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1 Patient Demographics Name: _ of Birth: SS# Phone # Home Cell Work (please circle) Alternate Phone # Home Cell Work (please circle) _ Home Address Insurance Information Insurance Provider: Group # (if any): Member ID: Insurance Phone #: Insurance Billing Address: (Disregard below if Guarantor is self) Guarantor: Guarantor DOB: Guarantor s relationship to the patient: Guarantor Gender: Male Female Guarantor s Address: _ Pharmacy & Lab Information Pharmacy Name: Pharmacy Phone #: Pharmacy Fax #: Pharmacy Address: Lab Name: Lab Phone #: Lab Fax #: Lab Address: _ 1 P a g e

2 Office Policies Welcome to Women s & Maternity Care Specialists. We are honored you chose us. Our goal is to provide world-class care for you. In an effort to keep your experience with us as smooth as possible, we must ask the following policies be noted by you, the patient. They are essential to the effectiveness of the practice. Thank you for understanding our drive to keep your care as fluid and efficient as possible. 1. Phone Calls. If you are needing to speak with a staff member about a non-emergency matter or have a question, you may either: a. Call our office and the receptionist will transfer your call or take a message. You will receive a call back from the desired staff member within one business day. i. *Please note that if your call is made after 4:00pm to speak with a clinical staff member, the call will be returned the next business day. b. You may also send a message straight to Women s & Maternity Care Specialists through your Athena Health account. This bypasses the reception desk and this message will go directly to our staff. They will call you back as soon as possible but may take up to one business day as well. 2. Rx Refills. Please allow hours for prescription refills. Prescriptions are filled between Monday and Friday during office hours. Your Pharmacy contact may contact our office for refills. In order for prescription refills to be approved by our office, you must have been seen within a year. a. *Please note birth control pills or pain medications are not considered an emergency. We advise that you plan accordingly, calling our office before the weekend to allow us time to accommodate your request. We understand pain medications and birth control are important to our patients well-being. 3. Tests. Please allow 7-10 days to be notified of lab test results or Ultrasound and X-Ray test results. 4. Forms/Letters. Disability forms and/or special request letters may take 7-10 days to complete for you. There is a charge of $15.00 with the completion of these forms. 5. Medical Record Requests. If you are sent by us to consult with another Physician, we will forward your records to that Physician in order to ensure continuity of care. If you would like copies of your records as well we would be happy to provide those for you. a. *Please note that in order to receive a copy of your records for personal use, the first 25 pages are $1.00 each. After 25 pages, each additional page is $0.25. This is another situation that requires additional time. Please understand that our policy is 7-10 days for personal medical record release. 6. Scheduled Appointments. It is very important that you keep all scheduled appointments. However, if an unexpected situation occurs and you need to cancel or reschedule an appointment, please contact us 24 hours before your scheduled appointment. There is a fee of $50.00 if you fail to notify Women s & Maternity Care Specialists within 24 hours of the scheduled appointment. Patient Printed Name Signature of Patient 2 P a g e

3 Financial Responsibility Agreement Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your healthcare benefits is between you and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims. Women's & Maternity Care Specialists, LLC is a wholly subsidiary of Florida Women Care, LLC who may file a claim for payment and accept assignment with my insurance company as required by contractual agreement. Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment. We require you to sign this form and/or any other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office. We require you to pay the co-payment, which is the amount not covered by your insurance company, at the time we provide service to you. Insurance payments ordinarily are received within days from the time of billing. If your insurance company has not made payments to our office within 60 days, we will ask you to pay the balance due at that time. You will be responsible for seeking reimbursement from your insurance company at that time. Should the account be referred to a collection agency or attorney for collection, the undersigned will pay all costs of collection, including a reasonable attorney's fee. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time. Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company requests to sort out any confusion or questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company. I have read and understand the above terms and conditions. I authorize my insurance company to pay my health benefits directly to the doctor. Patient Printed Name/Responsible Party Patient Signature/Responsible Party 3 P a g e

4 Privacy Notice The Notice of Privacy Practice provides information about how we may use and disclose protected health information about you, the patient. You have the right to review the Notice before signing this form. As provided in the Notice, the terms may change. If we change the Notice, you may obtain a revised copy by contacting us in writing. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. Women s & Maternity Care Specialists are not required to agree to this restriction, however, if we do, we are bound by the agreement. By signing this form, you consent to the use and disclosure of protected health information about you for treatment, payment and health care operations as described in the Notice. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. Printed Name/Responsible Party Signature of Patient/Responsible Party 4 P a g e

5 Authorization for Health Information Disclosure Women s & Maternity Care Specialists of Orlando LLC is a medical practice in complete compliance with HIPAA. Our staff abide by HIPAA rules and regulations when discussing the patient or the patient s information. We discuss patient information only with the patient, unless she has given specific permission in writing to speak with another individual. Our practice space is shared with the RDV Sportsplex Pediatrics medical practice. RDV Sportsplex Pediatrics staff members do not have access to your information and electronic medical records. We ensure your information is protected and will remain private unless you specifically authorize access. If you, the patient, wish for us to discuss your patient medical records or financial information, please share with us the individual(s) below and sign. Also, for certain situations, we may try to contact you to discuss information such as lab test results. Women s & Maternity Care Specialists is restricted as to what information we may leave on an answering machine. We may only leave our name, practice phone number, and a request for you to return our call. If you wish for us to leave more detailed information on your answering machine or voic , please designate in writing below what information you would like us to leave on the answering machine. Thank you for understanding our desire to keep your information and records confidential. I, (please print), give permission to Women s & Maternity Care Specialists of Orlando LLC to discuss my file, including medical and financial information, with the following individuals: Relationship: Relationship: Relationship: Relationship: I, (please print),, give permission to Women s & Maternity Care Specialists of Orlando LLC to leave the following information on my answering machine or voic if I am not available at the time of their phone call:. Printed Name/Responsible Party Signature of Patient/Responsible Party 5 P a g e

6 Authorization for Release of Medical Information Print patient s full name Street address City, state, zip code Birth (mo/day/year) SS# Phone number I hereby authorize you to release my records (please fill in the information from where we may receive your records): Name of Company/Agency/Facility/Person Street Address City, state, zip code Phone number s of Discharge Summary History & Physical Progress Notes Operative Notes Pathology Reports Laboratory Reports Radiology Reports ECG/EEG/Cardiac Cath Emergency Reports All Records Other I do I do not Authorize release of information related to AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) Infection, psychiatric care and/or psychological assessment and treatment for alcohol and/or drug abuse. I hereby authorize disclosure of the health information for the above named patient to Women s & Maternity Care Specialists. This authorization is valid for 12 months from the date of signature. I understand I may cancel this request with written notification but it will not affect any information released prior to notification of cancellation. I understand the written information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it and would then no longer be protected by federal regulations. I understand that the medical provider to whom this is authorized is furnished may not condition its treatment of me on whether or not I sign the authorization. Patient Signature/Responsible Party 6 P a g e

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