Patient Registration Form (ecw)

Patient Registration Form (eCW)

PATIENT INFORMATION (Please Print)

Dr. Miss Mr. Mrs. Ms. Sir

Patient’s Name (Last) (First) (MI) Previous Name

Address Line 1

City, State ZIP

Home Phone Cell No. Work Phone Ext.

Primary Care Provider (PCP) Referring Provider

Rendering Provider Name (this practice) E-Mail Address:

Date of Birth MM /DD /YYYY Sex F – Female M - Male Transgender

Race American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American White Hispanic Other Declined Language English Spanish Indian Japanese Chinese Korean French German Russian Other __________ Ethnicity Hispanic or Latino Not Hispanic or Latino Declined

Marital Status Married Single Divorced Widowed Legally Separated Partner

Social Security Number - - Employer Name

Employment Status 1 - Full-Time 2 - Part-Time 3 - Not Employed 4 - Self-Employed 5 - Retired 6 - Active Military Student Status F - Full-Time Student P - Part-Time Student N – Not a Student

Emergency Contact Last Name First Name

Phone Number Do you have a living will? Yes No

Emergency Contact Relationship to Patient Guardian

Address Line 1

City, State ZIP

Home Phone Work Phone _______ ____________ Ext. __________________

Referring Provider Name

RESPONSIBLE PARTY INFORMATION (information used for patient balance statements) Responsible Party Another Patient Guarantor Self Check here if information is same as patient

Responsible Party Name (Last) (First) (MI)

Guarantor Account Number Date of Birth MM /DD /YYYY

Telephone E -Mail Address

PRIMARY INSURANCE INFORMATION (provide your insurance card to the front desk at check-in)

Insurance Company/Phone Number ( )

Name of Insured Patient Relationship to Insured

Subscriber ID (Policy Number) Group ID Copay Amount

Effective Date Termination Date Date of Birth MM /DD /YYYY

SECONDARY INSURANCE INFORMATION (provide your insurance card to the front desk at check-in)

Insurance Company/Phone Number ( )

Name of Insured Patient Relationship to Insured

Subscriber ID (Policy Number) Group ID Copay Amount

Effective Date Termination Date Date of Birth MM /DD /YYYY

PHARMACY

Pharmacy Name / Phone Number ( )

Name: __________________________________________ DOB________________________________

Please list all your current medications: (including over the counter, vitamins/minerals/herbal

supplements)

Medication

Dose

Frequency

Prescribing Dr.

Medical History: (Please check all appropriate columns)

_______ No Known Medical Problems _______ Adopted

You Specific family

member/Age Details/Dates:

Abuse: Domestic, Emotional, Sexual

Alcoholism

Asthma: Adult/Childhood/Exercise

Birth Defects

Blood Clots in Legs or Lungs

Blood Transfusion

Breast Problems (specify)

Cancer

Ovarian

Breast

Colon

Other (specify)

Depression

Diabetes

Heart Disease

Hepatitis

High Blood Pressure

High Cholesterol

Kidney Problems

Liver Disease

Lupus

Osteoporosis

Seizures

Stomach/Bowel/Gall Bladder Problems

Stroke

Thyroid Disorder

Do you have any medical allergies? Y/N (please specify drug and reaction)

Drug:

Reaction:

Latex? Y/N

Iodine? Y/N

Penicillin? Y/N

Sulfa? Y/N

Other?

Other?

Gynecologic History

Have you ever had a mammogram?

Y/N Most recent _____________ Normal/Abnormal?

Do you do monthly self breast exams?

_____yes _____no

When was your last pap test?

____/____/____

Have you ever had an abnormal pap test?

______no yes: date/result _______________

What was your treatment? ___LEEP ___Cone Biopsy ___Other

Have you ever had a sexually transmitted disease?

___herpes ___genital warts ___trichomoniasis ___chlamydia ___gonorrhea

Have you ever had a bone density scan?

____/____/____ Result:

Have you ever had a colonoscopy?

_____no _____yes when/result__________________

Menstrual and Sexual History

How old were you when you first began menstruating?

_____________years old

What was the first day of your last period?

_____/_____/_____

How many days pass between the first day of each period?

_____________days pass

How long do your periods last?

_____________days long

On your heaviest day how many pads/tampons do you use?

______pads and/or ______tampons

How do you rate your menstrual pain?

____mild ____moderate ____severe

How do you treat your pain?

Have you ever had sex?

_____yes _____no

Are you currently in a sexual relationship?

_____yes _____no

Your sexual preference is:

_____men _____women _____both

Have had any new partners since your last visit?

_____yes _____no

What do you use to prevent pregnancy?

(specify)

How old were you when you went through menopause? ______________years old

Did you have a hysterectomy?

_____yes _____no

If yes, when?

______________years old

Why was this done?

(specify)

Do you still have your ovaries?

_____yes _____no

Pregnancy History

How many times have you been pregnant?

____________

How many times have you given birth?

____________

Have you ever been treated for post-partum depression? Y/N

Did you have any complications with your pregnancies?

Y/N

(specify)

Please list all of your pregnancy outcomes:

Date:

M/F

Weight

# of weeks

Delivery type Epidural?

Notes:

Surgical History:

Date/Details:

Date/Details:

Laparoscopy

Breast Surgery

C-Section

Bowel Surgery

Tubes Tied

Cosmetic

Gallbladder

Other (Specify)

Appendix

Social History:

Do you smoke? Y/N ______packs/day or ______c/day How long? ________________

Do you drink alcohol? Y/N ___________ drinks/week

Do you use recreational drugs?

______Marijuana _______ Cocaine/Crack _______ Heroin _________________________Other

Do you drink caffeine? Y/N ________drinks/day

Are you experiencing any of the following symptoms as an ongoing problem?

None

Fever

Chills

Night Sweats

Unexplained weight gain

Skin Changes

Excessive Hair Loss

Difficulty Sleeping

Fatigue

Anxiety

Depression

Diarrhea

Constipation

Painful Urination

Leaking Urine

Urinary Frequency

Bloody Stool

Swelling

Muscle Weakness

Genital Sores

Unexplained Rash

Breast Tenderness

Vaginal Discharge

Shortness of Breath

Chest Pain

Change in Appetite

Nausea

Vomiting

Heavy Periods

Menstrual Pain

Irregular Periods

Print Patient Name

Insurance Coverage of Ultrasounds

I have read and understand the information regarding my financial responsibility for associated ultrasound costs if not covered by my insurance.

______________________________________ _______________

Patient Signature Date

Consent for Cystic Fibrosis Carrier Blood Test

I have read and understand the information regarding cystic fibrosis carrier blood testing, and accept financial responsibility for any associated costs that are not covered by my insurance. Initial One: _____I CONSENT to the CF Carrier Testing ______ I DECLINE to the CF Carrier Testing

______________________________________ _______________

Patient Signature Date

Consent for Genetic Screening

I have read and understand the information regarding Nuchal Translucency and Blood Testing. I also accept financial responsibility for any associated costs that are not covered by my insurance. Initial One:

_____I CONSENT to the Nuchal Translucency _____ I DECLINE to the Nuchal Translucency and Blood Testing. and Blood Testing

______________________________________ _______________

Patient Signature Date

Please circle one:

YES NO Will you be 35 years or older at your due date?

YES NO Have you had alcohol (beer,wine,liquor) during your pregnancy?

YES NO Have you used any drugs (cocaine, marijuana, etc) during your pregnancy? If so what:___________________________________________________ YES NO During your pregnancy have you taken Acutance or epilepsy medication? YES NO During your pregnancy have you taken blood thinners or Lithium? YES NO Have you had radiation therapy or chemotherapy since your last period? YES NO Are you diabetic?

YES NO Are you and your partner related in any way (other than marriage)? YES NO Do you or your partner have a history of genital herpes?

YES NO Do you or your partner have a history of HIV or Hepatitis B or C?

YES NO Have you taken any medications (prescription or OTC) during your pregnancy? If so what:______________________________________________________

Have you OR your partner, OR anyone in either family ever had:

(please answer in all three columns)

MYSELF PARTNER EITHER FAMILY A child with Down Syndrome or other chromosome problems? Y N Y N Y N A child with mental retardation? Y N Y N Y N Open Spine (Spina Bifida), skull defect or Anencephaly? Y N Y N Y N Heart defect? Y N Y N Y N Muscle or neuromuscular disease (Muscular Dystrophy)? Y N Y N Y N A stillborn baby? Y N Y N Y N A baby that died shortly after birth or within the first year? Y N Y N Y N Cystic Fibrosis? Y N Y N Y N Hemophilia, Sickle Cell, Thalassemia, or other blood disorder? Y N Y N Y N Any birth defect or genetic disorder? Y N Y N Y N

Lara Lane, MD

10099 Ridge Gate Parkway Suite 280

Lone Tree, Co 80124

Phone: 303.325.2185

Fax: 303.790.0938

www.womenscareco.com

Lara Lane MD

10099 Ridge Gate Parkway Suite 280 Lone Tree, Co 80124 Phone: 303.325.2185 Fax: 303.790.0938 www.womescareco.com Lara Lane, MD

Juliet Leman DO

Patient Record of Disclosures

Patient Name (PLEASE PRINT)_________________________ DOB ______________________________

I wish to be contacted in the following manner (Check all that apply)

Home Phone _____________________________ Written Communication

O.K. to leave message with detailed information O.K. to mail to my home address Leave message with call-back number only O.K. to mail to my work/office address

O.K. to fax to this number

Work Telephone ___________________________ Cell Phone ______________________________ O.K. to leave message with detailed information O.K. to leave message with detailed information Leave message with call-back number only Leave message with call-back number only Other (Spouse, Children, Etc)

______________________________________________ ______________________________________________ ______________________________________________

_________________________________________________________ ______________________________________________

Patient Signature Date

_________________________________________________________ ______________________________________________

Print Name Birthdate

In general, the HIPAA privacy rules give individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by an alternate means, such as sending correspondence to the individuals office instead of the individuals home.

10099 Ridge Gate Parkway Suite 280 Lone Tree, Co 80124 Phone: 303.325.2185 Fax: 303.790.0938 www.womescareco.com Lara Lane, MD

Juliet Leman DO

HIPAA

Patient Name: _______________________________________________ DOB: ______________________________________ ______ (Patient initials) Notice of Privacy Practices. I acknowledge that I have received the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the Privacy Officer designated on the notice if I have a question or complaint. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.

______ (Patient initials) Release of Information. I hereby permit practice and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations.

• Healthcare information regarding a prior admission(s) at other HCA affiliated facilities may be made available to subsequent HCA-affiliated admitting facilities to coordinate Patient care or for case management purposes. Healthcare information may be released to any person or entity liable for payment on the Patient’s behalf in order to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer’s designee when the services delivered are related to a claim under worker’s

compensation.

• If I am covered by Medicare or Medicaid, I authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operative reports, physician progress notes, nurse’s notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.

• Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my

information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.

Disclosures to Friends and/or Family Members

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM YOU ALLOW TO PICK UP YOUR PRESCRIPTION OR THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM?”

I give permission to the follow people to pick up prescriptions from Lone Tree Woman’s Care on my behalf. Also the follow people have access to my Protected Health Information (PHI) to be disclosed for purposes of communicating results, findings, care decisions &/or billing concerns to the family members &/or other individual listed below. I fully understand this consent will remain valid until revoked.

Name Relationship Contact Number

10099 Ridge Gate Parkway Suite 280 Lone Tree, Co 80124 Phone: 303.325.2185 Fax: 303.790.0938 www.womescareco.com Lara Lane, MD

Juliet Leman DO

HIPAA

Consent to Email or Text Usage for Appointment Reminders and Other Healthcare Communications:

Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information.

If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from the Practice.

______ (Patient initials) I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing (see revocation section below).

The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is______________________________. 000 - 0000.

The email that I authorize to receive email messages for appointment reminders and general health reminders/feedback/information is______________________________.

The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

Revocation

I hereby revoke my request for future communications via email and/or text.

__I hereby revoke my request to receive any future appointment reminders, feedback, and general health via text messages.

__ I hereby revoke my request to receive any future appointment reminders, feedback, and general health via email. NOTE: This revocation only applies to communications from this Practice.

Patient Name: ________________________________________________________

Patient/Patient Representative Signature: _______________________________________________ Date: _____________________________ Time: ____________________

Consent for Photographing or Other Recording for Security and/or Health Care Operations

____ (Patient Initials) I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice’s health care operations purposes (e.g., quality improvement activities). I understand that the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or

recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used without a specific written authorization from me or my legal representative unless it is for treatment, payment or health care operations purposes or otherwise permitted or required by law.

____ (Patient Initials) I do not consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice’s health care operations purposes (e.g., quality improvement activities).

10099 Ridge Gate Parkway Suite 280 Lone Tree, Co 80124 Phone: 303.325.2185 Fax: 303.790.0938 www.womenscareco.com Lara Lane MD

Juliet Leman DO

Patient Responsibilities

Patient Name: ___________________________________ DOB:_______

I, the undersigned, in consideration for services being rendered by

Women's Care of Colorado

, understand and agree

to the following:

1. I understand that payment for co-pays, deductibles, coinsurance and account balances are payable at the time

of service.

2. I hereby authorize

Women's Care of Colorado

to file a claim with my insurance carrier and I authorize payment

for

medical services to

Women's Care of Colorado

.

3. I have read and understand the Notice of Privacy Practices. I give my consent to use and disclose my protected

health information to carry out treatment, payment activities and health care operations.

4. I authorize release of any and all medical records and information necessary for continuation of care and for

processing any claims associated with services I receive in this office.

5. I understand that my insurance benefits and referral requirements are my responsibility.

Women's Care of

C

olordao

will assist me in any area possible, but ultimately, I am responsible to understand my benefits and

obtain

any referrals necessary.

6. I will inform

Women's Care of Colorado

anytime my personal information or insurance coverage has changed.

7. I will keep my account balance current. In the event I fail to pay my account balance.

8. I understand

Women's Care of Colorado

reserves the right to not continue care due to excessive late arrivals to

appointment or “no-show” to scheduled appointments. It is important to cancel within twenty-four hours of

your scheduled appointment.

My signature below indicates I agree to all the terms set above.

________________________________________ _____________

*If this consent is signed by a personal representative on behalf of the patient, complete the following:

_______________________________________________________________

Personal Representative’s Name

_______________________________________________________________