The Providers & Staff of the Women s Institute for Gynecology & Minimally Invasive Surgery

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1 Julie Drolet, MD, FRCSC, FACOG Deborah Gobel, CRNP Sybil Mudloff, MSN, CRNP Sixth Avenue Professional Center 1600 Sixth Avenue, Suite 117 York, Pennsylvania Phone: Fax: Welcome to the Women s Institute for Gynecology & Minimally Invasive Surgery. We would like to take this opportunity to thank you for choosing our practice as yours. We ask that all new patients please arrive 30 minutes before their first appointment time. time This time will be spent reviewing your information with our nurse and allow us to ask any additional questions we might have following a review of your medical forms. If you arrive later than 30 minutes before your appointment time, you may be asked to reschedule. All paperwork must be completed and returned 3 business days before your appointment. It is also very important that you please bring the following items with you to your first appointment: Current insurance card Driver s license and/or photo ID Current medication list Any co-payment that may be due Patients under the age of 18 must have a parent or guardian accompany them Your appointment is scheduled with: Appointment Date: Time: New Patient Arrival Time: We strive to give our patients and their families the best of care. Our staff will be more than happy to assist you in any way we can to accommodate your schedule and ours. We do our best to keep appointments open daily for emergencies. We would appreciate if you would please be courteous to those patients who need to be seen in a more timely fashion, as this time was set aside specifically for your appointment. Please give us a call 24 hours in advance to cancel or reschedule. Thank you for choosing the Women s Institute for Gynecology & Minimally Invasive Surgery as your health care provider. We are committed to providing you with the best possible care. Sincerely, The Providers & Staff of the Women s Institute for Gynecology & Minimally Invasive Surgery POS Reorder #

2 1600 Sixth Avenue, Suite 117 York, PA Phone: (717) Fax: (717) COMMUNICATION CONSENT & HIPAA INFORMATION HIPAA is an acronym for the Health Insurance Portability and Accountability Act of 1996, a federal law. The Administrative Simplification section of this Act is of concern to our practice and requires us to comply with specific rules regarding: All of these rules have been developed by the Department of Health and Human Services. It is the policy of Women s Institute for Gynecology & Minimally Invasive Surgery, LLC not to release confidential and/or unauthorized information by home telephone, answering machine, work telephone, voice mail, , cellular phone, page and/or fax. Whenever returning telephone calls and a voice mail picks up, we will NOT leave a message if the name or telephone number is not on the recording message to identify the residence. We can only leave a generic message if you write down the numbers. Please list the telephone numbers where you would authorize Women s Institute for Gynecology & Minimally Invasive Surgery, LLC to contact you and leave a message. Please ឡ your preferred contact phone number. Telephone Number OK to Leave Message? Home Telephone Yes No Work Telephone Yes No Cellular Phone Yes No Please provide us with 2 emergency contacts and telephone numbers where you authorize, Women s Institute for Gynecology & Minimally Invasive Surgery, LLC to release your information: Emergency Contact Name Relationship Emergency Contact Telephone Number By my signature below, I authorize the release of any medical or other information deemed necessary by Women s Institute for Gynecology & Minimally Invasive Surgery, LLC including the transfer of all or a portion of any medical records to support medically necessary referrals to other healthcare providers. I have reviewed the Notice of Privacy Practices for Protected Health Information for Women s Institute for Gynecology & Minimally Invasive Surgery, LLC. I understand that Women s Institute for Gynecology & Minimally Invasive Surgery, LLC will not disclose my medical information for any other purpose than stated in the notice without my written permission. If you would like a copy of this HIPAA Consent or Notice of Privacy Practices, please ask the front desk staff. Parent/Guardian Signature Date Please Complete Other Side

3 1600 Sixth Avenue, Suite 117 York, PA Phone: (717) Fax: (717) CONSENT FOR CARE If we are seeing you for your annual exam and you wish to discuss other problems or issues at this visit, you need to be aware that we may be billing an additional charge to your insurance company. Since most insurance companies do not pay for addressing problems at an annual exam, you may wish to schedule an additional appointment at a later time to deal with those issues. The second visit may be paid by your insurance. Even if your insurance company pays for both visits, your insurance company may assess another copay for the second visit charge. It is your responsibility to know what is covered or not covered under your insurance plan. The physicians at Women s Institute for Gynecology & Minimally Invasive Surgery, LLC are available after hours for true medical emergencies that cannot wait until the next business day and can be reached through the answering service at (717) This is not for prescription refills, chronic conditions, or lab result discussions. Telephone calls received after hours are not a covered service by your insurance company and are your financial responsibility. You may be charged for these phone calls. Because of the nature of our practice, one doctor is on call at any given time. There are two very good hospitals in the area (York and Memorial). It may be possible that you will be directed to one or the other hospital for your gynecological care. We will do our very best to respect your preference of hospitals, but in order to give each patient all the attention they merit, it is impossible for us to care for two people at the same time at two different hospitals. It is therefore imperative that you call our office before going to any hospital or emergency room for a gynecological problem. By signing this statement, you agree to follow the direction given by the doctor on call. Failure to do so will constitute refusal of treatment and may cause irreparable harm to you. Also, by refusing to go to the suggested hospital, you release Julie Drolet, MD, Women s Institute for Gynecology & Minimally Invasive Surgery, LLC and all covering physicians from any and all liability. Signature Date POS Reorder #

4 1600 Sixth Avenue, Suite 117 York, PA Phone: (717) Fax: (717) WOMEN S INSTITUTE FOR GYNECOLOGY & MINIMALLY INVASIVE SURGERY S FINANCIAL POLICY We are committed to providing you with the best possible care. Please read our financial policy and sign it prior to treatment. Your insurance policy is a contract between you and your insurance company. Women s Institute for Gynecology & Minimally Invasive Surgery, LLC is not a party to that contract. As a courtesy to you, we will bill your insurance company for you. YOU MUST PROVIDE US WITH A CURRENT INSURANCE CARD AT THE TIME OF EACH VISIT. As dictated by your insurance company, you are responsible for co-pays, deductibles, and non-covered services at the time of service. Please be aware of your insurance company s provision for the annual routine exam; specifically if one calendar year is required between exams for visit payment. You are responsible for payment if you come in less than one year. Also, please be aware that if you have additional clinical problems that you want evaluated at the time of your well woman exam, there will be an additional charge for those services. If the problems are complicated, a follow up appointment may be necessary. Full payment is expected at the time of service. We accept cash, checks, MasterCard and Visa. A $20.00 service charge will be assessed for returned checks. If you do not show or if you do not call to cancel your appointment within 24 hours of the appointment, a charge will be applied. Failure to pay your co-pay at the time of service will result in a $10.00 charge. All patients with an unpaid balance after their first statement will be charged $10.00 for each additional statement for processing until the balance is paid. Nonpayment of your bill after 90 days will be submitted to a collection agency, at which time, that agency will add a 30% collection fee to your balance. Uninsured Patients: Patients without insurance will be responsible for payment of the entire fee at the time of service. Those patients paying in full at the time of service will receive a percentage discount off the regular fee. I hereby authorize Women s Institute for Gynecology & Minimally Invasive Surgery, LLC to release any and all information necessary concerning my diagnosis and treatment for the purposes of securing payment from my insurance company; and thereby authorize payment of the insurance benefits directly to Women s Institute for Gynecology & Minimally Invasive Surgery, LLC for any services rendered that are not paid for directly by me. By my signature below, I have read and understand the Financial Policy Signature Date Please Complete Other Side

5 1600 Sixth Avenue, Suite 117 York, PA Phone: (717) Fax: (717) MEMBER FINANCIAL LIABILITY ACKNOWLEDGEMENT FORM The undersigned hereby agrees to be financially liable for and to pay the Provider the amount of the charges for certain health care services which may be considered not covered under your plan. It is your responsibility to know what is covered or not covered under your insurance. THIS INCLUDES: Services that are considered a non-covered benefit: Services that require prior Authorization by your insurance: Services that may be determined to be not medically necessary by your insurance: I have read this form and understand its contents. Patient Signature Date POS Reorder #

6 1600 Sixth Avenue, Suite 117 York, PA Phone: (717) Fax: (717) PATIENT QUESTIONNAIRE Your health is very important to us, therefore the following information is necessary. Please take the time to fully and completely fill out all the information on this questionnaire. We are counting on you! PATIENT INFORMATION: Last Name: First Name: Address: Middle Initial: City: Home phone: State: Zip: Cell phone: Social Security Number: Date of Birth: Age: Address: Marital Status: Race: Married Caucasian Single African American Divorced Separated Hispanic Widowed Other Ethnicity: Date Form Completed: Referring Physician: Primary Care Physician: What is the reason for today s visit? Primary Health Ins.: ID#: Group#: ID#: Group#: Claims Mailing Address: Secondary Health Ins.: Claims Mailing Address: Employer: Local Pharmacy Name: Mail Order Pharmacy: Aetna Medco Local Pharmacy Address: Express Scripts CVS Caremark Local Pharm. City/St/Zip: Other: Please add any additional information here:

7 MEDICATION HISTORY CURRENT: Please list ALL medications you are currently taking including all herbal, over the counter, vitamins, etc. Medication Example Zantac Dosage 150 mg Frequency 1 tab every morning/evening Are you currently using any prescription/over the counter hormonal therapy? If so please list: ALLERGIES: (Please specify medication allergy and type of reaction): Medication Type of Reaction Other:

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10 Any other issues not mentioned above: I certify that I have received the foregoing information supplied by me and that it is true and complete to the best of my knowledge. Signature: Date: POS Reorder #