Advanced Women's HealthCare, SC Registration Form

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1 Patient Full Name Address Advanced Women's HealthCare, SC Registration Form Street Account # Provider Last First Middle Maiden(0ther) Apt/Suite# City State Zip Code Phone # (Please circle preferred contact number) Home Cell Work Can Messages be left on voice mail? Home: Yes / No Work: Yes / No Cell: Yes / No I authorize AWH to discuss my Protected Health information with the following person/s (please include date of birth): Martial Status: Single Married Divorced Widowed Sex (circle one) Female Male Date of Birth: Social Security Number of Patient: Patient Employer: Emergency contact person for patient: (Is this person listed in release to following person section?) Ethnicity & Race: Spouse employer: Name Phone Relationship Information below this line is for Responsible Party ---The person responsible for payment of bills Name of Responsible Party Address Street Last First Middle Date of Birth Apt/Suite# City State Zip Code Phone # Primary Insurance Home Cell Work Carrier Name Effective Date Group Name Group # Employer Subscriber full Name Last First Middle Social Security Number Date of Birth Relationship to Patient: (circle one) Phone # Other (explain) Self Spouse Child Copy of this insurance card in file Yes No Home Cell Work Secondary Insurance Carrier Name Effective Date Group Name Group # Employer Subscriber full Name Last First Middle Social Security Number Date of Birth Relationship to Patient: (circle one) Self Spouse Child Other (explain) Copy of this insurance card in file Yes No

2 Is this visit related to an accident: Yes No If yes, date of accident Page 2 Must provide Insurance Claim number: If no claim number visit/s will be billed as self pay Financial Agreement We accept most insurance plans and submit claims to those plans on your behalf. The accuracy of the information we request on the previous page is important so all your insurance plans requirements are met prior to providing services and submitting your insurance claim. It is your responsibility to pay for all services provided that are not covered by your insurance. That includes any amount denied, not covered, co pay by your insurance plan. Not all services are covered benefits with all insurance co. It is your responsibility to pay for all services not covered by your insurance. That includes non-covered services, copay, & deductible. Payment for the above are expected at the time of service. We accept cash, checks and most credit cards. Any check returned for non Sufficient funds will be charged $ Payment arrangements for OB patients are due as per written agreement which will be discussed at your first prenatal visit Payment of unpaid balances are due prior to any new services being provided. Appointments will not be scheduled until balance is paid in full. Should your account becomes deliquent it will be assigned to a collection agency, you will be responsible for the costs incurred in collection of this balance, which includes collection agency fees of 30 %, court costs and attorney fees and we will be unable to schedule you for any further appointments. I have been informed that effective June 25, 2013 Advanced Womens Healthcare, S.C. no longer accepts Medicaid as a secondary payer and I understand that it is my responsibility to pay any co-pays and deductible required by my commerical insurance. Initial I authorize Advanced Women's Healthcare, S.C. to release to my health insurance carrier and its agents any information to determine the benefits payable under their coverage. I authorize my insurance company and its carriers to disclose any information requested regarding claims for medical benefits, A copy of this authorization may be used in place of the original. I am aware if I decline to consent to this release of information I am responsible for all charges I incur while being treated. I also state that the information provided regarding insurance coverage is accurate and true. Initial After reading Advanced Women's Healthcare, S.C. Financial agreement I understand and agree that I am responsible for payment of any non-covered services not paid by your insurance policy. Your signature below indicates that you understand and agree to the above financial agreement. Signature of patient (or guarantor if patient is a minor) Name of patient or guarantor (Please print): If signed by guarantor, please print name of patient: Patient DOB Date signed: Consent to Treat I hereby authorize employees and agents; physicians, mid level practitioners of Advanced Women's Healthcare, SC office to render medical care to the patient indicated on this form and to fulfill the orders of the physicians: including consultants, associates and assistants of the physician choice. Signature of Patient, Parent or Legal Guardian: If patient is a minor: Date: My signature above authorizes evaluation and treatment for my child and also authorizes consent to medical and surgical procedures for the child named herein (Name of child).

3 Notice of Privacy Practices Acknowledgement for Advanced Women's Healthcare, S.C. Effective The attached notice describes how medical information about you may be used and disclosed. It also describes how you can get access to this information. Please review it carefully. I received the attached Advanced Women's Healthcare, S.C. Notice of Privacy Practices Please sign which applies below: Page 3 Signature of Patient Patient's Printed Name Signature of Parent/Legal Guardian/Legal Representative Printed Name of Parent/Legal Guardian/Legal Representative Date Patient's Date of Birth or MRN Date of Signature Relationship to Patient Healthcare regulations, required that we ask the following questions: 1. What category best describes your race? If you need additional definition please ask the front desk African American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Decline. I do not want to answer 2. Do you consider yourself Hispanic or Latino? No. Not Hispanic/Latino Decline. I do not want to answer Do not identify with any of the above captions Yes. Hispanic/Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, Latin American or Spanish culture or origin 3. What is your preferred language? Arabic Assyrian Bosnian Bulgarian Cantonese Croatian English French German Greek Gujarati Hindi Italian Japanese Korean Malayalam Mandarian Polish Russian Serbian Spanish Sign Language Tagalog Vietnamese Other Additional notes: For office use: Insurance(s) card scanned Y N Current insurance verified Y N Demographics verified and updated Y N Photo ID scanned Y N Employee initials Date:

4 Authorization for Release of Information Fax to Mail to: Advanced Women s Healthcare 2111 East Oakland Avenue, Suite B Bloomington, IL Dele Ogunleye, M.D. PH: PLEASE PRINT OR TYPE: Authorization is given to: Release records to: Advanced Women s Healthcare Dele Ogunleye, M.D. Signature verified by: Advanced Women s Healthcare Employee:

5 Advanced Women s Healthcare, S.C. Notice of Privacy Practices As required by the Privacy Regulation Created as Results of the Health Insurance Portability and Accountability Act of 1996 PATIENT RIGHTS: You have the right to inspect and copy your protected health information. Under federal law you may not inspect or copy the following records: psychotherapy notes, information compiled for use in a civil, criminal or administrative action. We may deny your request to inspevt or copy your health information if we determine that it is likely to endanger your life or safety or that it could cause harm to another person referenced within the information. You have the right to request a review of this decision. To inspect and copy your medical information, you must submit in a written request to the Privacy Officer. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request. You have the right to request a restriction on uses and disclosures of your health information. Your request must state specific restriction requested and to whom you want the restriction to apply. Advanced Women s Healthcare, S.C. is not required to agree to the restriction that you may request. We will notify you if we deny your request to a restriction. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. You have the right to request amendments to your health information. Requests must be made in writing and you must provide a reason to support the requested amendment. You have the right to receive an accounting of instances in which we disclosed your health information for purposes other than treatment, payment, healthcare operations for the last six years. If you request this accounting more than once in a 12-month period, we may charge you for responding to these additional requests. OUR DUTIES: Advanced Women s Healthcare, S.C. is required by law to maintain the privacy of your health information to you with this Privacy Notice of our privacy practices. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If we change the notice, we will provide a copy of the revised notice at your next visit. QUESTIONS AND COMPLAINTS: If you want more information about our privacy practices or have questions or concerns, please contact our Privacy Officer. If you are concerned that we have violated your privacy right or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of health information you may complain to us using the contact information listed at the end of the Notice. You also may submit a written complaint to the Privacy Officer. We will not retaliate against you in any way if you choose to file a complaint with us. Advanced Women s Healthcare, S.C East Oakland, Suite B Bloomington, IL Attention: Privacy Officer THE PRIVACY OFFICER CAN BE CONTACTED BY TELEPHONE AT THIS NOTICE IS EFFECTIVE October 15, 2012

6 NOTICE OF PRIVACY PRACTICE By signing this document, I acknowledge that a copy of Advanced Women s Healthcare Notice of Privacy Practices has been made available to me. I understand that I may request to receive a copy of the notice at any time. Please Print Patient s Name Signature of Patient or Legal Guardian if patient is a minor or unable to sign If someone other than the patient signed, please indicate relationship to patient Date of Signature

7 2111 East Oakland Avenue, Suite B Bloomington, IL Phone: Fax: & SMS Text Opt-in Agreement First name M.I. Last name Date of birth Address Home phone number Cell phone number address Opt-in More than 70% of patients say reminders help them remember an appointment. YES, I would like to receive correspondence for appointment follow-ups, reminders, and patient education information. NO THANK YOU, I would NOT like to receive correspondence for appointment follow-ups, reminders, or patient education information. Your information is strictly to help us provide better quality care and is not shared with anybody else. You may Opt-out at any time. SMS Text Opt-in YES, I would like to receive appointment reminders by having an SMS text sent to my cell phone within 24 hours of my appointment. NO THANK YOU, I would NOT like to receive appointment reminders by SMS text sent to my cell phone within 24 hours of my appointment. Your information is strictly for this purpose and not shared with anybody else. You may Opt-out at any time. September 28, 2012

* Do you wish to receive our monthly newsletter? Yes No Marital Status: Single Married Legally Separated Divorced Other Employer Name: (If applicable)

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