New Patient Form Scottsdale

Wombkeepers Scottsdale New Patient Information Form

Personal Information

* Indicates required field

Name *

First

Last

Date of Birth *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Primary Telephone Number *

Cell Phone Number *

Work Phone Number *

Emergency Contact

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Emergency Contact Relationship (Spouse, Parent, Significant Other, Sibling, Friend) *

May we release results to your emergency contact? *

Employment Information

Are you employed outside the home? *

Employer Name *

Job Title *

Insurance Information

Your name as it appears on your Insurance Card- Must be exact *

Insurance Company Name *

Member ID # *

Who is the primary insurance holder? (the person who's employer provides the insurance) *

Date of Birth of Primary Holder of Insurance Policy? *

Relationship to Patient of Insurance Holder? *

Secondary Insurance

Insurance Company Name *

Member ID # *

Who is the holder of this Insurance Policy? Full Name as it appears on Insurance Card *

Date of Birth of Holder of Insurance Policy *

Relationship to Patient of Insurance Holder *

Other

How would you like to be notified of results *

Is it okay to leave a message with your results? *

How did you hear about us? *

Name of Primary Care Physician *

Patient Health Information

Gynecologic History

First Day of Last Period *

Are your cycles regular? *

Are your cycles painful? *

Normal # if days from first day of period to first day of next *

Normal length of Cycles (Days of Bleeding) *

Last Pap Smear *

Last Mammogram *

Have you had an abnormal pap or mammogram? Please explain below... *

Are you sexually active? *

Are you using any method to prevent pregnancy? *

Obstetrics History

Miscarriages

Have you had a prior miscarriage? *

If you have had a previous miscarriage, please list the year and how many weeks pregnant you were when it occurred *

Termination of pregnancy

Have you had a previous termination of pregnancy? *

If you have had a previous termination of pregnancy, please indicate the year and whether it was a medical or surgical termination *

Vaginal and Cesarean Deliveries

Delivery #1

Year of Delivery #1 *

Cesarean, Vaginal, VBAC? *

Wt and sex of child Delivery #1 *

Did you use any pain medication or an epidural? *

Any Complications: *

Delivery #2

Year of Delivery #2 *

Wt and sex of child Delivery #2 *

Any Complications? *

Cesarean, Vaginal, VBAC? *

Did you use any pain medication or an epidural? *

Delivery #3

Year of Delivery #3 *

Wt and sex of child Delivery #3 *

Cesarean, Vaginal, VBAC? *

Did you use any pain medications or an epidural? *

Any Complications? *

Any other deliveries:

Please list any deliveries not included above. Please include year, sex of child, wt of child, mode of delivery and any complications *

General Medical History

Do you have any medical problems? *

Please list all current and past medical conditions for which you have seen a doctor and the years in which they began and ended *

Are you currently taking any medications or supplements? *

Please List all Current Medications *

Have you ever had surgery? *

Please List all Surgeries and Hospitalizations and the years they occured *

Do you have any allergies to medication? *

Please List any Allergies to Medication and what your reaction is *

Social History

Do you smoke? *

Do you drink alcohol? *

Do you use any substances? *

Comments *

Family History

Please list any medical conditions that run in your family, especially female cancers. Indicate which relative suffered from the condition. If none, write none. *

Review of Symptoms

Are you currently experiencing any symptoms that concern you? *

If so, please list your current symptoms or indicate in the list below *

ADDITIONAL QUESTIONS FOR PREGNANT PATIENTS or PRECONCEPTION CONSULTS ONLY

Have you seen a doctor yet in this pregnancy *

Yes No

Name of Genetic Father of the Baby *

Name of Your CoParent or Spouse (If different from above) *

Father of the baby is: *

Involved with this prengnacy Not involved

CoParent's Occupation *

Do you, the father of your baby, or anyone in either family have any of the following conditions: Thalessemia, Neural Tube Defect, Heart Defect, Tay-Sachs, Canavan Disease, Familial Dysautonomia, Sickle Cell Anemia or Trait, Hemophilia, Muscular Dystrophy, Cystic Fibrosis, Huntington's Chorea, Mental Disability or Autism, Other Genetic Disorder ,Recurrent Pregnancy Loss or Stillbirth. If yes, please indicated which genetic condition and who is afflicted. *

Father of the baby is your *

Please indicate your ethnic background to the best of your knowledge *

Please indicate the ethnic background of the father of the baby to the best of your knowledge *

Any infertility treatment for this pregnancy? *

Yes No

Have ever had or been exposed to any of the following: Hepatitis, Tuberculosis, Genital Herpes, Rash or Viral Illness since last period, History of STD (Chlamydia, Syphilis, HIV, Gonorrhea). If yes, please indicate which infection *

Please List any locations outside of the United States that you or your partner have travelled to during this pregnancy or in the three months prior to this pregnancy. *

HIPAA and Privacy Information

HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. IT ALSO SHOWS AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND RETAIN FOR YOUR RECORDS. The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information. As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations. • Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. • Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information by removing all references to individually identifiable information. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We, are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. • The right to inspect and copy your protected health information. • The right to amend your protected health information. • The right to receive an accounting of disclosures of protected health information. • The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of April 14, 2003. We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint For more information about HIPAA or to file a complaint, contact: The U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C. 20201 Tel. (202) 619-02570

HIPAA ACKNOWLEDGEMENT

With my consent, Wombkeepers may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO), as further detailed in the Notice of Privacy Practices. I have the right to review the Notice of Privacy Practices prior to signing this consent. Wombkeepers reserves the right to revise its Notice of Privacy Practices at anytime and patients may request to receive any revisions in person or in writing. With my consent, Wombkeepers may call my home or other designated location and leave a message, on voice mail or in person, in reference to any items that assist in my care or as necessary for payment. Wombkeepers may also mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.” With my consent, Wombkeepers may E-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Wombkeepers restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Wombkeepers use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES By signing this document I acknowledge that I have read and/or received a copy of the Wombkeepers Obstetrics and Gynecology HIPAA Notice of Privacy Practices. I have also read the contents of this form.
I consent to the use and disclosure of my protected health information by Wombkeepers in order to carry out treatment, healthcare procedures and payment. I have had the opportunity to ask questions and all my questions have been answered.

Signature- I have read the HIPPA ACKOWLEDGMENT *

Date *

Financial Policy

Thank you for choosing us as your healthcare provider. We are committed to providing you with the best possible medical care. Your clear understanding of our practice financial policy is important to our professional relationship. We make every effort to keep our fees reasonable while at the same time covering the cost of the services we provide. Payment of your bill is considered part of your overall treatment. In order to keep healthcare costs to an absolute minimum, we have adopted the following policies. Fees and Payments Fees are standard and based on the complexity of your visit. Payment in full is required at the time of your visit and can be made with cash, personal check, Visa, MasterCard, or Discover. Insurance co-payments are due at the time of service. We will not bill your secondary insurance for co-payments. If you are unable to pay your co-payment at your visit, your appointment may need to be rescheduled. If it is necessary that you be seen, a $25.00 Copay Service charge will be added to your account. While filing insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered. Your insurance is a contract between you, your employer and the insurance company, we are not party to that contract. In order for us to file a claim, you must present a CURRENT copy of your insurance at each visit and communicate any changes in your personal information. Not all services are a covered benefit in all policies, so it is very important that you understand the provisions of your individual policy. Insurance companies select certain services that they will not cover, therefore we can’t guarantee payment of all claims by your insurance company. Some common examples of non-covered services are contraception and infertility. Additionally, some plans do not cover preventative or obstetrical services. Reduction or rejection of your claim does not relieve you of your financial responsibility. PLEASE NOTE: Each visit is documented in your medical record and a diagnosis is made by the provider. Diagnoses are made based on medical information, not based on coverage by Insurance Companies. To request a diagnosis change solely for the purpose of securing reimbursement from an insurance carrier is inappropriate and is considered insurance fraud.
Required at Check-In
• Verify Personal Contact Information
• Present Current Copy of Insurance Card and Present Current Picture ID
• Payment of any Outstanding Balance and Payment of Today’s Visit

We will verify your coverage at each visit. If we are unable to do so, you will be considered self pay and will be responsible for your visit. Self-Pay In order to address the needs of our patients without insurance and patients with coverage limitations, we offer a 30% prompt payment discount. For gynecologic services, this 30% discount is available to patients paying upfront, prior to their visit. For obstetrics patients, this discount is available to patients paying their entire global fee prior to 36 weeks. This discount acknowledges the lower cost involved in billing and collections when a claim does not need to be submitted to a third party payer.

Annual Exams and Mammography Please verify that your insurance will cover these preventative services before making your appointment. Depending on your age and the plan, these services may not be covered. Also, some insurance companies are very strict in enforcing time limits between visits and may not cover your visit if you are even one day early.

Family Medical Leave Act and Disability Paperwork If your employer requires Family Medical Leave Act (FMLA) or Disability paperwork to be completed by your provider, we offer two options: • A form created by our practice that meets the needs of both employer and patient. Patients may request this form to be filled out at any time to clarify their current condition. The turnaround time for this form is 5 business days and there is no charge for this. • Forms directly from your employer requiring additional information take considerable time for the staff to complete. We are happy to complete these forms for you; however there is a 10 business day turnaround.

Miscellaneous Charges Returned Check Charge : Late accounts will be charged a fee: 25$ at 30 days, 50$ at 60 days, 100$ at 90 days, and 18% interest on the account after 120 days, accruing monthly. Non Sufficient Funds (NSF) checks are subject to a $25.00 fee (in addition to fees from your bank). Collections Charge: Accounts that are not paid within 120 days from due date may be sent to an External Collection agency and reported to the Credit Bureau. In addition to your outstanding balance, a 33% surcharge may be added to cover our costs. In addition, you may be removed from the practice.

Lab Charges: Depending on your insurance, you may get a separate bill from the lab facility that performs your lab work. These charges should be discussed directly with the Lab facility. Please understand that we do not have knowledge of what labs your insurance will and will not cover or at what cost. It is your responsibility to discover this information and we are not responsible for any lab costs associated with tests we order. We order the tests we deem appropriate to provide care and you may choose whether or not to have them performed.

Refunds: Patient Refunds are processed on the last Friday of the month. Any account that has outstanding claims will not be eligible for a refund.

I certify that I have read and understand this financial policy and that I have had the opportunity to ask questions and all questions have been answered.

Signature- I have read and agree to the Financial Policy *

Date *

Submit

Scottsdale, AZ

Wombkeepers OB/GYN and Midwifery
Maternity Wellness and Birthing Center

16700 N. Thompson Peak Pkwy Unit 130 Scottsdale AZ 85255

Phone: 480-256-8424

Fax: 480-546-5433

staff@wombkeepers.com

montclair, nj

One Oak Medical- Wombkeepers OB/GYN

109 Valley Rd. Montclair NJ 07042

Phone: 973-655-9662

Fax: 973-655-9665

wombkeepers@oneoakmedical.com

Please note these locations are under separate ownership and management. Please direct any questions and requests to the appropriate location.

New Patient FormPlease fill out completely, the more information we have, the better we can care for you.

Wombkeepers Scottsdale New Patient Information Form

​Personal Information

Emergency Contact

Employment Information

​Insurance Information

​Secondary Insurance

​Other

Patient Health Information

Gynecologic History

Obstetrics History

Miscarriages

Termination of pregnancy

Vaginal and Cesarean Deliveries

Delivery #1

Delivery #2

Delivery #3

Any other deliveries:

​General Medical History

​Social History

Family History

Review of Symptoms

ADDITIONAL QUESTIONS FOR PREGNANT PATIENTS or PRECONCEPTION CONSULTS ONLY

HIPAA and Privacy Information

​HIPAA ACKNOWLEDGEMENT

Financial Policy

Scottsdale, AZ

montclair, nj

New Patient Form
Please fill out completely, the more information we have, the better we can care for you.

Personal Information

Insurance Information

Secondary Insurance

Other

General Medical History

Social History

HIPAA ACKNOWLEDGEMENT