Dear Patient, We welcome you and your family to our office. While every pregnancy is different our goal is always the same; to have a healthy baby and mother. To better care for your pregnancy, we kindly ask that you print the consents and questionnaires, fill them out, and bring them to your first appointment. We also are providing you with information about our practice. If at any time you need any further assistance, please do not hesitate to contact our office. We welcome you to our office and look forward to seeing you soon. Sincerely, The Doctors & Staff at Willow Bend OB/GYN Page 1 of 14
Patient Office Policy These policies are designed so we can provide to you and all our patients the quality of care expected from our office in a prompt and courteous manner. Should you at any time have a question about our policies, please do not hesitate to contact our office. Office hours. Our office hours are Monday through Friday, 8:30 am to 4:30 pm. We are closed between the hours of 12:00 pm and 1:00 pm for lunch. After hours, weekends and holidays. To contact the doctor on call, call our main office phone number (972) 468 8158 and the answering service will page the doctor on call. Payment for services. At your second obstetric appointment, an office associate will meet with you to review your insurance coverage and financial responsibility to our office. If you have an amount due to our office, this amount is an estimate based upon information your insurance company provided to our office. We collect co payments, co insurance and deductibles at the time of service. Any deductibles or co insurance must be paid prior to any procedures. We charge you only the amounts your insurance company calculates is your financial responsibility to our office. These amounts will match exactly to the Explanation of Benefits (EOB) you receive from your insurance company. After each episode of care, we file a claim to your insurance company. If your insurance company determines there is a balance due to our office, we will mail you an invoice. Payment is due upon receipt of the invoice. As a courtesy, we mail account statements one time each month summarizing any outstanding balance(s) due to our office. Should your health insurance company deny coverage for services rendered by our office, you are still financially obligated to pay our office for services rendered. It is your responsibility to verify with your insurance company that the service(s) we provide are covered by your health insurance policy. In the event your account becomes past due, we may assess a $25.00 late fee each month that your account is past due. There is a $25.00 fee for any returned checks. We accept Master Card, Visa, Discover, personal checks and cash. Appointment cancellations. We request at least 24 hours notice if you are canceling your appointment. Punctuality. Unless your doctor is called away for an emergency, she generally starts and finishes on time. If you are late for your appointment, there will be less time available for your visit, or you may need to reschedule your appointment. Page 2 of 14
Medical forms. All medical, consent, and insurance forms should be filled out before your first appointment. In the event you do not have your forms filled out prior to your scheduled appointment, please arrive at least 30 minutes prior to your scheduled appointment. Medical records. We maintain your medical records at our office. If you would like us to release your records you must sign a written release. You may be assessed a fee for our office to forward medical records at your request. Laboratory tests. Our office is not responsible for the billing of any laboratory tests ordered by your doctor. Please contact your laboratory directly if you have insurance coverage questions. Treatment of minors. We require prior permission from the parent or legal guardian to treat any patient under the age of 18 years. Please make sure you sign the Consent for Examination of a Minor Child to give us permission to treat your minor. We will not be able to see any minors without this form completed. Patients under 18 years of age must be accompanied by an adult at all times. Children. Please do not bring children with you to your appointment. Our office is not equipped to safely monitor or care for children. We do not allow sick children in our office. Sonograms. From time to time, you will hear our office staff use the words ultrasound and sonogram interchangeably. An obstetric ultrasound is the use of a real time ultrasound machine scanner to capture a picture of your baby. The woman conducting your sonogram is a Registered Diagnostic Medical Sonographer (RDMS). The medical sonographer uses the ultrasound machine for many different reasons. Obstetric ultrasounds are used primarily to: Date the pregnancy (gestational age). Confirm fetal viability. Determine location of fetus, intrauterine vs ectopic. Check the location of the placenta in relation to the cervix. Check for the number of fetuses (multiple pregnancy). Check for major physical abnormalities. Assess fetal growth (for evidence of intrauterine growth restriction (IUGR)). Check for fetal movement and heartbeat. Determine the gender of the baby. While we routinely use sonograms for medical purposes, the FDA discourages the use of ultrasounds for non medical purposes such as fetal keepsake videos and photos. Here are a couple of guidelines to follow when you come to our office for a sonogram. Please invite no more than two people to attend your sonograms. We discourage small children from attending your appointment because they can become agitated thereby distracting your medical sonographer. Page 3 of 14
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This office may use and disclose medical and financial information related to your care that may be necessary now or in the future to facilitate payment by third parties for services rendered by us, or to assist with, aid in, or facilitate the collection of data for purposes of utilization review, quality assurance, or medical outcomes evaluation purposes. Such information may be released to insurance companies, HMO s and PPO s, managed care organizations, IPA s, Medicare/Medicaid, or other governmental or third party payors, or any organizations contracting with any of the above entities to perform such functions. Medical records may be delivered to a primary care physician or any other physician that is directly or indirectly responsible for your medical care or the payment thereof. At any time, you may revoke this authorization. You may request restrictions on certain uses and disclosures. This office is not required to agree to a requested restriction. You have the right to receive confidential communications of your protected health information. You have the right to inspect, copy and amend your protected health information. You may also request an accounting of disclosures of your protected health information from this office. We are legally obligated to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices and to abide by its terms. We reserve the right to change our privacy practices and apply revised privacy practices to protected health information. You may register a complaint with this office if you suspect that your privacy rights have been violated. We will investigate the complaint and inform you of the findings. No retaliation will be made against you by this office because you registered a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services. You may speak with the Office Manager to obtain additional information regarding any questions you may have concerning this Notice or to receive a printed copy of the Notice. This Notice of Privacy Practices is effective as of the appointment date. By signing this document I am stating that I have read and have a copy of the Notice of Privacy Practices. Printed Name of the Patient Date Signature of Patient Page 4 of 14
Ultrasound Informed Consent My doctor has recommended an ultrasound. I understand ultrasounds are to be performed to check fetal growth, fetal number, dating of my pregnancy, as well as other helpful information used during my pregnancy. I understand a routine ultrasound cannot detect all congenital defects. If a defect is suspected, the doctor may refer me to a doctor of maternal fetal medicine for an evaluation. I also understand ultrasounds are not performed for the sole purpose of determining the gender of my baby. Should any photos or videos be provided to me, these photos are not images made for diagnostic purposes. I understand the American College of Obstetricians and Gynecologists discourages the use of recreational 3 dimensional and 4 dimensonal sonograms. By signing this form, I acknowledge I have been given all the information I desire concerning this procedure and have had all questions answered. Print name: Date Signature Page 5 of 14
Consent for the HIV Blood Test I have been informed my blood will be tested in order to detect whether or not it contains antibodies to the Human Immunodeficiency Virus (HIV) which is the probable causative agent of Acquired Immunodeficiency Syndrome (AIDS). I understand the test is performed by drawing blood from my arm and processing the resulting specimen utilizing ELISA and Western Blot laboratory technologies. I have been informed the ELISA test being utilized produces three (3) false positives (indicates presence of anti HIV when it is not present) test results in every ten thousand (10,000) specimen processed, regardless of populations tested. I have also been informed that the test will be repeated, if positive, and a secondary level test (Western Blot) will also be performed. The combination of these tests reduces the possibility of a false positive to a very small fraction per ten thousand (10,000) tests processed. I have been informed that the ELISA test also fails to detect anti HIV in rare instances and for a period of time immediately after infection with the virus. I have been offered re testing if it is suspected that this has occurred. I have been informed that if I have questions regarding the nature of the blood test, the expected benefits, the risks, and alternative tests, I may ask those questions before I decide to consent to the blood tests. By my signature below, I acknowledge I have been given all the information I have requested concerning the blood test. Therefore, I acknowledge I have given consent for the performance of a blood test to detect antibodies to HIV. Signature of patient or guardian Witness Date Page 6 of 14
Informed Consent for Collection of Cord Blood I, (insert name of mother), have requested my healthcare provider collect the umbilical cord blood ( Cord Blood ) following the upcoming birth of my child ( Child ). I am of legal age and have legal authority to sign this consent. I consent to have samples of my blood and my Child s Cord Blood drawn at the time of delivery of my Child and consent to have these samples being sent to a laboratory to be tested. I have been informed the Cord Blood collected may be considered unsuitable for processing and storage in the event the test results of my blood and/or my Child s Cord Blood are abnormal. I have been informed as to the potential risks, benefits and alternatives regarding the collecting, testing, processing, storage and use of Cord Blood. All of my questions have been answered fully and to my satisfaction. I understand complications may occur during delivery which may preclude collection of the Cord Blood by my healthcare provider. I understand Cord Blood will be collected only if my healthcare provider has determined in her medical judgment the collection will not pose a threat to my health or to the health of my Child. I accept that my healthcare provider has absolute discretion to decide whether or not to proceed with the collection of the Cord Blood at the time of delivery. I understand there is no assurance that (i) the Cord Blood will be successfully collected, processed or stored, or (ii) if successfully collected, processed and stored, it will result in successful treatment in the future. I acknowledge that on this day of, 20 I have read this Consent Form in its entirety (or it has been read to me in its entirety) and any questions I have about this form, Cord Blood, Cord Blood collection and/or Cord Blood storage have been asked and answered satisfactorily and I sign it with full knowledge of its contents. Printed Name of Mother Signature of Mother Printed Name of Father (optional) Signature of Father (optional) Signature of Witness Printed Name of Witness Page 7 of 14
Patient Information Please print Name: Date: Last First MI mm/dd/yyyy Address: Street Apt # City, State Zip Code Date of Birth: mm/dd/yyyy Phone: Home Phone: Work Sinlge: Married: Divorced: Widowed: Primary Insurance Please print Person responsible for account: DOB Last Fist MI mm/dd/yyyy Relationship to patient: Address (if different from patient): Street Apt# City, State Zip Code Insurance Company Name: ID Number: Group Number: Secondary Insurance Please print Is the patient covered by secondary insurance? Yes No Subscriber name: Relationship to patient Address (if different from patient): Insurance Company Name: Phone: DOB mm/dd/yyyy ID Number: Plan Group Number: Assignment, Release and HIPPA Acknowledgement I, the undersigned certify I (or my dependent) have insurance coverage with Name of Insurance Company and assign all insurance benefits to Willow Bend OB/GYN, PLLC if any, otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Willow Bend OB/GYN, PLLC to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all insurance submissions. Responsible party signature Responsible party signature Relationship Date Page 8 of 14
Medical History for Obstetric Patients Name LMP: Date: Last First MI mm/dd/yyyy Birth Date: mm/dd/yyyy Past Pregnancies (Last Three) Single: Married: Widowed: Divorced: Separated: Date mm/yy Gest Weeks Length of Labor Birth Weight Sex M/F Type Delivery Anes. Place of Delivery Preterm Labor Yes/No Complications/Comments Medical History Detail Positive Remarks Include Date & Y/ N Treatment Diabetes Pulmonary (TB asthma) Hypertension Seasonal allergies Heart disease Drug/latex/allergies Autoimmune disorder Breast Kidney disease/uti Surgeries Neurologic/epilepsy Hospitalization year Psychiatric Anesthetic complications Depression/postpart Abnormal PAP Hepatitis/liver disease Uterine anomaly Varicosities/phlebitis Infertility Thyroid dysfunction ART treatment Trauma/violence Relevant family history Other: Y/ N Detail Positive Remarks Include Date & Treatment Tobacco Alcohol Illicit/recreational drugs Amt/Day Pre Pregnancy Amt/Day Pregnant # Years Use Symptoms since last menstrual period Page 9 of 14
Medical History for Obstetric Patients Name: Date: Last First MI mm/dd/yyyy Genetic screening/teratology counseling Includes patient, baby s father, or anyone in either family with: Yes Patients age 35 years or older as of estimated date of delivery Thalassemia (Italian, Greek, Mediterranean, Asian background) MCV less than 80 Neural tube defect (meningomyelocele, spina bifida, or anencephaly) Congenital heart defect Down syndrome Tay sachs (Ashkenazi Jewish, Cajun, French, Canadian) Canavan disease (Ashkenazi Jewish) Familial dysautonomia (Ashkenazi Jewish) Sickle cell disease or trait (African) Hemophilia or other blood disorders Muscular dystrophy Cystic fibrosis Huntington s chorea Mental retardation/autism If yes, was person tested for fragile X? Other inherited genetic or chromosomal disorder Maternal metabolic disorder (EG, type 1 diabetes, PKU) Patient or baby s father had a child with birth defects not listed above Recurrent pregnancy loss or a stillbirth Medications (including supplements, vitamins, herbs or OTC drugs) illicit/recreational drugs/alcohol since last menstrual period If yes, agent(s) and strength/dosage Other No Infection history Live with someone with TB or exposed to TB Patient or partner has history of genital herpes Rash or viral illness since last menstrual period Hepatitis B or C If yes, which? History of STD, Gonorrhea, Chlamydia, HPV, HIV, Syphilis (Circle all that apply) Other (see comments) Family History: Age Living Deceased Health or Cause of Death Father Mother Siblings Yes No Circle if any blood relative has had: Heart disease Kidney disease Tuberculosis Mental disorder High blood pressure Diabetes Tumors Seizures Down Syndrome Tay Sachs Muscular Dystrophy Hydrocephalus (Water on the brain) Sickle Cell Hemophilia Mental retardation Defects of spine (Spina Bifida) Stillborn birth Birth defects Polycystic kidney Chromosomal abnormalities Page 10 of 14
Patient Communication Permission Form Patient Name DOB Last First MI mm/dd/yy As a patient in our practice, from time to time, we may need to communicate with you when you are not in the office. To preserve your privacy, we would like you to indicate your preferred method for us to communicate information to you. Without specific permission, we will not release any of your medical information to another person. In some cases, you may wish another person to have access to your medical information. In the event that no one is available to answer your phone, we need your permission to leave certain types of information on your answering machine or with another person. Please indicate your preference by checking one or more of the boxes below. Do not leave any medical information on my answering machine or with another person. I give permission to Willow Bend OB/GYN personnel to leave medical information pertaining to me on my home answering machine at the number listed below. Telephone # I give permission to Willow Bend OB/GYN personnel to give any and all medical information pertaining to myself (or my child), including appointment reminders, to the individual listed below. Name I assume responsibility to inform the practice of any change in my phone number or my preferences. Signature Page 11 of 14
Resources for Postpartum Counseling and Assistance This list contains the names and addresses of professional organizations that can help you find a local resource that meets your needs (there are also some toll free assistance phone lines). The list will be updated regularly. If you do not see an organization on this list that you feel comfortable contacting, we encourage you to check with your healthcare provider or a clergy member as he or she may be able to give you some ideas as well. Statewide Resources Postpartum Resource Center of Texas (multi lingual) 811 Nueces Austin, TX 78701 877 474 1002 (toll free) www.texaspostpartum.org Mental Health Association of Abilene 500 Chestnut Street, Suite 1807 Abilene, TX 79602 915 673 2300 www.abilenementalhealth.org Local Resources Mental Health Association of Beaumont and Jefferson County 670 North Seventh Beaumont, TX 77702 800 240 9657 (toll free) www.mentalhealthbeaumont.org Mental Health Association of Fort Bend County 10435 Greenbough Dr., Suite 200 Stafford, TX 77477 218 261 1876 www.mhatbc.org Mental Health Association of Great Dallas 624 N. Good Latimer, Suite 200 Dallas, TX 75204 214 871 2420 www.mhadallas.org Page 12 of 14
Mental Health Association of Greater Houston 2211 Norfolk, Suite 810 Houston, TX 77098 713 523 8963 Information and referral line: 713 522 5161 www.mhahouston.org Willow Bend OB/GYN Mental Health Association of Greater San Antonio 8431 Fredericksburg Road., Suite 110 San Antonio, TX 78229 210 614 7566 Mental Health Association of Tarrant County 3136 W. 4th Street Fort Worth, TX 76107 817 335 5405 www.mhatc.org Mental Health Association of Tyler 113 E. Houston St. Tyler, TX 75702 903 592 0582 Toll Free Telephone Assistance Lines Postpartum Resource Center of Texas (multi lingual) 811 Nueces Austin, TX 78701 877 474 1002 (toll free) www.texaspostpartum.org Texas Department of Health Family Health Services Information and Referral Line 800 422 2956 Texas Information and Referral Network www.hhse.state.tx.us/tirn/tirnhome.htm On Line Assistance Page 13 of 14
2 1 1 Texas 2 1 1 Texas, formerly First Call for Help, is a service for the entire community. 2 1 1 is the new abbreviated dialing code for free, bilingual information and referrals to health and human services and community organizations. 2 1 1 serves as the number to call for information about community organizations, and it links individuals and families to critical health and human services provided by nonprofit organizations and government agencies in their own community. 2 1 1 Texas is currently available in: Amarillo, Austin, Beaumont, Belton, Bryan/College Station, Dallas/Fort Worth, El Paso, Houston, Lubbock, Midland, San Antonio, Sherman, & Weslaco. Page 14 of 14