Dr. T and the Magnolia Staff - Magnolia Women`s Healthcare

Welcome! We thank you for choosing us for your Obstetric and Gynecological healthcare
needs, and we are excited to have you as a new patient. Here at Magnolia Women’s
Healthcare, we want you to experience women’s care differently. Our staff strive to make
each visit to our office pleasant and comfortable, in our warm and welcoming atmosphere.
We look forward to showing you the Magnolia Women’s approach to healthcare –
medically, personally and professionally.
Dr. T and the Magnolia Staff
Practice Policies and Procedures:
Appointments:
We encourage every patient to do their best to make each appointment. If you cannot keep your scheduled
appointment, please call to reschedule or cancel within 24 hours of your appointment date and time. This allows our
schedule to open up for other patients that may need to schedule an appointment.
Upon arrival, please check-in with the receptionist 5-10 minutes prior to your appointment to give yourself enough
time for registration. If you are an established patient (someone seen by our practice in the past year) you will be asked
to verify your address, phone number, and insurance information. If you are a new patient, you will be asked to fill out
all of the “new patient” paperwork. Magnolia Women’s Healthcare updates all patient information every year in
accordance with federal regulations, insurance requirements, and as needed. As a result, you make be asked to review
and update certain information upon arrival to your appointment.
Your cooperation with our process is greatly appreciated. Regardless if you are a new patient or an established patient
you should always bring your current insurance information and a government form of identification (parents of
minors may be asked for their identification) to all of your office visits.
Because we know your time is valuable, we make every effort to honor your appointment time and recognize the
inconvenience of unexpected waiting periods. However, in a specialty OB/GYN office, we occasionally experience
unexpected delays due to deliveries or emergencies. Our receptionist will notify you if your healthcare provider is
running behind and offer you a choice of leaving and coming back when we are ready for you or rescheduling your
appointment. If you ever feel that you have been overlooked, please check with the receptionist.
Co-payments, deductibles, and time of service payments:
Co-pays:
Insurance companies will often require their patients to pay a “co-pay” for their office visits. The amount of your copay may or may not be listed on your insurance card. All co-pays required by your insurance company will be collected
upon your arrival at check-in.
Deductibles:
Now more than ever, deductibles have become a part of family and/or individual insurance plans. Your deductible is
considered to be your out-of-pocket expense that must be paid by you before your insurance company will cover your
medical expenses. Deductibles in healthcare can range anywhere from $100 to $10,000. It is always the policy holder’s
(patient’s) responsibility to know their insurance plan and the amount of their deductible. Here at Magnolia Women’s
Healthcare our policy is to collect a payment toward deductibles at the time of service. Meaning, if you have not yet
met your deductible you may be expected to pay your out-of-pocket expense on the day of your office visit.
Time of Service Payments:
Patients who have not reached their deductible or who do not have insurance are expected to pay for their medical
services at the time of their visit. If you have questions regarding what services will be applied to your deductible
please contact your insurance company. After speaking with your insurance company if you have any further questions
regarding billing and payment plan options please contact our Patient Advocate.
Patients who do not have insurance are eligible to receive a discount for paying in full for their office services at the
time of their visit. The payment collected at check-in is for the office visit only. Any labs or testing performed will be
additional. Please contact our billing department for more information.
*Note: Magnolia Women’s Healthcare will apply a $35 NSF fee on all checks returned for insufficient funds.*
Obstetrical Patients:
Because obstetrical care for visits and delivery is not billed out until after the delivery, you will be required to make
monthly payments during your prenatal care for any amounts not covered by your insurance company. If your
insurance company does not cover 100% of your OB care, we would encourage you to maintain a debit or credit card
on file in order to have your monthly payments processed automatically. Our office will work with your insurance
company to determine an estimated patient amount due. We will contact you to work out a payment plan, with the
intention of having the estimated portion due paid prior to delivery. Please contact East Georgia Regional Medical
Center to set up any special arrangements for payment they may require.
Prescription Refills:
Please allow at least 24 hours for all prescription refill requests. In order to request a refill on your medication you must
first contact your pharmacy (including when your prescription is out of refills). Your pharmacy will then send Magnolia
Women’s Healthcare an electronic refill request. If your prescribing provider has any questions regarding the request
they will contact you, otherwise, we will respond electronically to the pharmacy and they will process the request.
If you would like to transfer your prescriptions between pharmacies, please contact your new pharmacy and they will
request the transfer of records from your old pharmacy for you.
If you are changing to a mail order pharmacy please contact our office with the phone number and fax number of
pharmacy.
Magnolia Women’s Healthcare can only refill prescriptions that our healthcare provider has originally written. If you are
seeking a refill on a prescription that was not written by Magnolia Women’s Healthcare, you will need to make an
appointment so our providers can review your medical need.
Privacy Policy:
We respect your right to privacy. Any and all information collected at this site will be kept strictly confidential and will
not be sold, reused, rented, loaned, or otherwise disclosed. Any information you give to Magnolia Women’s Healthcare
will be held with the utmost care, and will not be used in ways to which you have not consented. A more detailed
explanation about how we care for your personal information is described below. If you have any questions, please
don't hesitate to let us know.
I have read the above policies and procedures that are established by Magnolia Women’s Healthcare and I agree to all
terms and conditions.
Print Name: __________________________________________________ Date:_____________________
Sign Name: ___________________________________________________ Date:_____________________
New Patient Demographics
How did you hear about our practice?_______________________ Referring Doctor:___________________________
Preferred Pharmacy:________________________________________________ City:__________________________
Patient Name:_____________________________________________________________________________________
First
Middle
Last
Preferred Name:__________________________
Primary Language:______________________
Date of Birth:_____________________________
SSN:___________-___________-__________
Parent or Guardian Name (if patient is under the age of 18):______________________________________________
Race: (Circle One)
American Ind./Alaska Native
Asian
Native Hawaiian/Pacific Islander
Ethnicity: (Circle One)
Hispanic/Latino
Marital Status: (Circle One)
Single
Black/African American
White
Other
Declined
Not Hispanic/Latino
Married
Divorced
Widowed
Address:______________________________________________________________________________________
City:_________________________________
State:__________________
Zip Code:_________________
Phone: Home:__________________________ Cell:__________________________
Email:____________________________________________
Employer:_____________________________________________________________________________________
Employer Address:____________________________________ City/State/Zip:_____________________________
Work Phone Number: _________________________ Ext:__________
Emergency Contact:
Name:______________________________Relationship:________________Phone:________________________
Insurance:
Primary:__________________________________ Policy #:_________________________________________
Policy Holder:______________________________ Relationship:______________ DOB:__________________
Secondary:________________________________ Policy #:_________________________________________
Policy Holder:______________________________ Relationship:______________ DOB:__________________
It is the policy of this office to pay for services in full when rendered except in cases of pregnancy or surgery. If this applies
to you, we will file your claim and you will be expected to pay only what the insurance does not pay. You must have your
current insurance card at time of service or you will be expected to pay in full. Insurance is not a guarantee of payment. It
is your responsibility to confirm your benefits.
In case any of the above named companies or individuals fail to make prompt payment, I hereby give my personal
guarantee of payment for all charges herein incurred. If this account is placed with a collection agency, the undersigned
parties agree to pay all fees for cost of collections.
I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non- covered
services. I also authorize the physician to release any information for the processing of this claim.
Patient or Guardian Signature: ___________________________________________________ Date:____________
HIPAA PRIVACY RULE: Please list the parties that you authorize Magnolia Women’s Healthcare to disclose your protected
health information (PHI). MUST BE FILLED OUT BY PATIENT ONLY
Name: _____________________________________________________
Relationship:_________________________________________________
Name: _______________________________________________________
Relationship: __________________________________________________
I HAVE RECEIVED/READ A COPY OF MAGNOLIA WOMEN’S HEALTHCARE NOTICE OF PRIVACY PRACTICES.
Patient or Guardian Signature:_________________________________________________ Date:______________
We understand that unplanned issues can come up and you may need to cancel an
appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled
at least 24 hours in advance.
Our doctor wants to be available for your needs and the needs of all our patients. When a
patient does not show up for a scheduled appointment, another patient loses an opportunity
to be seen.
Therefore, if you do not call to cancel your appointment 24 hours in advance, and/or do not
show up for your scheduled appointment, you will be marked as a “no show.” After 3 “no
shows,” you will then be discharged from our care. If you arrive more than 15 minutes past
your appointment time you will have to reschedule or be a “work in” and may have to wait
longer than expected.
Thank you for being a valued patient and for your understanding and cooperation as we
institute this policy. This policy will enable us to open otherwise unused appointments to
better serve the needs of all patients.
I, _______________________________, have read the above “No Show and Cancellation
Policy” for Magnolia Women’s Healthcare. I understand the policy and procedures and agree
to adhere to the guidelines. If I do not, I understand that I may be discharged from the practice
after 3 “no shows.”
Signature:_________________________________________ Date:_________________
Legal Assignment of Benefits and Release of Medical and Plan Documents
In considering the amount of medical expenses to be incurred, I, the undersigned, have Insurance
and/or employee health care benefits coverage with
___________________________________________________________________________
and hereby assign and convey directly to Dr. Nick Toussaint and Magnolia Women’s Healthcare all medical
benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such
physician and clinic. I understand that I am financially responsible for all charges regardless of any applicable
insurance or benefit payments. I hereby authorized the physician/clinic to release all medical information
necessary to process this claim. I hereby authorize any plan administrator or fiduciary, Insurer and my
attorney to release such physician and clinic any and all plan documents, insurance policy, and/or settlement
information upon written request from such physician and clinic in order to claim such medical benefits,
reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or
employee health benefits claim submissions.
I hereby convey to the above named provider to the full extent permissible under the law and under
any applicable insurance policies and/or employee health care plan any claim, action, or other right I may have
to such insurance and/or employee health care benefits coverage under any applicable insurance policies
and/or employee heal care plan with respect to medical expenses incurred as a result of the medical services I
received from the above named physician and clinic and to the extent permissible under the law to claim such
medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any
reasonable request for cooperation, I agree to cooperate with such physician and clinic in any attempts by
such physician and clinic to pursue such claim, action, or right against my insurers and /or employee health
care plan, including, if necessary bring suit with such physician and clinic against such insurers and/or
employee health care plan in my name but at such physician and clinic’s expense.
This lifetime assignment will include every spouse and/or dependent on my policy and will remain in
effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the
original. I have read and fully understand this agreement.
Policy Holder Name
Date
______________________________________________
_______________________
Policy Holder Signature
Date
_______________________________________________
________________________
Access to the Patient Portal
We are now enrolling patients for access to the Patient Portal. With the Patient Portal, you
have the ability to connect with Dr. Toussaint in a timely, secure, and convenient manner. You
are able to access many parts of your personal medical record, including lab results.
Patient name:
Date of birth:
Email address:
Access to the patient portal was offered to me on / /
□ I would like access to my personal medical record, including lab results, through the
patient portal
□ I decline my access to the patient portal
If declining access, please answer the following question:
□ I have access to internet or email
o Yes
o No
Signature:______________________________________Date:________________
Updated 07/23/14 BT
Magnolia Women’s Healthcare
Patient Medical History Form
Name:_______________________________________ DOB:____/_____/______ Today’s Date: ____/_____/______
Primary Care Physician:____________________________________________________________________________
Personal Medical History: Have you ever had any of the following conditions?
___ Anemia
___ Genetic Condition
___ Anxiety Disorder
___ Gallbladder disorder
___ Arthritis
___History of Alcoholism
___ Blood Clots
___History of blood transfusion
___ Chickenpox
___Heart Disease
___ High Cholesterol
___ Hepatitis A
___ Diabetes, Type 1
___ Hepatitis B
___ Diabetes, Type 2
___ Hepatitis C
___Esophageal Reflux
___Hypercholesterolemia
___ Cancer, what kind?________________________
___ Allergies, what kind?_______________________
___Other:_____________________________________________
___ Hyperlipidemia
___Hypertension, Benign
___ Hypertension, Malignant
___Kidney infection
___ Liver Disease
___ Migraine
___Mitral Valve Prolapse
___ Pneumonia
___ Seizures
___ Sickle Cell Disease
___Stroke
___ Thyroid disorder
___Tobacco Use
___Tuberculosis
___ Urinary Tract Infections
Family Medical History: Has any of your family members had any of the following conditions?
___ Anemia
___ Genetic Condition
___ Hyperlipidemia
___ Anxiety Disorder
___ Gallbladder disorder
___Hypertension, Benign
___ Arthritis
___History of Alcoholism
___ Hypertension, Malignant
___ Blood Clots
___History of blood transfusion
___Kidney infection
___ Chickenpox
___Heart Disease
___ Liver Disease
___ High Cholesterol
___ Hepatitis A
___ Migraine
___ Diabetes, Type 1
___ Hepatitis B
___Mitral Valve Prolapse
___ Diabetes, Type 2
___ Hepatitis C
___ Pneumonia
___Esophageal Reflux
___Hypercholesterolemia
___ Seizures
___ Cancer, what kind? ________________________
___ Sickle Cell Disease
___ Allergies, what kind? _______________________
___Stroke
___ Thyroid disorder
___Tobacco Use
___Other:_____________________________________________
___Tuberculosis
___ Urinary Tract Infections
Surgical History: Please list all surgeries you have had and dates below.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Obstetrical History:
____Check here if you have never been pregnant.
Please list all pregnancies in order, including miscarriages, premature births, stillbirths, ectopics, and abortions.
Delivery Date
M/F
Birth Weight
Type of Delivery
Length of Pregnancy
Problems
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Gynecological History:
Age of first period:_____
Age of last period:_____
Cycle Length: Every _____ days
Lasting _____days
Periods are:
____Regular
Flow is:
____Irregular
____ Painful
____Not really bothersome
____Light
____ Light to Moderate
____ Moderate to heavy
____ Very heavy
Are you sexually active? ___Yes ___No
Method of Birth Control?________________________________________________________________________
Have you ever had any of the following STDs?
____Chlamydia
____ Syphilis
____ Gonorrhea
____ Trichomoniasis
____ Herpes
____ HIV
____ HPV
____ Hepatitis B
____ Genital Warts
____ Hepatitis C
Have you ever had any of the following?
____Fibrocystic Breasts
____ Ovarian Cysts
____ Endometriosis
____ Uterine Fibroids
Date of last menstrual cycle: ________________________________________
Tampon use___Yes ___No Pad Use___Yes ___No
Approximately how many do you use on a daily basis?___________
Date of last pap smear:__________________________________________Normal_____ Abnormal_____
Date of last mammogram: _______________________________________ Normal_____ Abnormal_____
Date of last bone density:________________________________________ Normal_____ Abnormal_____
Date of last colonoscopy: :________________________________________Normal_____ Abnormal_____
Social History:
Alcohol use
Tobacco use
Street drug use
Sexual Abuse
Physical Abuse
Emotional Abuse
___Yes ___No
___Yes ___No
___Yes ___No
___Yes ___No
___Yes ___No
___Yes ___No
If yes, ______drink(s) per day/week/month
If yes, ______ pack(s) per day for _____years
Type and frequency_____________________
If yes, are you safe now?
___Yes ___No
Counseling? ___Yes ___No
If yes, are you safe now?
___Yes ___No
Counseling? ___Yes ___No
If yes, are you safe now?
___Yes ___No
Counseling? ___Yes ___No
Current Medication List:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Patient Signature________________________________
Clinician Signature_______________________________
Date____________________
Date____________________
Annual Review #2 Clinician Signature_______________________________
Annual Review #3 Clinician Signature_______________________________
Revised 04/30/2014
Date____________________
Date____________________