Name (Last, First, Middle) SSN#
Spouse/Parent/Guardian Name (If under age 18): Employer
Date of Birth:
Primary Insurance Company: Secondary Insurance:
Address: Address:
City, State, Zip Code: City, State, Zip Code:
Phone: Co-Pay: Phone: Co-Pay:
Insured Party ID# Insured Party ID#
Group ID# Group ID#
Name of Insured: Name of Insured:
Sex: Date of Birth: Sex: Date of Birth:
SSN of Subscriber: SSN of Subscriber:
Relationship to Patient:
*** Payment is due at time of service. ***
Relationship to Patient: Address
Age Marital Status
City, State Maiden Name Zip Code Address Business Phone City, State Alternative Phone Zip Code
Relationship (Parent, Spouse, Guardian) Patient Home Phone
In case of Emergency:
Patient Cell Phone Patient E-mail
Phone:
Patient Business Phone Patient Occupation
Do you have a living will? Y N Who referred you to our practice? Business Address
Patient’s Signature: Date:
City, State Zip Code
Assignment and Release; I, the undersigned certify that I (or my dependent) have insurance coverage as stated above and assign to Elite Women’s Health, Inc., all insurance benefits, if any, otherwise payable to me for services rendered, I understand that I am fully responsible for all charges not paid by my insurance company. I hereby authorize this practice to release all information necessary to secure the payment of benefits, I authorize the use of this signature on all submissions. I fully understand that any outside lab work performed will be billed by that lab, independently.
Patient Registration Form
Name:
Reason for Visit:
Past Medical History (please check all those that apply)
Blood Clots
Abnormal Pap Smear
Date of Last :
Epilepsy
Abnormal Mammogram
Pap :
Hypertension
Breast cancer
Mammo :
Osteoporosis
Bone Density :
Colonoscopy :
Past Surgical History (please list all past surgeries)
_____________
Medications (please list all medications you are currently on)
Pharmacy Name and Phone #:
Allergies
Do you have drug allergies? No
Yes, please list
Other allergies:
Family History (check all those that apply, if yes, explain)
Cancer
Heart Disease
Diabetes
Other
Reproductive History
Date of Last Menstrual Period:
Age at First Menstrual Period:
If menstrual period has stopped, age of last period:
Sexually Active:
Type of Contraception:
Are your periods regular? Yes
• No, Please Explain
Do you experience clots while menstruating? No
• Yes, Please Explain
Do you have problems with break through bleeding? No
• Yes, Please Explain
Are you on Hormone Replacement Therapy? Yes
No
P
ATIENT
H
ISTORY
F
ORM
Total Pregnancy
Full Term Birth
Premature Birth
Abortions
Miscarriages
Child’s
Name
Date of
Birth
Birth
Weight
Doctor’s
Name
Delivery
Method
Complications
1
2
3
4
5
6
7
Social History
Do you smoke? Y/N If so, packs per day:
Drink?
Use Drugs? ____ Marital Status: ______
Have you experienced depression or domestic violence? Please explain
(Confidentiality is Guranteed)SCREENING QUESTIONNAIRE
Please circle “Yes” or “No”
1. Do you have heavy periods? Yes No
2. Do you have pain with periods? Yes No
3. Do you have pain with intercourse? Yes No
4. Are you interested in permanent contraception? Yes No
5. Do you have fibroids? Yes No
6. Do you ever leak urine? Yes No
7. Do you leak urine with a strong urge on the way to the bathroom? Y / N
8. Do you leak urine when you cough, sneeze, laugh, lift, exercise? Y / N
9. Do you wear pads to protect your clothes from urine leaking? Y / N
10. Do you urinate frequently during the day? Yes No
11. Do you wake up at night to urinate? Yes No
Age of first intercourse: ________
5 or more sexual partners in a lifetime? Yes_______ No_______
Ever had a STD/STI? No _______
• Yes, Please List ___________________________________________________________
Financial Policies
This is an agreement between Elite Women’s Health and the responsible party:
Missed/Cancelled Appointments, procedures or surgeries: All efforts are made to accommodate our patients request for
appointments, procedures or surgery dates/times; therefore, it is important that you make every effort to keep your scheduled appointments. Cancellations of less than 24 hours or missed appointments will be subject to a fee up to $25.00. Cancellations of less than 7 days of procedures or surgeries are subject to a fee of up to $75.00
Fee for completion of forms, reports, and letters: This is a non-insurance covered service; therefore, a fee of $25.00 is charged for
the completion of forms or the writing of letters. All fees are due at the time the form is delivered.
Transferring of Records: All adult patients must sign a record release form if copies of your records are to be sent to another doctor
or organization. A medical records copy fee may be assessed for all non-physician requests and is due at the time the records are delivered.
Payment options if you do not have proof of insurance: You are responsible for payment by cash, check or credit card on the day of
service.
Monthly Statement: If you have a balance on your account exceeding $5.00, we will send you a monthly statement showing charges
to the account: Unless other arrangements are approved in advance, the balance, late fee if any, are due upon receipt. If your account becomes past due, Elite Women’s Health will take all necessary steps to collect this debt. If we have to refer your account to a collection agency or lawyer, you agree to pay all collection, lawyer and court fees that are incurred.
Returned Checks: There is a $25.00 fee for any checks returned by the bank.
Elite Women’s Health files your insurance as a courtesy. We ask that if the account remains unpaid after 45 days that you contact your insurance company for payment.
In consideration for the professional services rendered now and in the future, the undersigned hereby agrees to pay 2% per month on all balances which are unpaid sixty (60) days after the services are rendered: plus attorney’s fees which are hereby stipulated to be 33 1/3% of such outstanding balance whether suit is filed or not: plus court costs. If the undersigned fails to promptly pay for the services rendered, the undersigned authorizes the release by or to any credit reporting agencies of personal credit information of the undersigned and further agrees to pay all costs of obtaining such credit information and/or locating the undersigned, as may be necessary.
The undersigned understands that medical insurance claims may be billed by the provider, as a courtesy, if the provider participates in the patient’s insurance plan; and if the patient promptly furnishes the provider with all the correct insurance information. The undersigned is fully responsible for all sums due whether or not insurance coverage is available.
In the absence of prompt payment: the undersign understands that medical, personal and financial records concerning the professional services will be released to the provider’s attorney for collection. The attorney will act as the provider’s “Business Associate” in compliance with the federal “Health Insurance Portability and Accountability Act:”
I, the undersigned, certify that I ( ) am an active duty member of the US Armed Forces. ( ) am not an active duty member of the US Armed Forces.
___________________ __________________________________ Date Responsible Party
