Employer Phone Number City State ZIP Patient Relationship to Responsible Party. Name of Insured Date of Birth

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1 PATIENT INFORMATION Patient Registratin Frm (Please Print) Title (Mrs./Miss/Ms/Dr) Hw did yu hear abut us? Referral? Patient s Name (Last) (First) (Middle) Als Knwn As Name (Last) (First) Marital Status Married Single Divrced Widwed Legally Separated Other Scial Security Number Date f Birth Phne Numbers Hme Cellular Wrk Address Emplyment Status Emplyed Full-Time Student Part-Time Student Retired Self-Emplyed Unemplyed Emplyer Occupatin Emergency Cntact Name Phne Number Emergency Cntact Relatinship t Patient ***Required Meaningful Use Infrmatin: Race (check ne) American Indian r Alaskan Native Asian Native Hawaiian r Other Pacific Island White Refuse t Reprt Ethnicity (check ne) Hispanic r Latin Nt Hispanic r Latin Refuse t Reprt RESPONSIBLE PARTY INFORMATION (nly if ther than yurself) Respnsible Party Name (Last) (First) (Middle) Scial Security Number Female Male Date f Birth Address Phne Numbers Wrk Day Evening Hme Day Evening Address Emplyment Status Emplyed Full-Time Student Part-Time Student Retired Self-Emplyed Unemplyed Emplyer Emplyer Phne Number City State ZIP Patient Relatinship t Respnsible Party PRIMARY INSURANCE INFORMATION (prvide yur insurance card t the frnt desk at check-in) Name f Insured Date f Birth SSN Patient Relatinship t Insured Insured Emplyer Name Insurance Cmpany/Phne Number ( ) Subscriber ID (Plicy N.) Grup ID Cpay Amunt Effective Date SECONDARY INSURANCE INFORMATION (prvide yur insurance card t the frnt desk at check-in) Name f Insured Date f Birth SSN Patient Relatinship t Insured Insured Emplyer Name Insurance Cmpany/Phne Number ( ) Subscriber ID (Plicy N.) Grup ID Cpay Amunt Effective Date I agree that the infrmatin supplied n this frm is accurate and up-t-date t the best f my knwledge. Patient Signature Or Legal Representative Respnsible Party Signature (if applicable) Date Date phne: fax: B E. Altn Glr Blvd., Suite 130, Brwnsville, TX G u a j a r d M D. c m

2 J. Gabriel Guajard, M.D. 100B Altn Glr Blvd., Suite 130 Brwnsville, TX Phne: (956) Fax: (956) WELCOME TO OUR PRACTICE Welcme Yu, the patient, are the mst imprtant persn in ur ffice. We are cmmitted t prviding yu with the best pssible medical care. Excellence is ur gal. Thank yu fr chsing us as yur healthcare prvider. We lk frward t caring fr yu! Office Hurs Phnes: Telephnes are answered during nrmal business hurs. After business hurs, telephnes are answered by the answering service. They will cntact the physician in case f an emergency. Office Hurs: Mnday Tuesday Wednesday Thursday Friday 8 a.m.- 5 p.m. 8 a.m.- 6 p.m. 8 a.m.- 5 p.m. 8 a.m.- 5 p.m. 8 a.m.- 12 p.m. Emergencies: Fr life-threatening situatins, call 911. If yu have an urgent prblem, please call ur ffice (956) fr instructins. After hurs, ur answering service will infrm yu f hw t reach a physician n call. Test Results: Fr test results call ur ffice at (956) Prescriptins: All prescriptins and refill requests shuld be requested during nrmal ffice hurs. Please have yur pharmacy call the ffice at (956) fr renewal f medicatin. Abut Our Physician Juan Gabriel Guajard, M.D. Specializing in Obstetrics and Gyneclgy. Offering services f Infertility Management. Graduate f University f Texas Medical Branch in Galvestn, TX. Resident f Sctt & White Medical Center lcated in Temple, TX. Brn and raised in Brwnsville, TX. Prud native f the Ri Grande Valley. Appintments Fr appintments please call (956) Please call in advance fr rutine ffice visits. Make fllw-up appintments as yu leave. We make every effrt t stay n schedule, althugh emergencies arise. If we are seriusly delayed, we attempt t ntify patients befrehand. As a curtesy t ther patients and staff, please call the ffice as sn as pssible if yu are unable t keep yur appintment r are ging t be late. phne: fax: B E. Altn Glr Blvd., Suite 130, Brwnsville, TX G u a j a r d M D. c m

3 Insurance Prir t yur appintment, please check yur insurance infrmatin s yu will be infrmed abut referrals, c-payments, and any deductible required at the time f the visit. Fr yur first visit, please bring yur insurance card and arrive early t cmplete the necessary patient infrmatin frms. We accept Medicare and Medicaid as well as mst insurers; hwever, please review all insurance infrmatin with ur staff prir t services being rendered. Yur health insurance cntract is between yu and yur insurance cmpany. Unfrtunately, nt all services are cvered benefits. Sme insurance cmpanies arbitrarily select certain services they will nt cver. Any cmplaints regarding yur cverage shuld be directed t yur carrier. Financial Plicy We ask that all yur services be paid the day f yur visit. If yu have insurance, please present yur insurance card fr verificatin. If yur insurance changes, please ntify us immediately. C-payments, c-insurance, and any utstanding balances are expected at the time f service. Patients may be financially respnsible fr payment f all services even if their insurance cmpany des nt pay. Patient accunts nt paid prmptly are subject t third party cllectins and/r legal prcedures. We accept Visa, Mastercard, American Express, Checks, and Cash. If we are nt participating prviders with yur plan, we will prvide yu with a receipt fr yu t file with yur insurance cmpany. Any check returned frm the bank will result in an additinal $40.00 charge. If yur insurance carrier has nt respnded t a claim within 90 days, we reserve the right t frmally transfer all assciated liability fr the claim t the patient/respnsible party. Failure t prmptly reslve this balance may result in third party cllectin and/r legal prcedures will be taken. Please keep a clse watch fr carrier claim payment and cntact the insurance carrier r the clinic practice manager at (956) in the event a claim is nt reslved within 60 days frm the date f service. We realize that emergencies d arise that may affect timely payment f yur accunt. If such extreme cases d ccur, please cntact ur ffice Practice Manager at (956) I HAVE UNDERSTOOD AND AGREE TO THE FINANCIAL POLICY FOR J. GABRIEL GUAJARDO, M.D. I HEREBY ASSIGN ALL MEDICAL AND/OR SURGICAL BENEFITS TO WHICH I AM ENTITLED, INCLUDING, MEDICARE, MEDICAID, MY PRIVATE INSURANCE, TO J. GABRIEL GUAJARDO, M.D. THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING. A PHOTOCOPY OF THIS ASSIGNMENT IS TO BE CONSIDERED AS VALID AS THE ORIGINAL. I AUTHORIZE J. GABRIEL GUAJARDO, M.D. TO RELEASE ALL MEDICAL INFORMATION REQUESTED BY MY HEALTH INSURANCE CARRIER, MEDICARE (SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES), MEDICAID, OR ANY OTHER THIRD PARTY PAYOR. I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS: Print Name Signature f Patient Date r Legal Representative 2 G u a j a r d M D. c m

4 What D We Need Frm Yu? What Shuld Yu Expect Frm Us? T infrm the Medical Practice staff f any pertinent changes in insurance, emplyment, demgraphic infrmatin r relatinships with ther care/service givers. T arrive n time fr scheduled appintments and cancel, when necessary, with a phne call. T prvide payment fr services requested and delivered by the Medical Practice nt cvered by insurance within 90 days. T ntify the Medical Practice f any change in his/her health status. T fllw the recmmended treatment plan and infrm the Medical Practice f any physical r mental impairment requiring special accmmdatin. T ask questins if directins and prcedures are nt understd. T be treated with respect, dignity and be infrmed abut care needs t make apprpriate decisins. Help plan care and make changes t it. Expect that teaching materials will be prvided in a manner that can be understd. T be infrmed f the Medical Practice billing prcess. T keep recrds cnfidential except when cnsent has been given. T expect services t be prfessinal, timely, and apprpriate. T cmmunicate cmplaints t the Practice Manager and expect t receive fllw-up withut negative repercussins r changes in service. T receive care withut discriminatin due t race, religin, age, sex, disability r ethnic rigin. Patient Cnsent I HEREBY CONSENT TO THE ADMINISTRATION AND PERFORMANCE OF ALL TREATMENT, INCLUDING BUT NOT LIMITED TO ADMINISTRATION OF ANY NEEDED ANESTHETICS, PERFORMANCE OF PROCEDURES AS MAY BE DEEMED NECESSARY OR ADVISABLE, PERFORMANCE OF DIAGNOSTIC PROCEDURES/TESTS AND CULTURES, PERFORMANCE OF MEDICALLY ACCEPTED LABORATORY TESTS THAT MAY BE CONSIDERED MEDICALLY NECESSARY OR ADVISABLE BASED ON THE JUDGMENT OF THE ATTENDING PHYSICIAN OR THEIR ASSIGNED DESIGNEES. I FULLY UNDERSTAND THAT THIS CONSENT IF GIVEN IN ADVANCE OF ANY SPECIFIC DIAGNOSIS OR TREATMENT. I INTEND THIS CONSENT TO BE CONTINUING IN NATURE EVEN AFTER SPECIFIC DIAGNOSIS HAS BEEN MADE AND TREATMENT RECOMMEMDED. THIS CONSENT WILL REMAIN IN FULL FORCE UNTIL REVOKED IN WRITING. I UNDERSTAND THAT J. GABRIEL GUAJARDO, M.D. MAY INCLUDE CONSENT AT SATELLITE OFFICES UNDER COMMON OWNERSHIP. I UNDERSTAND AND ACKNOWLEDGE THAT J. GABRIEL GUAJARDO, M.D. WILL USE AND DISCLOSE MY INFORMATION FOR THE PURPOSE OF TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS AS DESCRIBED IN THE NOTICE OF PRIVACY PRACTICES. I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES AND AM ALSO AWARE IT IS AVAILABLE VIA THE INTERNET AT THE FOLLOWING WEBSITE: Print Name Signature f Patient Date r Legal Representative 3 G u a j a r d M D. c m

5 Whm t Cntact I HEREBY GIVE PERMISSION TO J. GABRIEL GUAJARDO, M.D. TO DISCLOSE OR DISCUSS ANY INFORMATION RELATED TO MY CONDITION(S) WITH THE FOLLOWING FAMILY MEMBER(S), SPOUSE, AND/OR CLOSE PERSONAL FRIEND(S). I WISH TO BE CONTACTED IN THE FOLLOWING MANNER TO DISCUSS PROTECTED HEALTH INFORMATION ABOUT ME (PLEASE CHECK WHAT YOU WISH TO BE APPLIED): ( Detailed Infrmatin refers t yur appintment time and date and/r infrmatin abut yur accunt, nt yur health cnditin ) HOME WORK CELLULAR OK TO LEAVE A MESSAGE WITH DETAILED INFORMATION AT HOME. OK TO LEAVE A MESSAGE WITH DETAILED INFORMATION AT WORK. OK TO LEAVE A MESSAGE WITH DETAILED INFORMATION ON THE CELL LISTED. WRITTEN COMMUNICATION OK TO MAIL TO MY HOME ADDRESS. OK TO FAX TO THIS NUMBER. OK TO ME AT. Print Name Signature f Patient Date r Legal Representative G u a j a r d M D. c m