New Patient Form - Altoona OB/GYN

Step 1 of 5

Name(Required)

First Middle Last

Maiden Name

Age(Required)

Date of Birth(Required)

Social Security #

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Work Phone

Employer

Occupation

Employer Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Care Physician

Primary Care Physician Address

Street Address City State / Province / Region ZIP / Postal Code

Pharmacy

Pharmacy Address

Ethnicity:

Hispanic

Latino

Non Hispanic

Other or Undetermined

Race:

Caucasian

African American

Other or Undetermined

Primary Language

Marital Status

The Notice of Privacy Practices is posted in our office for your review. A copy may be provided for you upon request. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan, and direct my treatment and follow-up among the health care providers who may be directly and indirectly involved in providing my treatment, obtain payment from third party payers and conduct normal health care operations such as quality assessments and accreditation. I certify that the above information is correct and I request services.

Signature(Required)

Date

FINANCIAL INFORMATION AND AUTHORIZATION

Name

First Middle Last

Madien Name

Date of Birth

FINANCIAL TYPE

Check all those that apply:

Commercial

Blues

Medicare

Medicaid

*Self Pay

*If self pay, amount needs paid at time of service unless prior arrangements have been made

INSURANCE

We will need to scan your insurance cards for our records

Primary Insurance

Insurance ID#

Group #

Insured's Name

Employer

Co-pay

Claims Mailing Address (on back of card)

Secondary Insurance

Insurance ID#

Group#

Insured's Name

Employer

Co-pay

Claims Mailing Address (on back of card)

SPOUSE/RESPONSIBLE PARTY NAME (POLICYHOLDER OF INSURANCE)

Spouse/Responsible Party Name

Date of Birth

Employer

Social Security #

Home Address

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone

Secondary Phone

Work Phone

MY FINANCIAL RESPONSIBILITY
I certify that the above information is correct. I understand that I am personally financially responsible for all services not paid for by my insurance. I am also responsible for any annual deductible's applicable, co-payments or non-covered services as may be required by my insurance plan.

Signature of patient or person acting on patient's behalf(Required)

Date

RELEASE OF MEDICAL INFORMATION AUTHORIZATION

I authorize the release of any medical or other information necessary to process my claims. I also request payment of government or private benefits either to myself or to the party who accepts assignment.

Signature of patient or person acting on patient's behalf(Required)

Date

PATIENT'S MEDICAL HISTORY

Name

First Middle Last

Maiden Name

Date of Birth

Gravida (Total Pregnancies):

Para:

Full term:

Preterm:

Miscarriages:

Ectopics:

Abortions:

Living:

Age at 1st menstrual period:

Age at 1st childbirth:

CURRENT MEDICATIONS:

Please list ALL medications you currently take along with the dosage and reason. Please bring a current list of medications to every office appointment.

Medications:

Medication

Dosage

Reason

Allergies: Please list allergies and your reaction.

Allergy

Reaction

PAST SURGICAL HISTORY: Please list the type of surgery and the date of the surgery.

List

Type of Surgery:

Date:

FAMILY HISTORY: Please list relationship to the family member and mark if they have/had any of the medical conditions listed below. If the family member has/had cancer please provide name of cancer and age of diagnosis.

List

RELATIONSHIP

MATERNAL/PATERNAL

HYPERTENSION (yes/no):

DIABETES (yes/no):

HEART DISEASE (yes/no):

CANCER:

OTHER:

Signature(Required)

Date

ALTOONA OBGYN ASSOCIATES, INC. FINANCIAL POLICY

We provide you with the best possible care and service. We consider your understanding of our financial policies an essential element of your care and treatment. We find that communication with our patients regarding our policies assists us in providing the best service possible. The following is our Financial Policy, which we require you to read and agree to prior to your treatment.

Insurance (1)
We participate in most insurance plans. We will file claims for all services we provide in the office and at UPMC Altoona. If you are not insured by a plan that we participate with, payment in full is expected at each visit. Please remember that insurance coverage is a contract between you and your insurance company. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Medicare (2)
We are a participating Medicare provider. Medicare as well as your secondary insurance (if any) will be billed for you. However, that does not mean that all the services are covered. Patients are responsible for paying their annual unmet deductible. You are also responsible for any co-insurance, which is usually 20% of the allowed amount for a service.

Non-Covered Services (3)
Medicare and some Medicare Advantage plans will only cover your yearly exam and pap smear every other year. If this happens, it is your responsibility to pay for our services. We will make every effort to inform you of what services may not be covered by your insurance plan, but you will still be responsible for all the balances.

Patient Billing (4)
All copayments must be paid at the time of service. Any additional services may incur additional charges along with the charge for your yearly exam. If a balance is due after receiving the explanation of benefits from your insurance company, you will be sent a billing statement. We ask that all balances are paid in full no later than 90 days from the date of service. If the balance remains unpaid after 90 days, your account will be fowarded to a collection agency. Please notify our billing office if you are unable to pay your bill in full. Special payment arrangements may be available.

Claim Submission (5)
We will submit your claim to your insurance company. However, your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Any unpaid balance not covered by your insurance is your responsibility.

Copy Fee (6)
We will provide copies of patient records at the patients’ request. Copies of records may be subject to a per page fee as follows: 1-20 pages are $1.83 per page; 21-60 pages are $1.36 per page and 61+ pages are $0.47 per page. (Fees are subject to change)

Forms Fee (7)
Forms including FMLA, Disability, etc. may take 7-10 business days to be processed and are $25 per form. (Fee is subject to change)

Canceled/Missed Appointment Fee (8)
If you cannot keep your appointment time, please call our office at least 24 hours prior to your scheduled appointment time. If you fail to give us notice of your missed appointment, you will be responsible for a missed appointment fee. The fee for missed procedures (i.e.: ultrasound, IUD/Nexplanon, colposcopy, urodynamics) is $75.00. Missed gynecological appointment is $50.00. This charge is not covered by your insurance company and will be your responsibility. If you arrive late for your appointment, we may need to reschedule your appointment in fairness to other scheduled patients. Repeated missed or late appointments may result in dismissal from our practice.

Surgeries (9)
When a surgical procedure is scheduled, we will give you an estimate of the amount you may be responsible to pay. This amount will be collected prior to the procedure being performed unless payment arrangements are made. Additional payments or refunds may be required after the insurance has processed your claim. Your insurance company will issue an EOB, explanation of benefits, indicating the responsible amount.

Minor Patients (10)
The parent or guardian accompanying a minor will be financially responsible for payment of services. Young adults (age 18 and over) and emancipated minors are legally responsible for their account.

I have read and understand the financial policy of this practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice.

Please Initial Each Area:

Insurance (1)(Required)

Medicare (2)(Required)

Non-Covered Services (3)(Required)

Patient Billing (4)(Required)

Claim Submission (5)(Required)

Copy Fee (6)(Required)

Forms Fee (7)(Required)

Canceled/Missed Appointment Fee (8)(Required)

Surgeries (9)(Required)

Minor Patients (10)(Required)

Patient Name

First Last

Date

Date of Birth

Signature(Required)

Altoona OB/GYN Associates, Inc. HIPAA & Emergency Contact Information

Patient authorization for use and disclosure of Protected Health Information (PHI) from the practice

By signing this form at the bottom, I authorize Altoona Ob/Gyn Associates, Inc., to use and/or disclose certain PHI about me to:

1)

Name

First Last

Relationship:

Cell Phone

Home Phone

Work Phone

Check all that apply to person listed above:

release PHI

pick up medical items/papers from office

emergency contact

2)

Name

First Last

Relationship:

Cell Phone

Home Phone

Work Phone

Check all that apply to person listed above:

release PHI

pick up medical items/papers from office

emergency contact

3)

Name

First Last

Relationship:

Cell Phone

Home Phone

Work Phone

Check all that apply to person listed above:

release PHI

pick up medical items/papers from office

emergency contact

If other, specifically describe the information to be used or disclosed, such as date(s), level of detail to be released or origin of information:

*This authorization will expire upon death or until revoked in writing*

Our office may contact you with appointment and medical information through cell, home, or work number with your HIPAA appointed person.

Signature(Required)

Today's Date

Name

This field is for validation purposes and should be left unchanged.