment prognosis and recommendations, as well as other pertinent data pertaining to your treatment of me to the following individuals and/or companies or facilities. Name: Relationship: Address: Phone #: Fax #: Name: Address: Relationship: Phone #: Fax #: This authorization may be revoked by the undersigned at any time by giving written notice to the party authorized herein. Any disclosure made prior to revocation in reliance upon this authorization shall not constitute a breach of rights of confidentiality of the patient. If no earlier revoked, this authorization will automatically expire 99 months from the date of signature. The party named above to receive the information is not authorized to make any further release or disclosure of the information received. This authorization does not authorize the release of any information except as provided herein. The following notice regarding re-disclosure of substance (drug and alcohol) abuse information must be included with any such information disclosed pursuant to this authority, if such disclosure is authorized herein: a. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR, part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosures expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by (42 CFS, part 2). A general authorization for the Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Medical information may be released as provided in this authorization. Signature of above named patient: Date:

7 Alpine Women s Health Name: Birthdate: Primary Care Physician Date: Referred by: Reason for visit: (Please fill out both sides of form) PAST MEDICAL HISTORY/Review of Systems: PERSONAL HEALTH INFORMATION Do you have or have you ever had any of the following? Yes No Comment Yes No Comment Stroke Chronic Headaches Vision Problems Epilepsy/neurologic Problems Asthma Tuberculosis Heart Attack Abnormal Heart Valve Heart Murmur Irregular Heart Beat Angina Gallbladder Disease Hepatitis Jaundice Hernia Stomach/Duodenal Ulcers Gastritis Diabetes Thyroid Disease Weight Gain/Loss Kidney Stones Kidney Failure Bladder Infections Blood in urine Leakage of Urine Infected or Clotted Veins Blood Transfusions Bleeding Disorder Anemia Breast Biopsies Breast Problems Abnormal Pap Smear Tumor or Cancer Osteoporosis Arthritis Lupus (SLE) Emotional Illness Sleep Problems STD Other HOSPITALIZATIONS: Have you ever had an operation or hospitalization other than for childbirth: DATE HOSPITAL DESCRIPTION FAMILY HISTORY: Relative Age Living Health Age Deceased? / Cause Has a blood relative or child had: Father Yes No Comment Mother Brother/Sister Diabetes High Blood Pressure Stroke Heart Disease/ Attack Kidney Disease Cancer/Tumor Mental Illness/ Suicide Other

8 Name: MEDICATION ALLERGIES: MEDICATION PERSONAL HEALTH INFORMATION (continued) REACTION MEDICATIONS/SUPPLEMENTS: List all, include those you buy without a prescription MENSTRUAL & GYNECOLOGICAL HISTORY Age of first period First day of last period Cycles: Regular Irregular Birth Control using Days between periods Duration Trying for pregnancy YES NO Cramping: mild med severe Date of last Pap smear Medications for cramps Normal Abnormal Age of menopause Date of last Mammogram Hormone replacement Now Ever Normal Abnormal Have you ever had the following surgeries: Laparoscopy Hysterectomy Removal of tube or ovary Hysteroscopy D&C Cone Biopsy Laser/LEEP/Freezing of Cervix Have you ever been diagnosed with: YES NO YES NO Endometriosis Herpes Gonorrhea Chlamydia PID (Pelvic Inflammatory Disease) Cervical Cancer Cervical Dysplasia (Pre-cancer) OBSTECTRICAL HISTORY: # of pregnancies # of miscarriages # of abortions # of living children *(LIST ONLY THE YEARS AND NAME OF CHILD - WE WILL HELP FILL OUT THE REST) MO/YEAR WEEKS IND/SPONT DEL TYPE WT SEX NAME REMARKS HABITS: Cigarettes packs/day Age started Street drugs Alcohol drinks/day Have you or has anyone close to you ever worried you may have a drinking problem Coffee cups/day Signature of Physician: Circle one: Peter DeKay, M.D. Corinne Capurro, M.D. Laura Thompson, M.D.

9 COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS To our Valued Patients: The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the Privacy Rule. We strive to achieve the very highest standards of ethics and integrity in performing services for our patients. It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI. We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly. Thank you for being one of our highly valued patients. PATIENT CONSENT FORM The Department of Health and Human Services has established a Privacy Rule to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment, or health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under the law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objection to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice. Print Name: Signature: Date: