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Overlake Obstetricians and Gynecologists, PC
LICENSE# LANGUAGE STATUS □ DIV □ SEP □ WID INSURANCE INFORMATION Iauthorizetreatmentandagreetopayallfeesassociatedwithsuchtreatment.Iauthorizemyinsurancebenefitstobepaiddirectlytomy Iauthorizetreatmentandagreetopayallfeesassociatedwithsuchtreatment.Iauthorizemyinsurancebenefitstobepaiddirectlytomy □ American Indian/Alaska Native □ Asian □ Black/African American RACE: ETHNICITY: □ Hispanic/Latino physician.Iauthorizemyphysiciantoreleaseanyinformationrequiredtoprocessmyclaim.IagreethatIamfinanciallyresponsibleforall physician.Iauthorizemyphysiciantoreleaseanyinformationrequiredtoprocessmyclaim.IagreethatIamfinanciallyresponsibleforall □ Native Hawaiian/Pacific Islander □ Caucasian □ Other □ Declined □ Non-Hispanic/Latino □ Declined servicesprovidedandshoulditbenecessarytorefertheaccounttocollectionsIwillberesponsibleforallcollectionfees,collectioncosts, servicesprovidedandshoulditbenecessarytorefertheaccounttocollectionsIwillberesponsibleforallcollectionfees,collectioncosts, attorneyfeesandcourtcostsinvolvedwithmyaccount. attorneyfeesandcourtcostsinvolvedwithmyaccount. ADDRESS CITY SETm ATpEloye APT# zIP AccXsIGNATURe:_________________________________________________DATe:______________________________________ ount Number Physician Name NCITYsTATe o. Date e InitiaZlIsP XsIGNATURe:_________________________________________________DATe:______________________________________ □ HOME PRIMARY Account Number Physician Name No. Date Em ployee Initia□ ls WORK ( umOF ( ) Date NUMBER AHOME ccNOTICE ount N be)r PRIVACY PRACTICES PhysWORK icia- nACKNOWLEDGMENT Na( me ) NCELL o. Em ployee Initia□ ls CELL AccNOTICE ount NumOF ber PRIVACY PRACTICES Physicia- nACKNOWLEDGMENT Name No. Date Employee Initials NAME Wekeeparecordofthehealthcareservicesweprovideyou.Youmayasktoseeandcopythatrecord.Youmayalsoasktocorrect □M WEBSITE □ PERSONAL HOW DID YOU LAST FIRST .I. Wekeeparecordofthehealthcareservicesweprovideyou.Youmayasktoseeandcopythatrecord.Youmayalsoasktocorrect □ REFERRAL □ WORK thatrecord.Wewillnotdiscloseyourrecordtoothersunlessyoudirectustodosoorunlessthelawauthorizesorcompelsustodoso. EMAIL HEAR ABOUT US ? NAME thatrecord.Wewillnotdiscloseyourrecordtoothersunlessyoudirectustodosoorunlessthelawauthorizesorcompelsustodoso. □ AD LAST FIRST M.I. YoumayseeyourrecordorgetmoreinformationaboutitbycontactingourMedicalRecordsDepartmentorPrivacyOfficer. NAME NAME YoumayseeyourrecordorgetmoreinformationaboutitbycontactingourMedicalRecordsDepartmentorPrivacyOfficer. LO ASRTMER NAMES (MAIDEN, ETC.) FIRST F PREFERRED NAME (NICKNAME, ETC.) M.I. FIRST M.I. EXsIGNATURe:_________________________________________________DATe:______________________________________ MPLOYED BLYAST OCCUPATION NAME XsIGNATURe:_________________________________________________DATe:______________________________________ F O R M E R N A M E S ( M A I D E N , E T C . ) P R E F E R R E D N A M E ( N I C K N A M E , E T C . ) NAME BIRTHDATE AGE SSN NAME FORMER NA ME/SDD (MA IDEN, ETC.) PREFERRED NAME (NICKNAME, ETC.) MM / YY FORMER NAMES (MAIDEN, ETC.) PREFERPHONE RED NAM(E (NICKN)AME, ETC.) WORK ADDRESS WORK FINANCIAL POLICY BIRTHDATE AGE SSN MARITAL □ SINGLE □ M A R R I E D D R I V E R S P R I M A FINANCIAL POLICY MM / DD / YY BIR THDATE AGE SSN RY Itisyourresponsibilitytounderstandthelimitsandrestrictionsaffectingcoverageforservicesprovidedbyourspecialty.Ifyourinsurance PREFERRED BPRIMARY IR THDATECARE AGE S SN SEP/ DD □ WID / YY LICENSE# LANGUAGE STATUS □ DIV □ MM Itisyourresponsibilitytounderstandthelimitsandrestrictionsaffectingcoverageforservicesprovidedbyourspecialty.Ifyourinsurance Pcompanyrequiresyoutouseaspecificlab,itisyourresponsibilitytonotifyusofthat.Insurancereimbursementisacontractbetweenyou HYSICIAN □ SINGLEMM□/ DD RR EF MARITAL MA/ YY RRIED DRIVE SERRED BY PPRHIA MRAM RA YCY companyrequiresyoutouseaspecificlab,itisyourresponsibilitytonotifyusofthat.Insurancereimbursementisacontractbetweenyou MARITAL SINGLE □□ MAWID RRINative ED D RIVE□ RSAsian □ Black/African American P RIMARY □ Hispanic/Latino DIV □ SEP LICENSE# LANGUAGE STATUS □ □ andyourinsurancecompany.Asacourtesytoyouwewillfileallprimaryandsecondaryclaimsforyou.Youwillberesponsibleforallco-pays, RACE: American Indian/Alaska ETHNICITY: MARITAL □ SINGLE □ MARRIED DRIVERS PRIMARY LICENSE# LANGUAGE STATUS □ DIV □ SEP □ WID andyourinsurancecompany.Asacourtesytoyouwewillfileallprimaryandsecondaryclaimsforyou.Youwillberesponsibleforallco-pays, □ SEP □ WID Islander LICENSE# LANGUAGE□ Non-Hispanic/Latino □ Declined STATUS □ DIV deductibles,andco-insuranceamountsnotcoveredbyasecondaryinsurancepolicyalongwiththeentireamountofanynon-covered □ Native □ Caucasian □ Other □ Declined SPOUSE’S NAME BIRTHDATE Hawaiian/Pacific □ AmericanLAST □ Asian □ Black/African American deductibles,andco-insuranceamountsnotcoveredbyasecondaryinsurancepolicyalongwiththeentireamountofanynon-covered RACE: Indian/Alaska Native ETHNICITY: □ Hispanic/Latino FIRST M.I. MM / DD / YY service.Foryourconvenience,weacceptcash,personalchecks,VisaandMasterCard.Inordertobestmeetyourneeds,pleasecallour □ American Indian/Alaska Native □ Asian □ Black/African RACE: American ETHNICITY: □ Hispanic/Latino □ Other □ □ Declined service.Foryourconvenience,weacceptcash,personalchecks,VisaandMasterCard.Inordertobestmeetyourneeds,pleasecallour Native Hawaiian/Pacific Islander Caucasian Declined Non-Hispanic/Latino □ □ □ □ RACE: American Indian/Alaska Native Asian Black/African American ETHNICITY: Hispanic/Latino businessofficeat425-454-6674orrefertoourwebsiteifyouhavequestionsregardingourfinancialpolicy.Patientswhodonothave ADDRESS □ Native Hawaiian/Pacific Islander □ Caucasian □ Other □ CITYsTATe □ Non-Hispanic/Latino □ZDeclined Declined businessofficeat425-454-6674orrefertoourwebsiteifyouhavequestionsregardingourfinancialpolicy.Patientswhodonothave CITY STATE zIP IP APT# □ □ □ □ □ □ Declined Native Hawaiian/Pacific Islander Caucasian Other Declined Non-Hispanic/Latino Einsurancecoverage(orproofofcoverage)orwhochoosetopayfornon-coveredservicesareexpectedtopayinfullatthetimeofservice. MPLOYED BY OCCUPATION □ HOME ADDRESS insurancecoverage(orproofofcoverage)orwhochoosetopayfornon-coveredservicesareexpectedtopayinfullatthetimeofservice. Ifyoucannotpaythefullamountthenyoumustmakesatisfactorypaymentarrangementswithourbusinessofficepriortoreceivingservices. CITY STPRIMARY ATE zIP ZIPWORK APT# CITYsTATe ADDRESS □ Ifyoucannotpaythefullamountthenyoumustmakesatisfactorypaymentarrangementswithourbusinessofficepriortoreceivingservices. ADDRESS C ITY ) STNUMBER ATE zIP ZIPCELL CITYsTATe ) )INSURANCEAPT# ( □ INFORMATION HOME ( WORK ( CELL CITY STATE zIP ZIPHOME APT# CITYsTATe XsIGNATURe:_________________________________________________DATe:______________________________________ □ HOME PRIMARY WORK XsIGNATURe:_________________________________________________DATe:______________________________________ □ PRIMA(RY ) ID# ROU P#NUMBER □ WEBSITE PRIMARY □ HOME ) ) WORK HOW G DID YOU CELL HOME WORK ( CELL□( PERSONAL PRIMARY □ WORK □ ( ) ( ) ( ) □ REFERRAL CELL HOME ( WORK ( CELL□( WORK EMAIL HEAR ABOUTNUMBER US ? ) ) ) □ CELL HOME WORK CELL NUMBER □ AD CARE WEBSITE □ PERSONAL PERMISSION PAST YES HOW G DID YOU SPREVENTATIVE ECONDARY ID# ROTO U PACCESS # PREVENTATIVE CARE □ WEBSITE REFERRAL □ PERSONAL HOW YOUUS ?(PBM) WORK MEDICATION HISTORY NO EMAIL HEAR DID ABOUT Yourhealthinsuranceplanmaynotprovidecoverageforpreventiveservices.Itisimportantthatyoucontactyourinsuranceproviderto □ WEBSITE □ HOW DID YOU PERSONAL □ AD REFERRAL □ WORK EMAIL E MYourhealthinsuranceplanmaynotprovidecoverageforpreventiveservices.Itisimportantthatyoucontactyourinsuranceproviderto P L O Y E D B Y O C C U P A T I O N HEAR ABOUT US ? □ REFERRAL □ determineifyourplanoffersbenefitsforthisserviceandwhattheirschedulingguidelinesareforit.Weuseindustrystandardcodesand EMAIL □ YES □ NO HEAR ABOUT US ? □ AD IS ANYONE OTHER THAN PATIENT THE MAIN POLICY HOLDER ON INSURANCE? WORK □ AD determineifyourplanoffersbenefitsforthisserviceandwhattheirschedulingguidelinesareforit.Weuseindustrystandardcodesand YES, EIF Mguidelinestosubmitclaimstotheinsurancecompaniesbasedonthescheduledencounteranddocumentationinthepatient’smedical P LOYPLEASE ED BY COMPLETE POLICY HOLDER’S INSURANCE INFORMATION OCCUPATION guidelinestosubmitclaimstotheinsurancecompaniesbasedonthescheduledencounteranddocumentationinthepatient’smedical ) E MPLOADDRESS YED BY OCCUPATION WORK WORK PHONE ( EMrecord.Currentlawsregardingfraudandabusewithbillingproceduresprohibitusfromchangingtheprocedurecodesand/ordiagnosis PLOYED BY CCUPATION record.Currentlawsregardingfraudandabusewithbillingproceduresprohibitusfromchangingtheprocedurecodesand/ordiagnosis POLICY HOLDER’S INSURANCE OINFORMATION codesinordertogettheclaimpaidbytheinsurancecompany.DsHsdoesnotpayforannualexams,paymentisyourresponsibility. PREFERRED ) WORK ADDRESS WORK PHONE ( PRIMARY CARE PREFERRED codesinordertogettheclaimpaidbytheinsurancecompany.DsHsdoesnotpayforannualexams,paymentisyourresponsibility. PHARMACY ) &HLOCATION WORK WORK PHONE P HXsIGNATURe:_________________________________________________DATe:______________________________________ YSICADDRESS IOF ANINSURED REFERRED BY P ARM ACY ( NAME ) WORK ADDRESS WORK PHONE ( LAST FIRST M.I. PRIMARY CARE PREFERRED XsIGNATURe:_________________________________________________DATe:______________________________________ P HYSICIAN REFERRED BY PHARMACY PRIMARY CARE PREFERRED PRIMARY CARE PREFERRED RELATIONSHIP TO INSURED ID# P HYSICIAN REFERRED BY PHARMACY SPOUSE’S NAME BIRTHDATE PHNOTICE YSICIAN TO ERLAST REFEFIRST RRED BY PHARMACY PATIENTS M.I. MM / DD / YY Overlake Obstetricians and Gynecologists, PC PATIENT REGISTRATION FORM Overlake Obstetricians and Gynecologists, PC Overlake Obstetricians and Gynecologists, Overlake Obstetricians and Gynecologists, PC PC PATIENT REGISTRATION FORM PATIENT PATIENT REGISTRATION REGISTRATION FORM FORM NOTICE TO ER PATIENTS Thepurposeofthisnoticeistoinformyouthatyourvisitinourclinictodayisareferralforfollow-uptoyourvisitintheemergencyRoom. SPOUSE’S NAME BIRTHDATE BIRTHDATE EMPLOYED BY Thepurposeofthisnoticeistoinformyouthatyourvisitinourclinictodayisareferralforfollow-uptoyourvisitintheemergencyRoom. EMPLOYED BY OCCUPATION LAST FIRST M.I. MM / DD / YY SPOUSE’S NAME BIRTHDATE MM / DD / YY Today’sappointmentisindependentofyourvisittothehospitalandyouwillbebilledfortheservicesrendered.Thisvisitdoesnotestablish SPOUSE’S BIRTHDATE LAST FIRST M.I. MM / DD / YY EMToday’sappointmentisindependentofyourvisittothehospitalandyouwillbebilledfortheservicesrendered.Thisvisitdoesnotestablish PLOYEDNAME BY OCCUPATION LAST FIRST M.I. MM / DD / YY youasapatientofOverlakeObstetriciansandGynecologists,PC. HOW DID YOU HEAR ABOUT US? youasapatientofOverlakeObstetriciansandGynecologists,PC. EMPLOYED BY OCCUPATION CONTACT NAME OF PERSON WITH YOU: NOT LIVINGINFORMATION INSURANCE ELOCAL MXsIGNATURe:_________________________________________________DATe:______________________________________ PLOYEEMERGENCY D BY OCCUPATION EMXsIGNATURe:_________________________________________________DATe:______________________________________ PLOYED BY OCCUPATION PN RA IM A R Y I D # INSURANCE INFORMATION ME RELATIONSHIP PHONEGROUP# INFORMATION AUTHORIZATION TO SHARE HEALTH CAREINSURANCE INFORMATION INSURANCE INFORMATION P ICM IID G TO SHARE HEALTH CARE INFORMATION SR EAUTHORIZATION OANRDYARY D# # GR RO OU UP P# # 04/14 (PLEASE GIVE ALL INSURANCE CARDS TO RECEPTIONIST)G PRYoumaysharethefollowinghealthcareinformationwith: IMARY ID# ROUP# PRYoumaysharethefollowinghealthcareinformationwith: IMARY ID# GROUP# (over) SEName:_____________________________________________Relationship:____________________________________________ CONDARY ID# GROUP# SIS ECANYONE ONDARYOTHER THAN PATIENT THE MAIN POLICY HOLDERIDON # INSURANCE? □ YES □ NO GROUP# SEName:_____________________________________________Relationship:____________________________________________ CONDARY ID# GROUP# IF Pleasecheckallthatapply: YES, PLEASE COMPLETE POLICY HOLDER’S INSURANCE INFORMATION □ □ IS ANYONE OTHER THAN PATIENT THE MAIN POLICY HOLDER ON INSURANCE? YES NO 458664 Overlake OB-GYN.indd 3/12/13 4:12 PM Patient Registration Form 5.2012.pdf1 1 3/12/13 4:10:07 PM □ YES □ NO ISPleasecheckallthatapply: ANYONE OTHER THAN PATIENT THEPOLICY MAIN POLICY HOLDER ON INSURANCE? Insuranceandbillinginformation HOLDER’S INSURANCE INFORMATION 476105_Overlake_Comp.indd 1 COMPLETE 4/30/14 7:25 AM □ YES □ NO ISAllhealthcareinformationinmymedicalrecord ANYONE OTHER THAN PATIENT MAIN POLICY HOLDER ON INSURANCE? IF YES, PLEASE POLICY THE HOLDER’S INSURANCE INFORMATION Allhealthcareinformationinmymedicalrecord Insuranceandbillinginformation IF Healthcareinformationinmymedicalrecordrelatingtothefollowingtreatment:__________________________________________ YES, PLEASE COMPLETE POLICY HOLDER’S INSURANCE INFORMATION IF YES, PLEASE COMPLETE POLICY HOLDER’S POLICYINSURANCE HOLDER’SINFORMATION INSURANCE INFORMATION Healthcareinformationinmymedicalrecordrelatingtothefollowingtreatment:__________________________________________ NAME OF INSURED POLICY HOLDER’S INSURANCE INFORMATION Other(appointments,testresults,etc.) LAST M.I. POLICY HOLDER’S INSURANCEFIRST INFORMATION Other(appointments,testresults,etc.) INSURANCE INFORMATION NAME OF INSURED Thisauthorizationends: RELATIONSHIP TO INSUREDLAST ID# Iauthorizetreatmentandagreetopayallfeesassociatedwithsuchtreatment.Iauthorizemyinsurancebenefitstobepaiddirectlytomy NAME OF INSURED FIRST M.I. Thisauthorizationends: NAME OF INSUREDwill be inLAST This authorization effect until otherwise notified by the patient. FIRST M.I. In90daysfromthedatesigned On(date):_____________________ physician.Iauthorizemyphysiciantoreleaseanyinformationrequiredtoprocessmyclaim.IagreethatIamfinanciallyresponsibleforall FIRST M.I. In90daysfromthedatesigned On(date):_____________________ RELATIONSHIP TO INSUREDLAST ID# BIRTHDATE EMPLOYED BY servicesprovidedandshoulditbenecessarytorefertheaccounttocollectionsIwillberesponsibleforallcollectionfees,collectioncosts, • Mayleavedetailedmessageonvoicemailat:Home#________________Work#________________Cell#________________ RELATIONSHIP TO INSURED ID# MM / DD / YY RELATIONSHIP TO INSURED ID# • Mayleavedetailedmessageonvoicemailat:Home#________________Work#________________Cell#________________ attorneyfeesandcourtcostsinvolvedwithmyaccount. BIRTHDATE EMPLOYED BY • Mayleaveinformationwith:spouse/PartnerorFamilyMemberName:_______________________________________ • Mayleaveinformationwith:spouse/PartnerorFamilyMemberName:_______________________________________ BIRTHDATE EMPLOYED BY MM / DD / YY BIRTHDATE EMPLOYED BY • MaysendtexttoremindyouofupcomingappointmentsYesNoto#______________________ XsIGNATURe:_________________________________________________DATe:______________________________________ MM / DD / YY LOCAL EMERGENCY CONTACT OF PERSON NOT LIVING WITH YOU: • MaysendtexttoremindyouofupcomingappointmentsYesNoto#______________________ MM / DD /NAME YY XsIGNATURe:_________________________________________________DATe:______________________________________ LOCAL CONTACT NAME OF PERSON NOT YOU: XsIGNATURe:_________________________________________________DATe:______________________________________ NANOTICE ME EMERGENCY RELALIVING TIONSHWITH IP PHONE OF PRIVACY PRACTICES - ACKNOWLEDGMENT LOCAL EMERGENCY CONTACT NAME– OF PERSON NOT LIVING WITH YOU: NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT LOCAL EMERGENCY CONTACT NAME OF PERSON NOT LIVING WITH YOU: Wekeeparecordofthehealthcareservicesweprovideyou.Youmayasktoseeandcopythatrecord.Youmayalsoasktocorrect NAWe MEkeep a record of the health care services we provide you. RELAYou TIOmay NSHask IP to see and copy that record. You PHO NE also ask to correct that04/14 may (PLEASE GIVE ALL INSURANCE CARDS TO RECEPTIONIST) thatrecord.Wewillnotdiscloseyourrecordtoothersunlessyoudirectustodosoorunlessthelawauthorizesorcompelsustodoso. NArecord. ME RELA TIONus SHIPdo PHO E direct orN us to do so. You NAME We will not disclose your record to others unless you RELA TIONSHto IP so or unless the law authorizes PHO Ncompels E (over) YoumayseeyourrecordorgetmoreinformationaboutitbycontactingourMedicalRecordsDepartmentorPrivacyOfficer. may see your record or get more information about it by contacting our Medical Records Department or Privacy Officer. 04/14 (PLEASE GIVE ALL INSURANCE CARDS TO RECEPTIONIST) 476105_Overlake_Comp.indd 2 4/30/14 7:25 AM 04/14 7:25 AM 476105_Overlake_Comp.indd 2 4/30/14 (PLEASE 04/14 (over) (PLEASE GIVE GIVE ALL ALL INSURANCE INSURANCE CARDS CARDS TO TO RECEPTIONIST) RECEPTIONIST) XsIGNATURe:_________________________________________________DATe:______________________________________ 458664 Overlake OB-GYN.indd Patient Registration Form 5.2012.pdf1 1 476105_Overlake_Comp.indd 1 FINANCIAL POLICY 458664 Overlake OB-GYN.indd Patient Registration Form 5.2012.pdf1 1 476105_Overlake_Comp.indd 458664 Overlake OB-GYN.indd 11 1 Patient Registration Form 5.2012.pdf (over) 3/12/13 4:12 PM 3/12/13 4:10:07 PM (over)(over) 08/15 4/30/14 7:25 AM 3/12/13 4:12 PM 3/12/13 4:10:07 PM 4/30/14 3/12/13 7:25 4:12 AM PM 3/12/13 4:10:07 PM LOCAL EMERGENCY CONTACT NAME OF PERSON NOT LIVING WITH YOU: NAME RELATIONSHIP PHONE (PLEASE GIVE ALL INSURANCE CARDS TO RECEPTIONIST) 04/14 (over) INSURANCE INFORMATION 458664 Overlake OB-GYN.indd 3/12/13 4:12 PM Patient Registration Form 5.2012.pdf1 1 3/12/13 4:10:07 PM Iauthorizetreatmentandagreetopayallfeesassociatedwithsuchtreatment.Iauthorizemyinsurancebenefitstobepaiddirectlytomy 476105_Overlake_Comp.indd 1 4/30/14 7:25 AM physician.Iauthorizemyphysiciantoreleaseanyinformationrequiredtoprocessmyclaim.IagreethatIamfinanciallyresponsibleforall servicesprovidedandshoulditbenecessarytorefertheaccounttocollectionsIwillberesponsibleforallcollectionfees,collectioncosts, attorneyfeesandcourtcostsinvolvedwithmyaccount. XsIGNATURe:_________________________________________________DATe:______________________________________ X SIGNATURE: DATE: NOTICE PRIVACY PRACTICES - ACKNOWLEDGMENT PRIMARYOF INSURANCE ID# GROUP # Wekeeparecordofthehealthcareservicesweprovideyou.Youmayasktoseeandcopythatrecord.Youmayalsoasktocorrect thatrecord.Wewillnotdiscloseyourrecordtoothersunlessyoudirectustodosoorunlessthelawauthorizesorcompelsustodoso. PRIMARYSUBSCRIBERS SUBSCRIBER NAME DOB YoumayseeyourrecordorgetmoreinformationaboutitbycontactingourMedicalRecordsDepartmentorPrivacyOfficer. XsIGNATURe:_________________________________________________DATe:______________________________________ SECONDARY INSURANCE ID# GROUP # SECONDARYSUBSCRIBERS FINANCIAL POLICY SUBSCRIBER NAME DOB Itisyourresponsibilitytounderstandthelimitsandrestrictionsaffectingcoverageforservicesprovidedbyourspecialty.Ifyourinsurance companyrequiresyoutouseaspecificlab,itisyourresponsibilitytonotifyusofthat.Insurancereimbursementisacontractbetweenyou andyourinsurancecompany.Asacourtesytoyouwewillfileallprimaryandsecondaryclaimsforyou.Youwillberesponsibleforallco-pays, deductibles,andco-insuranceamountsnotcoveredbyasecondaryinsurancepolicyalongwiththeentireamountofanynon-covered service.Foryourconvenience,weacceptcash,personalchecks,VisaandMasterCard.Inordertobestmeetyourneeds,pleasecallour businessofficeat425-454-6674orrefertoourwebsiteifyouhavequestionsregardingourfinancialpolicy.Patientswhodonothave insurancecoverage(orproofofcoverage)orwhochoosetopayfornon-coveredservicesareexpectedtopayinfullatthetimeofservice. Ifyoucannotpaythefullamountthenyoumustmakesatisfactorypaymentarrangementswithourbusinessofficepriortoreceivingservices. XsIGNATURe:_________________________________________________DATe:______________________________________ PREVENTATIVE CARE Yourhealthinsuranceplanmaynotprovidecoverageforpreventiveservices.Itisimportantthatyoucontactyourinsuranceproviderto determineifyourplanoffersbenefitsforthisserviceandwhattheirschedulingguidelinesareforit.Weuseindustrystandardcodesand guidelinestosubmitclaimstotheinsurancecompaniesbasedonthescheduledencounteranddocumentationinthepatient’smedical record.Currentlawsregardingfraudandabusewithbillingproceduresprohibitusfromchangingtheprocedurecodesand/ordiagnosis codesinordertogettheclaimpaidbytheinsurancecompany.DsHsdoesnotpayforannualexams,paymentisyourresponsibility. XsIGNATURe:_________________________________________________DATe:______________________________________ NOTICE TO ER PATIENTS Thepurposeofthisnoticeistoinformyouthatyourvisitinourclinictodayisareferralforfollow-uptoyourvisitintheemergencyRoom. Today’sappointmentisindependentofyourvisittothehospitalandyouwillbebilledfortheservicesrendered.Thisvisitdoesnotestablish youasapatientofOverlakeObstetriciansandGynecologists,PC. XsIGNATURe:_________________________________________________DATe:______________________________________ AUTHORIZATION TO SHARE HEALTH CARE INFORMATION Youmaysharethefollowinghealthcareinformationwith: Name:_____________________________________________Relationship:____________________________________________ Pleasecheckallthatapply: Allhealthcareinformationinmymedicalrecord Insuranceandbillinginformation Healthcareinformationinmymedicalrecordrelatingtothefollowingtreatment:__________________________________________ Other(appointments,testresults,etc.) Thisauthorizationends: In90daysfromthedatesigned On(date):_____________________ • Mayleavedetailedmessageonvoicemailat:Home#________________Work#________________Cell#________________ • Mayleaveinformationwith:spouse/PartnerorFamilyMemberName:_______________________________________ • MaysendtexttoremindyouofupcomingappointmentsYesNoto#______________________ XsIGNATURe:_________________________________________________DATe:______________________________________
