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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI hereby acknowledge that I have received or have been given the opportunity to receive a copy of Coeur OBGYN, PLLC’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be made available to me upon request.Signed:_________________________________________________ Date:_________________________________Print Name:_____________________________________________If not signed by the patient, please indicate relationship:________________________________________________________________________________________________________________________________________________PATIENT’S CONSENT FOR COEUR OBGYN, PLLC TO SHARE PROTECTED HEALTH INFORMATION WITH OTHER NAMED PARTIESIn addition to our normal operational disclosures of privacy information, please identify to whom we may release your health care information. Each name must be identified. These should be people who help you with your health care needs and may need to be knowledgeable about your condition, treatment, billing and options. It is still the responsibility of the below named parties to request this information.Name:Relationship:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I hereby give my consent for Coeur OBGYN, PLLC or their staff to leave information regarding my treatment, results, appointment information, or recommendations on my answering machine at the phone numbers I have provided.____________ I hereby give my permission for Coeur OBGYN, PLLC or his staff to phone me at my work.____________ I hereby give my permission for lab results to be sent to me at the address I have supplied.I am aware that I may change the above authorizations with a written request at any time. The new authorization will only become effective once a written request is received by Coeur OBGYN, PLLC ‘s office and is posted by our Privacy Officer.Please initial the above referenced information you wish to authorize.Signature of Patient:_________________________________________ Date:___________________________________Legal Guardian (if under the age of 14 years):_____________________________________________________________Witness________________________________________Patient Initials___________Date reviewed & Revised:______________________Patient Initials___________Date reviewed & Revised:______________________CREDIT POLICYAs a service to our patients, we would like to outline our policy toward payments for services.Payment for the first visit if expected on all new patients.We will gladly bill your insurance company on your behalf, so please bring all necessary information with you. This includes your current ID card, referral information and copay amount.Payment on established account is due within 30 days by your insurance company or responsible party (patient, parent or legal guardian). Although we are billing your insurance as a courtesy to you, you are responsible for your account.Your signature authorizes us to contact references in case it becomes necessary to locate you.We encourage you to contact our office if you have any questions regarding your account.Patient with past due or delinquent accounts are required to make payment at the time of future services. My signature below verifies that I have read and received a copy of the above credit policy. I understand that regardless of insurance coverage, I am responsible for payment on my account.Patients Name___________________________________________Signature____________________________________Date______________________________Full Legal Name:__________________________________________________ Previous Last Name(s):__________________________LastFirstMIDate of Birth:_____/_____/_____SSN:_______-_______-_______Martial Status:S M W DEmail Address:___________________________________________________________ Would you like Patient Portal access? Y NAddress:______________________________________________________________________________________________________Street or PO BoxCityStateZipHome Phone (______)_______________________________Cell Phone (______)_______________________________Work Phone (______)________________________________ Which phone number is preferred? Home Cell WorkEmployer _______________________________________ Occupation ___________________________________________________Race_______________________ Language _____________________ Ethnicity ___________________ Religion__________________Spouse’s Name/Significant Other:____________________________________________ Occupation___________________________Spouse’s Employer_________________________________________ SSN____________________________ DOB_________________Work Number____________________________________ Cell Number____________________________________EMERGENCY CONTACTName:________________________________________ Relationship:___________________ Phone (______)____________________PRIMARY CARE OR FAMILY DOCTOR_____________________________________________________________________REFERRING PROVIDER (not clinic)_______________________________________________________________________HOW DID YOU HEAR ABOUT US (circle please)? PREVIOUS PATIENT FACEBOOK INTERNET PHONE BOOK FRIEND/FAMILYINSURANCEPrimary Insurance:Insurance Company Name:_____________________________________________________________ID #_______________________________________________ Group #__________________________________Subscriber/Employee Name:__________________________________________________DOB:__________________ Social Security Number:_________________________ Relationship:___________________GUARANTOR INFORMATION (person responsible for the bill, if not same as above)Full Legal Name:________________________________________________ Relationship to patient:____________________________LastFirstMIDate of Birth:_____/_____/_____SSN:_______-_______-_______Male________ Female _________Home Phone (______)_______________________________Cell Phone (______)_______________________________AUTHORIZATION FOR RELEASE OF INFORMATION AND PAYMENTI request that payment of authorized Medicare/Insurance benefits be made on my behalf to Coeur OBGYN, PLLC for any services furnished to me by that physician. I authorize any holder of medical information about me to be released to the Health Care Financing Administration/Insurance Company, and its agents any information needed to determine these benefits or the benefits payable for related services.Signature of Patient or Legal Guardian:_______________________________________ Date:_____________________Relationship to Patient:_____________________________________________________ ................
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