Read Proof of Pregnancy Form text version

Date:

Patient Registration

PATIENT INFORMATION Social Security # ___________________________ Home Address ____________________________ First Name _________________ Middle ________ P.O. Box _________________________________ Last Name ________________________________ City ________________ State ____ Zip _______ Sex ______ Date of Birth ____/____/_____

Marital Status __ Married __ Divorced __Single __ Widowed Referring Physician ________________________

Home Phone ( )_________________________ Work Phone ( )_________________________ Cell Phone ( )_________________________ (Check one) __ Employed __ Retired __ Full Time Student Employer Address ___________________________ Employer _________________________________ City ______________ State ____Zip _______

Emergency Contact

First Name ____________________ Int. ____ Last Name ____________________________ Work Phone ( ) ______________________

Sex ______ Relationship _____________________ Home Phone ( Cell Phone ( )_________________________ )____________________________

Spouse / Guarantor / Responsible Party

Social Security # ___________________________ Sex ____

Date of Birth ____/_____/_____

First Name ___________________ Int. ________ Last Name ____________________________ Employer ______________________________ Employer Address Work Phone ( 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 claims.

________________________________________ Signature Date

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

/ / Spouse / / Parent / / Self / / Other

Social Security #

____________________

Date of Birth

______________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I.D. Number Group No. Co-Pay Insured's Employer _____________________ ________________ ________ ________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Insurance Company Plan Name

Policy Holder

________________________________

____________________________ Primary ___

Relationship Social Security #

____________________

Secondary ___

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. Date ___________Signature__________________________Print Name____________________________

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 ______________________________________ Person Obtaining Consent __________________________ Date ___________________

Alpine Women's Health

645 N. Arlington, Ste. 340 Reno, 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

File: My Documents/Consent/HIV

Consent to Release Medical Information to Family or Others Each person must be listed separately Print: Patient Name: _____________________________ Date of Birth: _____________________________

Date: ________________ 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: ___________________ Address: __________________ __________________ __________________ Relationship: __________________ 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.

Signature of above named patient: ________________________ Date: ___________

Alpine Women's Health

Name: Birthdate:

Primary Care Physician

Date: Referred by:

Reason for visit: (Please fill out both sides of form)

PAST MEDICAL HISTORY/Review of Systems:

Yes Stroke Chronic Headaches Vision Problems Epilepsy/neurologic Problems Asthma Tuberculosis Heart Attack Abnormal Heart Valve Heart Murmur Irregular Heart Beat Angina Gallbladder Disease Hepatitis Jaundice Hernia Stomach/Duodenal Ulcers Gastritis Diabetes Thyroid Disease Weight Gain/Loss No Comment Kidney Stones Kidney Failure Bladder Infections Blood in urine Leakage of Urine Infected or Clotted Veins Blood Transfusions Bleeding Disorder Anemia Breast Biopsies Breast Problems Abnormal Pap Smear Tumor or Cancer Osteoporosis Arthritis Lupus (SLE) Emotional Illness Sleep Problems STD Other

PERSONAL HEALTH INFORMATION

Do you have or have you ever had any of the following?

Yes No Comment

HOSPITALIZATIONS: Have you ever had an operation or hospitalization other than for childbirth:

DATE HOSPITAL DESCRIPTION

FAMILY HISTORY:

Relative

Father Mother Brother/Sister Diabetes High Blood Pressure Stroke Heart Disease/ Attack Kidney Disease Cancer/Tumor Mental Illness/ Suicide Other

Age

Living Health

Age

Deceased? / Cause

Has a blood relative or child had:

Yes No Comment

Name: MEDICATION ALLERGIES: MEDICATION

PERSONAL HEALTH INFORMATION (continued)

REACTION

MEDICATIONS/SUPPLEMENTS: List all, include those you buy without a prescription

MENSTRUAL & GYNECOLOGICAL HISTORY Age of first period Irregular Cycles: Regular Duration Days between periods med severe Cramping: mild Medications for cramps Age of menopause Hormone replacement Now Ever Have you ever had the following surgeries:

YES NO

First day of last period Birth Control using Trying for pregnancy YES Date of last Pap smear Normal Abnormal Date of last Mammogram Normal Abnormal

NO

Have you ever been diagnosed with:

YES NO

Laparoscopy Hysterectomy Removal of tube or ovary Hysteroscopy D&C Cone Biopsy Laser/LEEP/Freezing of Cervix

Endometriosis Herpes Gonorrhea Chlamydia PID (Pelvic Inflammatory Disease) Cervical Cancer Cervical Dysplasia (Pre-cancer)

OBSTECTRICAL HISTORY: # of pregnancies MO/YEAR 1 2 3 4 5 HABITS: Cigarettes packs/day Age started Street drugs drinks/day Alcohol Have you or has anyone close to you ever worried you may have a drinking problem cups/day Coffee Signature of Physician: Circle one: Peter DeKay, M.D. Corinne Capurro, M.D. Laura Thompson, M.D. WEEKS # of miscarriages IND/SPONT DEL TYPE # of abortions WT SEX NAME # of living children REMARKS *(LIST ONLY THE YEARS AND NAME OF CHILD - WE WILL HELP FILL OUT THE REST)

HIPAA Notice of Privacy Practices

__________________________________________(NAME)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your protected health information (HGI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control of your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage you health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary to a home health agency that provides care to you. Your protected health information may also be provided to a physician to whom you have been referred to ensure that physician has the necessary information to diagnose and/or treat you. Payments: Your protected health information will be used, as needed to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health Issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers Compensation, Inmates, Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164,500. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization. ------------------------------------------------------------------------------------------------------------------------------------------------

Your Rights Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information, under federal law. However, you may not inspect or copy the following records; psychotherapy notes, information complied in reasonable anticipation of, or used in civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibit access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve that right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filling a complaint. This notice was published and becomes effective on/or before April 14, 2003.

-------------------------------------------------------------------------------------------------------------------------------------------------We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Print Name: _________________________ Signature: _________________________ Date: ________

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Proof of Pregnancy Form

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