Patient Registration
Date:
PATIENT INFORMATION
Social Security # ___________________________ Home Address ____________________________
First Name _________________ Middle ________ P.O. Box _________________________________
Last Name ________________________________ City ________________ State ____ Zip _______
Sex ______ Date of Birth ____/____/_____ Referring Physician ________________________
Marital Status __ Married __Single Home Phone ( )_________________________ __ Divorced __ Widowed Work Phone ( )_________________________ Cell Phone ( )_________________________ (Check one) __ Employed __ Retired __ Full Time Student
Employer Address ___________________________
Employer _________________________________
City ______________ State ____Zip _______
Emergency Contact
First Name ____________________ Int. ____ Sex ______ Relationship _____________________
Last Name ____________________________ Home Phone ( )_________________________
Work Phone ( ) ______________________ Cell Phone ( )____________________________ Spouse / Guarantor / Responsible Party
Social Security # ___________________________ Sex ____ Date of Birth ____/_____/_____
First Name ___________________ Int. ________ Last Name ____________________________
Employer ______________________________ Work Phone ( )________________________
Employer Address City State Zip
Authorization to pay benefits to physician: I hereby authorize payment directly To the Physician of the surgical and/ Medical Benefits. If any otherwise payable
To me for his/her services as described, realizing I am responsible to pay non- ________________________________________ Covered services. Signature (Patient or Parent if Minor) Date _________________________________________________________________________________________________________________________ Authorization to release information: I hereby authorize the Physician to release
any information acquired in the course of my treatment necessary to process ________________________________________
INSURANCE INFORMATION
INSURANCE (9(Circle One) Commercial Medicaid Medicare Other None ____- THIS SECTION MUST BE FILLED OUT COMPLETELY OR INSURANCE CANNOT BE BILLED Insurance Company Plan Name ____________________________ Primary ___ Secondary ___
Policy Holder Relationship Social Security # Date of Birth / / Spouse / / Parent / / Self / / Other
________________________________ ____________________ ______________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I.D. Number Group No. Co-Pay Insured’s Employer
_____________________ ________________ ________ ________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Insurance Company Plan Name ____________________________ Primary ___ Secondary ___
Policy Holder Relationship Social Security # Date of Birth / / Spouse / / Parent / / Self / / Other
________________________________ ____________________ ______________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I.D. Number Group No. Co-Pay Insured’s Employer
_____________________ ________________ ________ ________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
INSURANCE AUTHORIZATION AND ASSIGNMENT
I hereby authorize ALPINE WOMENS HEALTH to furnish information to insurance carriers concerning my illness and treatments and I hereby assign to the physician(s) all payments for medical services rendered to myself or my dependents, I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE.
Alpine Women’s Health
645 N. Arlington Ave., Ste. 340 Reno, NV 89503
Phone: 775-827-0777 Fax: 775-322-5744 Financial Agreement
Date: _____________________
This is a formal agreement between the patient ____________________________ and Alpine Women’s Health for the payment of Gynecological or Obstetrical care.
I understand that it is my responsibility to know and understand my
insurance coverage and to pay my co-payments at the time of service. I
certify that the insurance presented today is in effect and that I am in good standing with them. Int: ___________I understand that I will not be seen if I do not pay my co-payment at the time of service. Int: __________
I will inform the office staff of any changes in my insurance or demographics. Int: ____
FEES FOR LAB WORK, HOSPITAL STAYS, ASSISTANT SURGEONS AND SOME RADIOLOGY SERVICES ARE BILLED BY THEM AND ARE NOT THE
RESPONSIBILITY OF THE PHYSICIAN.
IT IS YOUR RESPONSIBILITY TO INFORM US WHAT HOSPITAL, LAB AND RADIOLOGY GROUP IS CONTRACTED WITH YOUR INSURANCE.
The office policy has been explained to me, and I understand and acknowledge that I am responsible for all fees whether or not they are paid by my insurance company.
Patient’s Signature: ______________________________ Date: ____________
************************************************************************ ****IF YOU ARE UNABLE TO MAKE YOUR PAYMENT, WE WILL
WITHDRAW YOU FROM FURTHER PROFESSIONAL SERVICES.
I owe Alpine Women’s Health $ ___________
I would like to set up a monthly installment of $ _____ to be applied to a deposit of $ _________ which is to be paid in full by ____________.
Patient’s Signature: ________________________________________ Date: _________ Office Signature: __________________________________________ Date: __________
Alpine Women's Health
645 N. Arlington, Ste. 340 Reno, NV 89503
Phone: 775-827-0777 Fax: 775-322-5744
Informed Consent Regarding PAP and HPV Testing
Routine PAP tests are performed annually. The PAP test is a procedure in which the doctor collects cells from the cervix and sends the sample to either LabCorp or Quest.
If the PAP results are inconclusive—meaning they don’t look clearly abnormal, but they aren’t clearly normal either—the doctor will automatically ask the lab to test the cervical cells for high-risk HPV.
Women over the age of 30 will automatically be tested for HPV in compliance with the American College of Obstetricians and Gynecologist’s protocol.
HPV, also called Human Papillomavirus, is a sexually transmitted virus which can lead to cervical cancer. A persistent HPV infection places the patient at an increased risk for cervical disease or cancer.
Knowing the HPV status of a patient can help the doctor (1) determine when additional tests or procedures are needed or (2) ensure that treatment is initiated before cancer can develop.
Test results remain confidential. No disclosure of a positive test will be made to anyone except you.
Be aware that your insurance company MAY NOT pay for the additional HPV test. You would then be responsible for that charge payable to the lab.
I understand that a HPV test may be run automatically if my PAP result is inconclusive.
Patient’s Signature ________________________________ Date ___________________ Print Name ______________________________________
Alpine Women’s Health
645 N. Arlington, Ste. 340Reno, NV 89503
Phone: 775-827-0777 Fax: 775-322-5744
Informed consent regarding HIV (AIDS) test
Your doctor has requested that you have a screening test for AIDS in preparation for your delivery or surgery. This office is now performing this test routinely on ALL Obstetrical patients. It’s important that your physician knows whether this is a risk for you.
Exposure to your surgeon and other health care workers is also a concern.
I have been informed that in some patients with AIDS, pregnancy or surgery can make the disease worse. _________ Initials
The serologic test performed is one of the most accurate scientific tests available in medicine today, but there can be false-positives. All positive serologic tests (Elisa) for the HIV virus (AIDS) are confirmed by a different more involved test called a Western Blot Test. Since it requires 3-6 months for a person to convert to a positive after exposure to the AIDS virus, there can also be false-negatives during that period of time. The test you are going to have is confidential. No disclosure of a positive test will be made to anyone except you. Therefore, the information cannot be used to discriminate against you in your employment, housing, or insurability.
I hereby consent, of my own free will, to undergo the serologic test.
Patient’s Signature Date______________
Print Name_____________________________________________
Person Obtaining consent Date
Consent to Release Medical Information to Family or Others Each person must be listed separately
Print:
Patient Name: _____________________________ Date: ________________ Date of Birth: _____________________________ Acct. #: ______________
I hereby authorize you to release, disclose and deliver medical information of the diagnoses, treatment prognosis and recommendations, as well as other pertinent data pertaining to your treatment of me to the following individuals and/or companies or facilities.
Name: ___________________ Relationship: __________________ Address: __________________ Phone #: ______________________
__________________ Fax #: ________________________ __________________
Name: ___________________ Relationship: __________________ Address: __________________ Phone #: ______________________
__________________ Fax #: ________________________ __________________
This authorization may be revoked by the undersigned at any time by giving written notice to the party authorized herein. Any disclosure made prior to revocation in reliance upon this authorization shall not constitute a breach of rights of
confidentiality of the patient. If no earlier revoked, this authorization will automatically expire 99 months from the date of signature.
The party named above to receive the information is not authorized to make any further release or disclosure of the information received. This authorization does not authorize the release of any information except as provided herein. The following notice regarding re-disclosure of substance (drug and alcohol) abuse information must be included with any such information disclosed pursuant to this authority, if such disclosure is authorized herein:
a. This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR, part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosures expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by (42 CFS, part 2). A general authorization for the Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. Medical information may be released as provided in this authorization.
Alpine Women’s Health
Name: Date:
Birthdate: Referred by:
Primary Care Physician Reason for visit:
(Please fill out both sides of form) PERSONAL HEALTH INFORMATION
Yes No Comment Yes No Comment
Stroke Kidney Stones
Chronic Headaches Kidney Failure Vision Problems Bladder Infections Epilepsy/neurologic Problems Blood in urine
Asthma Leakage of Urine
Tuberculosis Infected or Clotted Veins
Heart Attack Blood Transfusions Abnormal Heart Valve Bleeding Disorder
Heart Murmur Anemia
Irregular Heart Beat Breast Biopsies
Angina Breast Problems
Gallbladder Disease Abnormal Pap Smear
Hepatitis Tumor or Cancer
Jaundice Osteoporosis
Hernia Arthritis
Stomach/Duodenal Ulcers Lupus (SLE)
Gastritis Emotional Illness
Diabetes Sleep Problems
Thyroid Disease STD
Weight Gain/Loss Other
PAST MEDICAL HISTORY/Review of Systems: Do you have or have you ever had any of the following?
HOSPITALIZATIONS: Have you ever had an operation or hospitalization other than for childbirth:
DATE HOSPITAL DESCRIPTION
FAMILY HISTORY:
Relative Age Living Health Age Deceased? / Cause Has a blood relative or child had:
Father Yes No Comment
Mother Diabetes
Brother/Sister High Blood
Pres-sure
Stroke
Heart Disease/
Attack
Kidney Disease
Cancer/Tumor
Mental Illness/
Suicide
Name: PERSONAL HEALTH INFORMATION (continued)
MEDICATION ALLERGIES:
MEDICATION REACTION
MEDICATIONS/SUPPLEMENTS: List all, include those you buy without a prescription
MENSTRUAL & GYNECOLOGICAL HISTORY
Age of first period First day of last period Cycles: Regular Irregular Birth Control using
Days between periods Duration Trying for pregnancy YES NO Cramping: mild med severe Date of last Pap smear
Medications for cramps Normal Abnormal Age of menopause Date of last Mammogram
Hormone replacement Now Ever Normal Abnormal
Have you ever had the following surgeries: Have you ever been diagnosed with:
YES NO YES NO
Laparoscopy Endometriosis
Hysterectomy Herpes
Removal of tube or ovary Gonorrhea
Hysteroscopy Chlamydia
D&C PID (Pelvic Inflammatory Disease)
Cone Biopsy Cervical Cancer
Laser/LEEP/Freezing of Cervix Cervical Dysplasia (Pre-cancer)
OBSTECTRICAL HISTORY:
# of pregnancies # of miscarriages # of abortions # of living children
*(LIST ONLY THE YEARS AND NAME OF CHILD - WE WILL HELP FILL OUT THE REST)
MO/YEAR WEEKS IND/SPONT DEL TYPE WT SEX NAME REMARKS 1
2 3 4 5
HABITS:
Cigarettes packs/day Age started Street drugs
Alcohol drinks/day
Have you or has anyone close to you ever worried you may have a drinking problem Coffee cups/day
Signature of Physician:
COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS To our Valued Patients:
The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with
government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rule.” We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.
It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI.
We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.
Thank you for being one of our highly valued patients.
PATIENT CONSENT FORM
The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.
As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment, or health care operations, in order to provide health care that is in your best interest.
We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.
You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under the law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.
If you have any objection to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.
Print Name: ______________________Signature: ____________________Date: ______
