General Info Sheet - Chattanooga Center For Women

Chattanooga Center for Women, PC and Jack M Rowland, MD, PLLC
Phone: (423)648-6020
2015
Fax: (423) 648-6025
PATIENT-FINANCIAL INFORMATION AND AUTHORIZATION
**Please check the box next to the name of the provider you are scheduled to see:
Gary Brunvoll, DO
Sabrina Collins, MD
Jack Rowland, MD
Sarah Smith, DNP, CNM
Katie Garrett, CNM
Amy Miller-Anderson, CNM
Meg Brasel, CNM
Last Name: _____________________________ First: _______________________________ MI: _______
Name you prefer to be called by: _______________________ Maiden: ______________ Race: __________
DOB: ____________ SSN# ________________ Marital Status: Married
Driver’s License: ____________________________
Single
Divorced
Widowed
Primary Language: __________________________
Address: __________________________ Apt: _______City: _______________ State: _____ Zip: _______
Home #
_________________________________
Work #
_________________________________
Cell #
_________________________________
**It is our office policy to use these #’s to contact you. **
Employer: ____________________________________ Occupation: _________________ Dept: _________
In case of Emergency Notification (someone NOT living in your home):
Name: _________________________________ Relationship: ______________ Phone: ________________
Do you have a living will?
Yes
No
If “yes”, have you provided us with a copy?
Yes
No
Primary Insurance
Secondary Insurance
Ins. Company: _____________________________
Ins. Company: ______________________________
Address: __________________________________
Address: ___________________________________
__________________________________
___________________________________
Phone #___________________________________
Phone # ___________________________________
Your ID/Subscriber #: _______________________
Your ID/Subscriber #: ________________________
Your Group #: _____________________________
Your Group #: ______________________________
Policy Holder’s Name: ______________________
Policy Holder’s Name: _______________________
Policy Holder’s SSN#:_______________________
Policy Holder’s SSN#:________________________
Policy Holder’s DOB: _______________________
Policy Holder’s DOB: ________________________
Policy Holder’s Employer: ___________________
Policy Holder’s Employer: ____________________
(PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM)
FINANCIAL CONSENT:
I have read and understand the Patient Information form provided on the reverse side, and do
hereby confirm that all the information I have supplied is true and correct, to the best of my knowledge.
I agree to notify Chattanooga Center for Women, PC (here after named as “CCW”) and/or Jack M. Rowland, MD, PLLC in a timely
manner of any changes to my health status, demographic, or financial/insurance information.
I hereby acknowledge that I am ultimately responsible for the full payment of any and all fees for services provided to me. I
authorize both entities to furnish my insurance company all the information necessary to process claims in a timely manner. The
filing of claims with any insurance carrier is a courtesy and does not in any way relieve me of my financial responsibility for the cost
of services rendered. Reminder: A verification of benefits does not guarantee payment. Payment is issued based on the benefits
that are in effect at the time of service.
I waive all rights of exemption under the laws of the State.
Most lab services are billed by a laboratory that employs the phlebotomist we have on-site. However, some of the testing can be
filed by our office. You will receive a statement from each company for any balances due after your insurance carrier has processed
the claim, or sooner if you are a self-paying patient.
There is a separate administrative fee for the processing of any outside forms received by our office. This fee must be paid in full
prior to the completion of these forms. The process of copying medical records is also a billable charge depending on the number of
pages being requested.
I understand that certain procedures are not covered by Medicare and/or Medicaid. If I request a non-covered Medicare or Medicaid
procedure, I will be financially responsible for that service and agree to pay all fees and charges.
I understand that co-payments will be collected at the time services are rendered. I further agree to pay any “return check” fee posted
to my account as a result of the bank notifying this office of a “stop pay” or “insufficient funds” status. I also agree to pay all
collection costs of no less than 33% of the uncollectible balance, as well as any court costs and/or attorney fees, should the agency
choose to pursue legal action.
Please be advised that Drs. Brunvoll & Rowland have an investment interest in the Physician’s Surgery Center of Chattanooga and
Drs. Brunvoll and Collins have an interest investment in Women’s Diagnostic Center.
_____________________________________________________________________________________
Who may we thank for referring you to our office?
Friend/Relative
Ins. Directory
( Please Check )
Phone Book
Hospital
Other
*If referred by a medical provider, please list his/her name: Last: _______________ First: _______________
_____________________________________________________________________________________
HIPAA: I authorize the individual listed below to have access to the following information contained in my records
(circle all that apply): MEDICAL FINANCIAL BOTH. You may revoke this authorization in writing at any time.
Name: ________________________________________ Relationship to the Patient: ________________________
I have received notice of the “Private Practices” observed by the office of Chattanooga Center for Women, PC and Jack
M. Rowland, MD, PLLC as required by federal guidelines.
____________________________________________________________________________________
The signature below represents a full understanding of the contents of this agreement and consent to receive treatment
based on your Provider’s recommended plan of care.
Patient’s Signature: __________________________________________
Date: _____________
Legal Guardian’s Signature (if applicable): ______________________ Date: ______________
FOR OFFICE USE ONLY: Witness’s Signature: ____________________ Date: ____________ Acct #: ________