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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