Patient’s Name:__________________________ S
Patient’s Name:__________________________ S.S.#__________________
D.O.B.:____________ Age: _____yrs. Marital Status: S M D W DP
(Domestic partner)
Address______________________________ City________________
State___ Zip______ Home Phone: ( )___________Cell ___________
Preferred Way to be contacted: ___Home ___Work ___Cell ___Email
DO NOT CALL HOME___ DO NOT CALL WORK___ DO NOT LEAVE MESSAGE ON ANSWING MACHINE___
We may share you medical information with? First name_______________ Last name _______________
Email ______________________________ Race: ______________ Ethnicity:_________
Do you speak English? ____ Yes ____No, Language? _________________________
Emergency Contact _________________ Phone _______________ Relationship ___________
Employer____________________________ Work Phone ____________________
Pharmacy_________________ ( )_____________ Referred By:______________
Primary Physician:______________________ Phone ( )___________
PRIMARY INSURANCE INFORMATION: (if the patient is not the subscriber, please fill out all of the information below)
Ins. Comp.________________________ Subscriber’s Name _______________________
ID#__________________ Group #_________ Subscriber’s D.O.B.___________________
Relationship to patient _______________ Subscriber’s S.S.# ________________________
SECONDARY INSURANCE: (if the patient is not the subscriber, please fill out all of the information below)
Ins. Comp.__________________________ Subscriber’s Name _____________________
ID#__________________ Group #_________ Subscriber’s D.O.B.___________________
Relationship to patient _______________ Subscriber’s S.S.# ________________________
I hereby authorize and request Dr. Stemmer to release minimal medical information including only date of service, procedure, and diagnosis codes from my examination necessary to process the claim. I also request that the payment go directly to Dr. Stemmer. I hereby acknowledge that payment for services is due in full when service is rendered. I understand that if there is an outstanding balance more than 30 days past due, I will be responsible for a service charge of 1.5% per month of the outstanding balance. Accounts that go to collections will be subject to a 30% charge and you will be responsible for all collection costs including attorney fee and court cost.
Patient’s Signature: _____________________________ Date: _________________
Date: ____________________________
Name____________________________ Date Of Birth ______/_____/______ Age_____ Height _______
Social Security #______-_____-_______ Previous Dr.__________________ Marital Status S M D W DP
(Domestic partner)
Chief Complaint: ______________________________________________________________________
Major illness: ________________________________________________________________________
Present Medications: ___________________________________________________________________
Allergies: _____________________________________ Blood Transfusions: YES______ NO______
Smoker?____ How much?______ How long?______ Stopped Smoking ____ Alcohol?______ How much?_____ Drugs? ____
Jehovah witness Yes______ No_____ *in case of emergency would you accept blood transfusions? Yes_____ No______
Sexually Active Yes______ No_____ Perference Male _____ Woman _____ Both _____
History: (if you check one, please give a brief description)
STD’s
Chlamydia_____ Gonorrhea ______ Trichomonas _____ HPV ___ Herpes _____
Bladder infection_____ Chest pain _____ Hemorrhoids _____ Kidney Infection _____
Back pain _____ Constipation _____ Headaches_____ Kidney stone_____
Bone disease _____ Blood in stool _____ Indigestion_____ Appetite: poor ___ normal_____
Get up at night to urinate ___________ Loss of urine when: laughing______ coughing____ sneezing______
Menstrual History: Age started ________ Every_______ days for_______ days
Menstrual Flow: _____ scant ____moderate ____profuse Menstrual Pain ___ mild ____ Moderate _____severe
Discharge ______ Itchy _______ Burning ______ Odor ______ Difficulty getting pregnant ________
Bleeding between periods: ____ After intercourse:____ Last Period ___/____/___ Last Pap ____/_____/_____
Colonscopy Y___ N___ _____/_____/_____ Bone Density: ___/___/___ ___ normal
Last Mammogram _____/_____/_____ ___ abnormal
OPERATIONS: YEAR HOSPITAL COMPLICATIONS
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
FAMILY HISTORY: CANCER ___________ DIABETES ______________ HEART DISEASE _____________
MENTAL DISORDER ______ HIGH BLOOD PRESSURE ________ TWINS _______ ABNORMAL BABIES ________
HISTORY OF BIRTHS: # of Pregnancies _______ # of Deliveries _______ # of live children _______
Spontaneous Abortions _____ How long into pregnancy? ________ wk Cause?________ Elective Abortions _______
LABORS DATE SEX WT. LABOR DURATION HOSPITAL COMPLICATIONS _____________________________________________________________________________________________________________________________________________________________________________________________________________________Financial Policy
We welcome you to our practice. The following is a statement of our financial policy. All patients must complete our Patient Information Sheets before seeing the doctor.
Unless previous arrangements have been made, all payments are due at the time of the appointment. Payment may be made by cash, check, Master Card, Visa or Discover. We will only bill insurance carriers with whom we participate (have signed and agreement with).
Regarding Managed Care Insurance with which we participate: You are responsible to supply our staff with your primary and secondary insurance identification card(s) at the time of your appointment. If your insurance company requires a referral from your primary doctor, you must also present this to our receptionist prior to being seen, as we cannot bill your insurance without it. If you do not obtain a referral when your insurance company requires one, you will be required to pay for the visit in full. If your insurance company requires a copay, it must be paid at the time of the appointment.
Regarding Non- participating Insurances: If we do not participate with your insurance, the bill is your responsibility and is due at the time of service. We accept cash, check, Master Card, Visa or Discover. Your insurance policy is a contract between you and your insurance company. Our office is not part of the contract.
Our practice is committed to providing the highest quality of treatment to our patients, and we charge what is usual and customary for our area. We know how confusing insurance plans can be. If you have any questions, feel free to ask us. We may be able to help you.
We do participate with Medicare. This means that we will submit your claim to Medicare. The 20% difference between what Medicare “allows” and what Medicare “pays” will be sent to your secondary insurance if you have one, or to you. You will also be responsible for payment of your yearly deductible.
Returned Check Fee- $25.00 will be added to your bill if this occurs, since our bank charges us a fee for any checks that are returned.
Any outstanding balance for which the patient is responsible is due within 30 day of billing and will be responsibe for a service charge of 1.5% per month of the outstanding balance. Any account that has gone 90 days without payment is subject to immediate collection process. Accounts that go to collections will be subject to a 30% charge and you will be responsible for all collection costs including attorney fee and court cost.
Thank you for your cooperation. If you have any questions or concerns, please feel free to ask. If you cannot pay in full at the time of service, please let us know before you see the doctor that you would like to discuss a payment plan.
I have read the above Stemmer OB/GYN Financial Policy. I understand and agree to abide by its terms.
_________________________________________ ____________________
Signature of Patient/Parent/Guardian Date
_____ Do not phone at home _____ Do not phone at work
_____ Send all mail to alternate address: _______________________________________________
_____________________________________________________________________________
_____ Restrict information to individuals: _______________________________________________
_____ Do not leave messages on answering machine
_____ Do not mail reminder cards
_____ Other privacy request initials and date:_______________________
|Chart was sent to: |Initials and date |Pt.’s initials or verbal date |
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ACKOWLEDGMENT OF RECEIPT
OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy Practices for Dr. Stemmer.
Patient Name: _________________ Signature: ____________________
If person signing is not the patient, please print your name and relationship to patient:
Name:_______________________ Relationship:_________________
__________________________________ requested a copy of Notice of Privacy Practices for Dr. Stemmer. _____YES _____NO
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Office Use
__ Patient/ representative requested copy of Notice of Privacy Practices for Dr. Stemmer.
______ If no acknowledgment could be obtained, state the reasons why and the efforts taken to try to obtain the acknowledgment. ________________
_______________________________________________________
_______________________________________________________
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