Welcome to the Center for Women s Health!

Transcription

1 Robert L Berk, MD Neil D. Bluebond, DO Amy L. Harvey, MD Mark D. Kuhn, MD Meghan A. Patel, MD Lester A. Ruppersberger, DO Stephanie J. Schwartz, MD Anne Walker, MD Cindy Cullen, CNM Lisa Diasio, MSN, CRNP Karen Nyirjesy, MSN, CRNP Kathie Olson, MSN, CRNP Susan Ritorto, MSN, CRNP Mary Woltjen, MS, CNM, CRNP Welcome to the Center for Women s Health! Enclosed are Patient Registration Forms, kindly complete and bring them with you to your initial visit with us, as well as insurance card, photo ID, and co-pay (if applicable). We would appreciate it if you could arrive 30 minutes prior to your appointment so we can input all of your information into our new electronic system in a timely manner. Office telephone hours are Monday Thursday 8:00am 4:00 pm and on Fridays 8:00am 3:00pm. If you need to reschedule or make a new appointment please call choose Option 2 on the telephone menu. We also provide the following additional services: Mammograms by Ella Health, OB Ultrasounds, Laser Hair and Spider Vein Removal, Nutrition, Skin Care, and Massage. Please see any member of our staff for brochures describing these services. In addition, if you have access to the internet, visit our website where you can read about these services. Again, thank you for choosing Center for Women s Health. If you have any questions or need any additional information, please call me directly at ext. 131 Sincerely, Christine Kolodi Practice Administrator 540 N. Woodbourne Road, Langhorne, PA

2 Please complete the following information as accurately as possible. Your answers on this form will help your provider understand your medical concerns and conditions better. If you cannot remember specific details, please give best estimates. We realize that this is a very lengthy form, but we are asking you to provide a comprehensive history for our Electronic Medical Record which results in improved care for you. PATIENT REGISTRATION FORM Name: Date of Birth: Age: Today s Date: Social Security #: Driver s License Number & State: Street Address: City, State, Zip Code ADDRESS: Home Phone #: Cell Phone#: Work Phone #: Preferred Method of Communication: Phone Mail Text PREFERRED METHOD OF PHYSICIAN / NURSE CONTACT: If your physician or nurse needs to contact you by phone, please list your preferred number:. Is it okay to leave detailed information at this number? Yes No Marital Status: Single Married Divorced Separated Widowed Race: Caucasian Hispanic African American Asian Other: Date of Birth: Social Security #: Phone Number: Spouse s Name: If under 18 Parent/Guardian: Parent/Guardian Social Security #: Emergency Contact: Phone: Relation: Primary Care Physician: Phone #: Local Pharmacy Name: Address & Phone #: Mail Order Pharmacy Name: Address & Phone #: Reason For Your Visit What is the reason for your visit today? Annual exam Obstetric first visit GYN Problem If you are here for a problem what are your concerns? Other Physicians You See: Medical Provider Information 3/15ck 1-4

3 HEALTH MAINTENANCE SCREENING TESTS: Colonoscopy: Yes No If yes, date : / / Results: Normal Abnormal Dexa Scan: Yes No If yes, date : / / Results: Normal Abnormal Mammogram: Yes No If yes, date : / / Results: Normal Abnormal PAP SMEAR HISTORY: Pap Smear Yes No If yes, date : / / Results: Normal Abnormal LEEP/Cone Biopsy Yes No If yes, date : / / Results: Normal Abnormal Colposcopy Yes No If yes, date : / / Results: Normal Abnormal History of HPV Yes No If yes, date : / / Results: Normal Abnormal Received HPV Vaccine Yes No If yes, date : / / Results: Normal Abnormal GYN HISTORY: Age at first period: 1 st day (date) of last period: / / Number of days bleeding: Describe Period: Light Normal Heavy Number of pads/tampons used per day: Do you have concerns regarding your period? Describe: Are you currently sexually active? Yes No If Yes, what age did you become sexually active: Sexual Preference: Heterosexual Homosexual Bisexual Type of contraception used by you or your partner: Currently: Past: Approximately how many days in between periods? Are you in menopause? Yes No Are you on hormone replacement therapy? Yes No Pelvic Prolapse Yes No Endometriosis Yes No Pelvic Infection Yes No Polycystic Ovary Syndrome Yes No Infertility Yes No Incompetent Cervix Yes No Herpes Yes No Bartholin Gland Abscess/Cyst Yes No Fibroids Yes No Gardasil Vaccination Yes No DES Exposure Yes No Interstitial Cystitis Yes No OB HISTORY: Total Number of Pregnancies: Total Number of Miscarriages: Number Total Number of Deliveries: Total Number of Abortions: Number Date Late/Early/On- Time Labor (Hours) Delivery Type Sex Weight Complications ALLERGIES: ( Food, Drugs, Environmental) None Latex Iodine Allergy Interaction Allergy Interaction 3/15ck 2-4

4 MEDICAL HISTORY: Check Yes or No to all that apply to YOU. High Blood Pressure Yes No Depression / Anxiety Yes No Asthma / COPD Yes No Skin Condition Yes No High Cholesterol Yes No Heart Disease Yes No Bowel / Liver Disorders Yes No Migraine Yes No Kidney Problems / Stones Yes No Stroke Yes No Anemia / Clotting Disorders Yes No Blood Clots / DVT Yes No Blood Transfusions Yes No Breast Cancer Yes No Thyroid Disease Yes No Epilepsy Yes No Osteopenia / Osteoporosis Yes No Anesthesia Complications Yes No Other Cancers (provide details): Other Medical Problems (provide details): FAMILY MEDICAL HISTORY: Please check all that apply for your immediate family. Indicate which family member by checking the appropriate column and AGE OF ONSET: No Family History Adopted Mother Father Brother Sister Children Grand Mother (Maternal) Heart Disease Diabetes Blood Clots / DVT Breast Cancer Colon Cancer Ovarian Cancer Uterine Cancer Grand Mother (Paternal) Grand Father (Maternal) Grand Father (Paternal) Other Cancers: SURGICAL HISTORY: YEAR OPERATIONS/ PROCEDURES SURGEON CURRENT MEDICATIONS: None (You may attach a copy of your medications list to this form) Medications Dosage (mg) Frequency Prescribing Physician 3/15ck 3-4

5 CONTINENCE HISTORY: Do you leak urine on the way to the bathroom? Yes No Do you leak urine but are unsure when it occurs? Yes No Do you wear a pad and it gets wet with urine? Yes No Do you leak urine when you cough, sneeze, laugh, exercise? Yes No Do you urinate frequently (less than every 2 hours)? Yes No Do you get up more than twice/night to urinate? Yes No Do you have problems with your bowels? Yes No SOCIAL HISTORY: Use Tobacco? Current Never Former Packs per day: Ever Try to Quit? Yes No Do you Drink Alcohol? Never Rare Occasional: / week Daily: / day Do you use recreational drugs? Yes No If Yes, what kind? : Do you Exercise? Yes No Daily Weekly Occasionally Type of Exercise: Do you take Vitamin Supplements? Yes No Type: Occupation: Have you ever been a victim of abuse or domestic violence? Yes No Do you feel safe at home? Yes No Do you live alone? Yes No NOTE: Cervical testing for Gonorrhea (GC) and Chlamydia is routinely done for all women age 25 and younger per CDC guidelines unless you opt out by initialing here. Your insurance may or may not cover this service. AUTHORIZATION AND RELEASE: I hereby certify that I have completed the above information to the best of my knowledge. I authorize, consent, request, and agree to actively participate in such services as routine assessments, the performance of diagnostic tests, procedures, care, and treatment as self-referred or as ordered by my physician, his/her assistant or designees. Patient Signature Date Please mail or complete your completed form to our office prior to you appointment. If you cannot return your form prior to your appointment, you must arrive 30 minutes early so we can enter your information into the computer. Thank you for your attention and cooperation. 3/15ck 4-4

6 Robert L Berk, MD Neil D. Bluebond, DO Amy L. Harvey, MD Mark D. Kuhn, MD Meghan A. Patel, MD Lester A. Ruppersberger, DO Stephanie J. Schwartz, MD Anne Walker, MD Cindy Cullen, CNM Lisa Diasio, MSN, CRNP Karen Nyirjesy, MSN, CRNP Kathie Olson, MSN, CRNP Susan Ritorto, MSN, CRNP Mary Woltjen, MS, CNM, CRNP AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Patient Name: Date of Birth: Today s Date: 1. By signing my signature below, I hereby authorize the disclosure of my protected health information to the person(s) listed below: Patient Signature: Date: 2. By signing below, I hereby authorize the practice to leave my protected health information (including but not limited to results, prescriptions, and appointments on my answering machine or cellular phone. Patient Signature: Date: 3. By signing below, I hereby authorize the practice to mail appointment reminders/letters to my home address. Patient Signature: Date: THIS AUTHORIZATION DOES NOT EXPIRE UNLESS OTHERWISED NOTED 1/15ck 540 N. Woodbourne Road, Langhorne, PA

7 Robert L Berk, MD Neil D. Bluebond, DO Amy L. Harvey, MD Mark D. Kuhn, MD Meghan A. Patel, MD Lester A. Ruppersberger, DO Stephanie J. Schwartz, MD Anne Walker, MD Cindy Cullen, CNM Lisa Diasio, MSN, CRNP Karen Nyirjesy, MSN, CRNP Kathie Olson, MSN, CRNP Susan Ritorto, MSN, CRNP Mary Woltjen, MS, CNM, CRNP Billing, Collection and Financial Policy The Center for Women s Health is pleased to welcome you to our practice and to let you know that we are committed to not only providing you with the very best medical treatment, but to ensure you that your patient experience is a pleasant one. We have developed this financial policy to help you to understand our billing policies and procedures to avoid any miscommunication about the handling of your bills and account. Keeping your information up-to-date is very important and we ask you to verify that your information remains true at each visit, and to update any new changes before you see a physician. Any co-pay, co-insurance or deductible amounts owed by you are due at the time of service. If your insurance plan/coverage denies payment, defers payment to you or does not respond to our claim within 60 days, we will send you a statement. All patient invoices are due and payable upon receipt. Patients are ultimately responsible for paying for the care they receive even if they have insurance coverage. For your convenience we accept cash, personal checks, debit cards, Visa, MasterCard, Discover, American Express and Care Credit. Self Pay: If you are self-pay, you will be expected to pay the days charges on the day of service. You will also be billed for services that may have been provided at the visit but not known at the time of your payment. Surgery: If you are having surgery, we will check your benefit allowed amounts and you will be required to pay any self-pay or patient responsibility amounts prior to your surgery date. Missed Appointment Fee: We request that patients give at least 24 hour notice to cancel appointments. Center for Women s Health Reserves the right to charge $25.00 fee to patients who miss their appointments and do not call ahead of time to cancel appointment. Returned Check Fee: Center for Women s Health will charge a returned check fee of $35.00 for any check returned by your bank on payments (insufficient funds). 540 N. Woodbourne Road, Langhorne, PA

8 Past Due Accounts/Collections: Patients who have a past due account will be required to satisfy their outstanding balance prior to scheduling appointments. If we refer your account to a collection agency, you must pay all past due amounts or make agreeable payment terms before you can schedule further appointments with our providers. Robert L Berk, MD Neil D. Bluebond, DO Amy L. Harvey, MD Mark D. Kuhn, MD Meghan A. Patel, MD Lester A. Ruppersberger, DO Stephanie J. Schwartz, MD Anne Walker, MD Cindy Cullen, CNM Lisa Diasio, MSN, CRNP Karen Nyirjesy, MSN, CRNP Kathie Olson, MSN, CRNP Susan Ritorto, MSN, CRNP Mary Woltjen, MS, CNM, CRNP If you have any questions or concerns regarding your account or insurance claim, please contact our billing department by calling our main telephone number and press Option #7. Our billing representatives will make every effort to assist you and provide you will all information necessary to resolve your billing problem or concern. By signing below, I acknowledge receipt of and agree to the patient billing and collection policy terms of the Center for Women s Health. Signature Date 4/2015ck 540 N. Woodbourne Road, Langhorne, PA