PatientPop

 Please send completed forms to frontoffice@ in advance of your first appointment.101600139700PATIENT REGISTRATION101600139700Patient InformationName: ______________________________________ Address:_________________________________________Apt:________ City:_____________________________________ Zip Code:_______________________________Home Phone: ____________________ Cell Phone:_____________________ Work Phone:___________________Social Security#:_______________________ Date of Birth:______________________ Age:__________________Marital Status: __Married ___Single____Divorced _____Widowed Ethnicity:________ Race:________________Employment Status: ?Employed ?Retired ?Student Other:________________________________________Employer: ____________________________________ Address:________________________________________How may we contact you? Text____Phone_____Email_____ I have received a pin number to register for Boardwalk Portal for Patient __________ intials E-Mail Address:__________________________________ Phone to text__________________________________ Insurance InformationInsurance Company ___________________________ Policy# _____________________ Group #______________Subscriber’s Name:_____________________________ Date of Birth: ___________ Relationship: _____________Secondary Insurance InformationInsurance Company ___________________________ Policy# _____________________ Group #______________Subscriber’s Name:_____________________________ Date of Birth: ___________ Relationship: _____________Pharmacy InformationPharmacy Name _______________________________Phone Number _________________________________Address ___________________________________________________________________________________NAME: __________________________________Emergency ContactName:______________________________________ Phone#: _________________ Relationship:____________AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO ABOVE MENTIONED PERSONMy signature below serves as authorization to release private and protected medical information to the above said person in the manner marked: VERBALLY____ MESSAGE VIA PHONE______RECEIVE MEDICAL RECORDS ON MY BEHALF_______DO NOT RELEASE MEDICAL INFORMATION TO ANYONE OTHER THAN MYSELF ________SIGNATURE_______________________________________________________ DATE:_________________ASSIGNMENT OF BENEFITSI hereby assign all of my rights, tides, interests, and payment of any medical or surgical reimbursement benefits to which I am entitled (by my insurance policy, including Medicare, Private transfer, or any third party) to BOARDWALK OB/GYN ASSOCIATES. I request that payment for such be made directly to BOARDWALK OB GYN ASSOCIATES. I authorize this office and its employees the right to release and disclose all or part of my medical information to any entity which is liable for charges. I authorize this office and its employees the right to send such records via fax or any other form of secured electronic means for assistance in payment of charges and to provide the patient with the most appropriate medical care. This authorization will remain valid until revoked by written notice. A photocopy of this agreement is to be valid as an original. The signature furnished below shall suffice for all insurance forms on a continuing basis.Signature: ________________________________________Date: _______________________________________NAME:________________________ AGREEMENT TO PAYIN THE EVENT THAT MY INSURANCE DETERMINES THAT A SERVICE OR PROCEDURE IS A NON COVERED SERVICE OR NOT MEDICALLY NECESSARY, THIS FORM SHALL SERVE AS AN ADVANCE WRITTEN NOTICE THAT I WILL BE BILLED FOR THE NON COVERED SERVICES.I ALSO UNDERSTAND THAT IT IS MY RESPONSIBILITY TO KNOW THE BENEFITS OF MY POLICY. I UNDERSTAND THAT THE PROVIDER RENDERING CHARGES IS NOT RESPONSIBLE FOR OBTAINING MY BENEFITS. I UNDERSTAND THAT ANY BENEFITS OR COVERAGE INFORMATION PROVIDED TO ME IS NOT A GUARANTEE OF BENEFITS NOR VERIFICATION OF ELIGIBILITY. I AM SOLEY RESPONSIBLE FOR ALL COPAYS, DEDUCTIBLES, COINSURANCE AND ANY NON COVERED OR NON PAYABLE SERVICES.I ACKNOWLEDGE THIS DISCLOSURE AND AGREE IN WRITING TO ACCEPT THE NON COVERED SERVICES AS BILLABLE TO ME AND ACCEPT FINANCIAL RESPONSIBILITY FOR SUCH CHARGES.SIGNATURE: _______________________________________________________DATE_______________________________I further understand and agree that if my account is turned over to a collection agency, I am financially responsible for all additional charges. These include a 27% fee for accounts less than a year old and 45% for accounts older than a year, leaving me responsible for a total made up of the balance and the collection fee. Signature: ______________________________________ Date: ________________________________________GENERAL CONSENTBy signing this form, I consent to give Boardwalk OB GYN and its associated staff the authorization to perform and render any and all necessary medical care during my office visits and to fulfill the orders of the physicians and staff associated with Boardwalk Ob/Gyn.By signing this form, I consent to authorize Boardwalk Ob/Gyn and associated staff the right to disclose treatment illness (except for psychotherapy notes), use of alcohol or drugs, communicable diseases such as Human Immunodeficiency Virus (HIV), and Acquired Immune Deficiency Syndrome (AIDS) for treatment, payment, healthcare operations, and as otherwise allowed by law.The duration of this consent is indefinite and continues until revoked in writing.NAME: __________________________________DATE___________________________________ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI ________________________________________ acknowledge that I have received a (Name of Patient)copy of BOARDWALK OB/GYN ASSOCIATES ‘Notice of Privacy Practices’.This Notice describes how BOARDWALK OB/GYN ASSOCIATES may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.I also acknowledge that I have been afforded the opportunity to read the notice of Privacy Practices and ask questions._______________________________________________________________(Signature of Patient, or Personal Representative) (Date)______________________________________________________________________(Relationship to Patient)NAME: __________________________________Laboratory ServicesPlease be advised that the majority of laboratory services performed in our facility are processed through an outside laboratory. The laboratories that we currently use are Quest Diagnostics and LabCorp; these may be subject to change. Our office will collect the specimen here and forward them to the contracted laboratory along with your billing and insurance information. We determine where your specimens will be sent based upon your insurance companies’ contract with each facility. Based upon your insurance policy, your benefits may vary for laboratory services. All billing of laboratory services will be handled by the specific laboratory used. For any out-of-pocket expenses or billing disputes, please contact the laboratory directly.Normally when Pap Smears are read at a laboratory, they are read by a Cytotechnologist. If there are any abnormalities found in the review of the Pap Smear, it may be forwarded to a physician who then reviews and interprets the Pap Smear again. This ensures that a precise reading had been performed and that the results are as accurate as possible. If a laboratory physician is required to review your Pap Smear, there will be an additional charge of $16.00 to $20.00 added to your account that may not be reimbursable based on your insurance plan. In the event that you are charged this additional fee, you will receive a bill from our office or from the laboratory.By signing below, you state that you understand the above statements and agree to pay the laboratory bill to them separately._____________________________________________________________________________________Patient SignatureDateConsent to Treat a Minor_______________________________________, (Minor Child) has an appointment at Boardwalk OB/GYN, on ___________________________________(Date) for an examination and treatment.I, ________________________________________ (Parent/Guardian) give Boardwalk OB/GYN my permission to examine and treat the above named child.Name:__________________________HIPAA PRIVACY ACT INFORMATION FORMPlease check one of the boxes below for release of medical information:Release information only to me:□ Yes □ NoWhere may we call to verbally communicate medical information: cell_________ home_________ work_________Where may we leave a message: cell___________ home ______________ work___________ none___________What can we leave on the message: call back_________ leave medical info________ do not leave message______-34289988900-34289988900Release information to my spouse/partner/other:□ Yes □ NoWhat information to release: verbal ___________copies of records____________Spouse’s Full Name: ___________________________________________ cell_____________home________ work_________________Other Person: __________________________________________________ cell ___________ home _______ work__________________Where may we call to verbally communicate medical information: spouse_____ cell_________ home_________ work_________ Other _______ cell_________ home_________ work_________Where may we leave a message: spouse_____ cell_________ home_________ work_________ Other _______ cell_________ home_________ work_________ What can we leave on the message: spouse call back_________ leave medical info________ do not leave message______ : spouse call back_________ leave medical info________ do not leave message______ -292099101600-292099101600Acknowledgement of Receipt of Communication PoliciesYour signature confirms approval of the HIPPA communication of information preferences. You may change your preferences at any time, but this must be done by completing a new form. Signature_________________________________________________________________________ Date___________________________Patient Name:____________________________________________________Date of Birth__________________________ Reason for Visit-76199152400-76199152400What brings you in today?____________________What other concerns would like to address?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Current Medications □ No medicationsAllergies□ No Known Drug Allergies-76199152400-76199152400What medications are you taking?___________Are you allergic to: □ Tape □ Latex □ Iodine______________________ _______________ _______________________________ ______________________Name Dose FrequencyName Reaction______________________ _______________ _______________________________ ______________________Name Dose FrequencyName Reaction______________________ _______________ _______________________________ ______________________Name Dose FrequencyName Reaction______________________ _______________ _______________________________ ______________________Name Dose FrequencyName ReactionPast Medical History □ I have no known medical problems-76199190500-76199190500□ Alcoholism□ Allergies□ Anemia□ Anxiety□ Asthma□ AIDS/HIV□ Autoimmune Disorders□ Back problems□ Bleeding□ Blood Disorders□ Blood Transfusion□ Breast Cancer□ Clotting Disorder□ Colon Cancer□ Diabetes□ Depression□ Eating Disorders□ Ear Problems□ Epilepsy□ Glaucoma□ Gout□ Heart Disease□ Heart Defects□ Hepatitis A,B, or C□ High Blood Pressure□ High Cholesterol□ Liver Disorder□ Kidney Disorder□ Joint Disorder□ Lung Disorder□ Measles□ Migraines□ Osteoporosis□ Pneumonia□ Polio□ Psychiatric Illness□ Rheumatic Fever□ Stroke□ Thyroid Disorder□ Stomach Ulcer□ Substance Abuse□ Skin Disorder□ Tuberculosis□ Sexually Transmitted DiseaseOther details:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Patient Name:____________________________________________________Date of Birth__________________________ Family Medical History □ No Family Medical Problems-114299-12699-114299-12699□ Alcoholism□ Allergies□ Anemia□ Anxiety□ Asthma□ AIDS/HIV□ Autoimmune Disorders□ Back problems□ Bleeding□ Blood Disorders□ Blood Transfusion□ Breast Cancer□ Clotting Disorder□ Colon Cancer□ Diabetes□ Depression□ Eating Disorders□ Ear Problems□ Epilepsy□ Glaucoma□ Gout□ Heart Disease□ Heart Defects□ Hepatitis A,B, or C□ High Blood Pressure□ High Cholesterol□ Liver Disorder□ Kidney Disorder□ Joint Disorder□ Lung Disorder□ Measles□ Migraines□ Osteoporosis□ Pneumonia□ Polio□ Psychiatric Illness□ Rheumatic Fever□ Stroke□ Thyroid Disorder□ Stomach Ulcer□ Substance Abuse□ Skin Disorder□ Tuberculosis□ Sexually Transmitted DiseaseOther details:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Past Surgical History □ I have never had surgery-114299-12699-114299-12699________________________________________________ _________________________ __________________________SurgeryDateWhere Performed________________________________________________ _________________________ __________________________SurgeryDateWhere Performed________________________________________________ _________________________ __________________________SurgeryDateWhere Performed________________________________________________ _________________________ __________________________SurgeryDateWhere Performed________________________________________________ _________________________ __________________________SurgeryDateWhere PerformedLifestyle-50799152400-50799152400Are you sexually active?□ Yes□ NoHow many partners? (past year)________ (total lifetime)________If not currently active, have you ever been sexually active?□ Yes□ NoSexual Partner(s) is/are:□ Male□ Female □ BothWould you like to be checked for sexually transmitted diseases?□ Yes□ NoHas anyone in your home physically or verbally hurt you?□ Yes□ NoDo you smoke? □ Yes □ No packs/day________ Have you ever smoked? □ Yes □ No Quit Date________Do you use recreational drugs? □ Yes □ No What types/Frequency_________________________________________How much alcohol do drink per week?______________________________________________________________________How much caffeine do you drink per day?__________________________________________________________________How many times per week do you exercise?________________________________________________________________Patient Name:____________________________________________________Date of Birth__________________________ Pregnancy History □ I have never been pregnant-25399165100-25399165100_______________ ___________ ___________ _________________ ______________# pregnancies#term#preterm#miscarriages#abortionsDate #Weeks Type of Delivery M/F Weight Living Complications________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you currently pregnant? □ Yes □ NoAre you trying to become pregnant? □ Yes □ NoWhat is your current method of birth control? □ None □ Abstinence □ Condoms □ Intrauterine Device □ Implanon/Nexplanon □ Vaginal Ring (Nuva Ring) □ Contraceptive Patch□ Spermicide □ Natural Family Planning/Rhythm Method □ Withdrawal □ Diapragm/cervical cap□ Oral contraceptive Pills: (name)______________________________ □ Other:_____________________________Menstrual HistoryHealth Maintenance-38099139700-38099139700Age at first period?__________Last pap smear __________ □ never had oneDate of last period?__________Last mammogram __________ □ never had oneFrequency of periods?__________Last colonoscopy __________ □ never had oneLength of period?__________Last bone density __________ □ never had one Are your periods regular? □ Yes □ No Last general health checkup __________Age at menopause?__________ □ N/AImmunizations up to date? □ Yes □ NoOB/GYN History - □ I do not have any OBGYN problems-25399152400-25399152400□ Abnormal vaginal bleeding□ Abnormal pap smear□ Bleeding between periods□ Breast Lump/Mass□ Breast Cancer□ Breast Surgery□ Cervical Cancer□ Cervical Dysplasia□ Chlamydia□ Colposcopy previously□ Cryosurgery□ DES exposure□ Fecal/Flatus Incontinence□ Fibroids□ Genital Warts□ Gonorrhea□ Herpes□ Hot Flashes□ HPV (Human Papilloma Virus)□ Infertility□ Irregular Periods□ Menstrual Pain□ Nipple Discharge□ Ovarian cysts□ Ovarian Cancer□ Painful Intercourse□ Pelvic Inflammatory Disease□ Uterine Cancer□ Uterine Hyperplasia□ Urinary Incontinence□ UTI – frequent□ Vaginitis (BV) – frequent□ Yeast - frequent ................
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