Please bring your insurance card and photo identification with you when you check in for your appointment for all visits.

7625 Maple Lawn Boulevard, Suite 1 Midtown Medical Center Fulton, MD 20759 Voice: 410·531·7557 Fax: 410·531·0818

Dear Patient,

Enclosed are the forms to which we referred when we made your upcoming

appointment. To help make your visit go as smoothly as possible, we ask that you

complete them (front and back, where applicable) and mail them back to us as

soon as possible or fax them to us at 410-531-0818. Also, please enclose a copy of

your insurance card, front and back if possible. Please arrive 15 minutes before

your appointment time to review this documentation once it is in our system.

If you are unable to mail or fax these forms along with a copy of your insurance

card, you must arrive 30 minutes prior to your scheduled appointment time with

your completed forms, and present them upon arrival.

If you are unable to complete the enclosed forms in advance, you must arrive 45

minutes prior to your appointment time and please make our staff aware, when

you check in, that you need assistance.

Please be aware that if you are unable to arrive in a timely manner we may need

to reschedule your appointment and that Capital Women’s Care may impose a

no-show fee of $35.00 for appointments not cancelled 24 hours in advance.

Please bring your insurance card and photo identification with you when you

check in for your appointment for all visits.

We thank you for your understanding and cooperation. There are a number of

steps to the check-in process and when our new patients follow the instructions

above it contributes to our efforts to keep the appointments for all our patients on

time. We look forward to seeing you at your upcoming appointment. For your

convenience, we have enclosed directions to our office on the following page.

Sincerely,

The Providers and Staff at

Capital Women’s Care

Christine P. Richards, MD, FACOG, FRCS(C) • Marvin P. Davis, MD, FACOG • Mark A. Esposito, MD, FACOG • Michelle R. Seavey, MD, FACOG Nicole D. Pilevsky, MD, FACOG • Laura A. Burnham, CRNP • Beverly Carrigan, Practice Administrator

We are located at 7625 Maple Lawn Boulevard, Suite #1, Maple Lawn, MD, 20759,

just south of Johns Hopkins APL campus and closer to Howard County General

Hospital than our previous location. Also, unlike our previous location, there is

ample parking at the rear of the building.

Please note that we are in a relatively new community and some GPS units may

list our address as Fulton.

To reach our office from Howard County General Hospital:

Exit the hospital parking lot turning left to southbound Cedar Lane. Cedar

Lane turns left slightly past route 32 and becomes Sanner Road. Follow

Sanner to the next traffic light and continue straight on Maple Lawn

Boulevard. At the first traffic circle, our offices are in the building on your

left.

To reach our office from points north and east of Route 29:

Take Route 29 south. Take exit 15 for Johns Hopkins Road toward Gorman

Road. Turn right onto Johns Hopkins Road. Turn left at Maple Lawn

Boulevard, the first traffic light west of the APL campus. Go south on Maple

Lawn Boulevard and at the first traffic circle, our offices are in the building

on your left.

From points west:

Take Route 32 east to Sanner Road, the first exit past 108. Turn right at the

bottom of the ramp and follow Sanner Road. Sanner becomes Maple Lawn

Boulevard south just past APL.

Alternatively stay on 32 to 29 south. Take exit 15 for Johns Hopkins Road

toward Gorman Road. Turn right onto Johns Hopkins Road and turn left at

Maple Lawn Boulevard.

When you're on Maple Lawn Boulevard south, our offices are on your left at

the first traffic circle.

From points south:

Head north on 29 and take the Route 216 West exit. At the end of the ramp,

keep right and turn right onto 216 West/Scaggsville Road. At the first traffic

circle, continue straight to stay on 216 West. At the second traffic circle,

take the first exit onto Maple Lawn Boulevard. This is the Downtown area

and we are located in the residential Midtown area.

At the first traffic circle on Maple Lawn, take the second exit and stay on

Maple Lawn Boulevard. Our offices are in the building to your right just

before the next traffic circle.

REV. 12/14

Christine P. Richards, MD, FACOG, FRCS(C) • Marvin P. Davis, MD, FACOG • Mark A. Esposito, MD, FACOG • Michelle R. Seavey, MD, FACOG Nicole D. Pilevsky, MD, FACOG • Laura A. Burnham, CRNP • Beverly Carrigan, Practice Administrator

CAPITAL WOMEN'S CARE, LLC.

Please update the information below, sign the form, and return the form to the front desk. Thank you. Patient Information

Today's Date: Account N b

Referring Physician:

Name: Marital Status: Gender: Date of Birth: Social Security #:

Address: City,State, Zip:

HOME MSG YES CELLULAR MSG YES Ext:

GUARANTOR/FINANCIALLY RESPONSIBLE PARTY

Guarantor Name: Phone 1:

Address: Phone 2:

Employer: Employer Address:

Insurance Company: ID #: Group #:

Policy Holder's Name:

City, State, Zip: Phone:

Address:

Policy Holder's Date of Birth: Policy Holder'sSocial Security #:

Policy Holder's Employer: Patient's Relation to Policy Holder: Insurance Effective Date:

Insurance Company: ID #: Group #:

Address: City, State, Zip: Phone:

Policy Holder's Name: Policy Holder's Date of Birth: Policy Holder's Social Security #:

Policy Holder's Employer: Patient's Relation to Policy Holder: Insurance Effective Date:

City, State, Zip: APT #:

SECONDARY INSURANCE INFORMATION Please note, insurance companies require you to notify them if you have other insurance. If they do not have this information in their system, they will not pay the claim for this visit.

Occupation: Appt Info:

PERSONAL REPRESENTATIVE AUTHORIZED TO ACCESS PROTECTED HEALTH INFORMATION

Name: Phone#: Name2: Phone#:

I certify that the information I have provided regarding my insurance coverage is correct and I authorize Capital Women's Care to verify insurance coverage and benefits allowed in accordence with my insurance plan's coverage.

I authorize that payments be made directly to Capital Women's Care for all medical insurance benefits which are payable under the terms of my insurance policy for services provided. I agree to pay any copayment, coinsurance, or deductible as required by my insurance for medical care provided to me or my dependant. I understand that I am responsible for knowing the terms and regulations of my insurance plan.

Capital Women's Care may impose a no-show fee of $35.00 for appointments not cancelled 24-hours in advance. Capital Women's Care may impose reasonable interest, late charges, direct collection costs( 25% ) and or reasonable attorney's fees should my account become delinquent. There will be a $40.00 fee assessed for all returned checks.

I hereby authorize Capital Women's Care to submit a claim and a copy of medical records related to such services, to my insurance company, health and welfare fund, Medicare or Medicaid for medical services provided to me or my dependant. I also authorize Capital Women's Care to provide a copy of this release and a copy of medical records related to such services if requested by the payor. Further, I authorize Capital Women's Care to release medical information to my consulting or primary physician to assit with continuity of care. This release will expire one year from the date of my signature below, unless I cancel this release in writing prior to that date.

1. Financial Responsibility: 3. Release of Medical Information for Billing:

4. Receipt of Privacy Notice:

2. Payment in full at time of service: 5. Non-Covered Services:

I have been given the opportunity to review the Capital Women's Care Notice of Privacy Practices which provides a detailed description of how my Protected Health Information (PHI) is used and disclosed.

I understand that if Capital Women's Care does not participate with my insurance or I do not have insurance, payment is due in full at the time of service

I agree to pay for medical services provided to me or my dependant which are not covered by the benefits in my insurance plan.

I AGREE TO THE ABOVE STATED CONSENT

Signature of Patient or Legal Guardian: Date:

Date of Birth: Social Security #:

CAPITAL WOMEN'S CARE, LLC.

Please update the information below, sign the form, and return the form to the front desk. Thank you.

Patient Information

Today's Date:

Name: Account Number:

Patient Medications ( please include the dosage for each medication ) Patient Allergies ( please include your reaction to each allergy )

Patient Preferred Pharmacy Pharmacy Name:

Street Address: City, State Zipcode: Pharmacy Phone#: n o it c a e R n e g r e ll A e g a s o D s n o it a c i d e M Email Communications

Capital Women’s Care physicians are dedicated to helping our patient’s live healthy lifestyles. Your physician would like the opportunity to send patients reminders about preventative health services - such as well women exams - or other information that may assist our patients in living a healthy lifestyle. Also, there may be other messages we would like to send our patients, such as the announcement of new physicians or contract changes with insurance companies.

Capital Women's Care makes this commitment to our patients about the collection of e-mail information. 1. They will be for Capital Women’s Care use only. They will not be given or sold to any other entity.

2. The patient’s privacy will be protected. The e-mail address will not be used to communicate any personal health information or in any manner inconsistent with the Health Insurance Portability and Accountability Act (HIPAA).

Our e-mailing to our patients will be one way communications and, therefore, will not allow for conversations between the patient and physician/staff. All Health related questions should continue to be addressed to the appropriate Capital Women’s Care staff. Additional comments and questions should be directed to the Capital Women's Care Compliance Officer at privacy@cwcare.net<mailto:privacy@cwcare.net> or (301) 340-8339, ext. 201. Patient Name: (printed) ____________________________________________________

E-Mail Address: ____________________________________________________ Patient Signature: ____________________________________________________ Date: ____________________________________________________

How did you learn about our practice? Patient Referral Other Referral Website / Internet Advertising / Radio / TV Other:

Patient Race and Ethnicity ( please circle your responses )

Ethnicity: Race:

Hispanic/Latino OR Not Hispanic/Latino

7625 Maple Lawn Boulevard, Suite 1 Midtown Medical Center Maple Lawn, MD 20759 Voice: 410·531·7557 Fax: 410·531·0818

Use and Disclosure of Protected Health Information

 Page 1 of 2

Section I: PATIENT ACKNOWLEDGEMENT & CONSENT FORM

The educational pamphlet entitled "Notice of Privacy Practices" provides information about how Capital Women's Care, LLC may use and disclose protected health information about you, and is compliant with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our Notice of Privacy Practices states that we reserve the right to change terms described. Should this happen we will display the new policy and effective date at each Capital Women's Care Location.

You have the right to request restrictions on how your protected health information may be used or disclosed for treatment, payment, or health care operations. We are not required to agree with your restrictions; but if we do, we are

bound by our agreement with you. By signing below, you acknowledge receipt of our Notice of Privacy Practices.

___________________________________________________________ Patient’s Signature Date

___________________________________________________________ Print Full Name

Section II: CONSENT FOR USE AND DISCLOSURE OF INFORMATION

By signing below, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this consent, in writing, except where we have already made disclosures in trust on your prior consent.

I request that payment of authorized Medicare/Insurance carrier benefits be made on my behalf to Capital Women's Care, LLC for any services furnished to me by my physician. I authorize any holder of medical information about me to release to the Centers for Medicare/Medicaid Services and its agent and/or any other Insurance Carriers for which I have coverage, any in formation needed to determine these benefits or the benefits for related services. I agree to provide all reference and treatment plan(s) as required by my insurance carrier(s). All co-pays must be paid at the time of service in accordance with the contracted Insurance Carrier agreements.

___________________________________________________________ Patient’s Signature Date

___________________________________________________________ Print Full Name

Section III (Optional):

PERSONAL REPRESENTATIVE, FAMILY OR OTHER ENTITIES AUTHORIZED ACCESS

TO PROTECTED HEALTH INFORMATION TO BE USED AND/OR DISCLOSED

Name or specifically identify these persons and/or other entities you are authorizing to make use of and/or to disclose your protected health information regarding treatment, payment and other healthcare operations.

_____________________________________________________________________________ Name of Authorized Person or Entity Relationship Phone #

_____________________________________________________________________________ Name of Authorized Person or Entity Relationship Phone #

 Page 2 of 2

Section IV: AUTHORIZATION FOR USE OF ANSWERING MACHINE AND/OR VOICE MAIL

Capital Women's Care physicians and healthcare staff routinely are unable to contact patients directly during normal business hours. On these occasions our offices leave messages on communication devices provided by our patients. Due to the new federally mandated HIPAA Privacy Rule we must obtain your authorization to continue this mode of communication.

Protected Health care Information that we may possibly disclose on your home, work, or cell phone would include, but is not limited to: test/lab results, prescription/pharmacy information, appointment instructions for visits and procedures, and surgical posting/scheduling information.

_____ (Initial) Yes, I agree to allow Capital Women's Care physicians and healthcare staff to leave messages that include Protected Healthcare Information on all three communication devices: home, work and cell phone.

_____ (Initial) I agree to allow Capital Women's Care physicians and healthcare staff to leave messages that include Protected Healthcare Information on the following: Please initial next to the applicable communication devices: ______ home number, ______ work number or ______cell number.

_____ (Initial) No, I do not agree to allow Capital Women's Care physicians and healthcare staff to leave messages that include Protected Healthcare Information on my home, work and cell phone.

___________________________________________________________ Patient’s Signature Date

FOR OFFICE USE ONLY

Section V: UNABLE TO OBTAIN NOTICE RECEIPT ACKNOWLEDGEMENT

Option 1: I could not obtain a signed Notice Receipt Acknowledgement from the patient for the following reason: ____________________________________________________________________________________ ____________________________________________________________________________________

Option 2: I attempted to obtain a signed Notice Receipt Acknowledgement from the patient on ____/___/___, but was unable for the following reason:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

CWC Employee Signature ___________________________________ Date ________________________________

FOR MORE INFORMATION OR TO REPORT A PROBLEM: If you have questions or would like additional information, please

contact the HIPAA Policy Officer for this practice. If you believe your privacy rights have been violated, you may file a written complaint with the Secretary of Health and Human Services. There will be no retaliation for filing a complaint.

Age: Marital Status: Occupation: Primary Care Provider: Reason for your visit today:

Current Contraception:  None  Natural Family Planning  Diaphragm  Condoms  Birth Control Pills - Brand:

 Contraceptive Gel/Foam  Patch  Nuvaring®  DepoProvera®  IUD

 Tubal Ligation  Essure®  Nexplanon®  Implanon®  Vasectomy

If Postmenopausal, are you on Hormone Replacement Therapy?  Yes  No Have you ever been on HRT?  Yes  No

Medication Allergies:  None 

List all prescription medications you are currently using:  None 

List all non-prescription medications or supplements you are currently using:  None 

What was the first day of your last menstrual period? When was your last mammogram?

Do you perform breast self-exams monthly? ...  Yes  No When was your last PAP test?

Do you have a history of Sexually Transmitted Disease? ...  Yes  No Have you had 5 or more sexual partners? ...  Yes  No Was your age at first intercourse under 16? ...  Yes  No Were you exposed to DES before your birth? ...  Yes  No

Do you exercise regularly? ...  Yes  No Do you use seat belts? ...  Yes  No Do you smoke? ...  Yes  No How much?

Do you drink alcohol? ...  Yes  No How much & how often?

Do you use any recreational drugs? ...  Yes  No What & how often?

Have you ever had an abnormal PAP smear? ...  Yes  No Surgeries or Hospitalizations:  None

Type of surgery or reason for hospitalization Date Doctor Hospital or Facility

Pregnancies (include losses and terminations)

Year Male/Female Weight Vaginal or Section Complications

Do you have or have you ever had…

Yes No Yes No Yes No Yes No

Diabetes   High blood pressure   Chronic lung condition   Osteoporosis  

Asthma   Mitral valve prolapse   Alcohol abuse   High cholesterol  

Stroke   Seizures/Epilepsy   Drug/substance abuse   Rheumatic fever  

Ulcers   Tuberculosis   Hepatitis/liver disorder/Jaundice   Blood transfusion   Heart disease   Bowel trouble   Blood clots in legs/lung/heart   Transfusion reactions  

Chronic anemia   Kidney stones   Autoimmune diseases (lupus, etc.)   Anesthetic reactions   Thyroid disorder   Bleeding disorder   Depression, anxiety   Eating disorder  

Cancer  Yes  No If yes, Type, Date and Treatment: Other disease?

Please list any major illnesses that have occurred in your family. Is there a family history of…

Yes No Yes No Yes No Yes No

Breast Cancer   Thyroid disorder   Osteoporosis   Stroke   Ovarian Cancer   Coronary artery disease   Diabetes   High blood pressure  

Colon Cancer   High cholesterol   Other: REV. 12/14

P

ATIENT

H

ISTORY

F

ORM

Thank  you  for  scheduling  your  well  woman  exam  today.    A  “well  woman  exam”  is  

considered  a  preventative  or  wellness  visit.  This  visit  will  address  preventative  health  only  

and  is  not  meant  to  diagnose  or  treat  problems.    

If  your  provider  addresses  and/or  treats  other  health  issues  at  this  visit  that  are  new  or  

chronic  in  nature  instead  of  scheduling  you  for  a  follow  up  or  sick  visit,  your  health  

insurance  company  may  assess  an  additional  patient  liability  for  those  services.    Although  

most  insurance  plans  include  benefits  for  one  preventative  health  visit,  some  do  not.  If  

you  have  any  doubts,  please  check  with  your  insurance  plan.  

If  you  need  further  explanation  about  incurring  additional  fees  for  services  provided  

during  your  visit  today,  please  discuss  your  concerns  with  your  provider.  

I  acknowledge  that  I  have  read  this  notice  prior  to  being  seen  and  I  understand  that  

depending  on  the  issues  addressed  or  treated  during  today’s  visit,  additional  charges  may  

apply.