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July 2011 Issue
June 2010 Issue

Established Patients Form

PLEASE HELP US TO SERVE YOU BETTER BY TAKING A FEW MINUTES TO PROVIDE FOLLOWING INFORMATION.

FIRST NAME:*
LAST NAME:*
Date of Birth: / / *
Age:
Appointment Date: / /
Pharmacy Name:
Pharmacy Phone:
Pharmacy City/State:
e-mail:
Emergency Contact:

REASON FOR TODAYS VISIT:

MEDICAL HISTORY:(Please list new illnesses SINCE YOUR LAST VISIT)

SURGICAL / ACCIDENTS / HOSPITALIZATIONS: (List all operations, serious accident, and hospitalizations SINCE YOUR LAST VISIT)

OBSTETRICAL HISTORY: (Please list all pregnancies,
SINCE YOUR LAST VISIT)

GYNECOLOGIC HISTORY:
Last menstrual period / /
Have your periods changed? Yes No
How?
Usual number of days between periods?
How many days do periods normally last?
Cramps or Pain with periods? Yes No
Any spotting between periods? Yes No
When was your last PAP smear? / /
Do you need sexually transmitted disease screening today?
Number of new sexual partners since last visit
Gender of sexual partners: M and/or F
Do you use condoms to prevent STDs? Yes No
Number of HPV / injections: none 1 2 3
What are you doing to prevent pregnancy? Birth control pill
Condoms IUD Diaphram Vasectomy tubal ligation
other (please explain)

List any vaginal or female infections you have had
SINCE YOUR LAST VISIT:

SCREENINGS/TESTS (Please note with date)
Colonoscopy / /
Bone Density / /
Most recent mammogram / /

ALLERGIES:
Drug: Food:
Latex Allergy: Yes No

MEDICATIONS: (List all current medications, vitamins, and herbal supplements you are taking)
DRUG / DOSAGEFREQUENCY / TAKEN


SOCIAL HISTORY:
Single Engaged Married Life partner Lesbian Separated
Divorced Widow

Are you currently a victim of domestic violence? Yes No
Physical Sexual

Do you exercise regularly? Yes No

Use of alcohol? Yes No
Is this a change in use? Yes No

Use of tobacco: Yes No
Is this a change in use? Yes No

Use of recreational drugs? Yes No
Previously quit Currently/what?

FAMILY HISTORY:
(List any 1st DEGREE relatives (mother/father/siblings/children) diagnosed with or deceased from any illnesses SINCE YOUR LAST VISIT)

Family History of Breast Cancer:
Mother’s side
Father's side

REVIEW OF SYSTEMS: (Please CHECK any symptoms you currently have)
CONST: Fatigue chills, body aches, recent weight loss, recent weight gain, fever, chills, night sweats
EYES: Impaired vision, Blurred vision
ENT: Frequent headaches
BREASTS: Lumps, swelling, tenderness, nipple discharge
CARDIO: Chest pains, rapid heart rate or irregular heart beats
RESP: Shortness of breath, cough, wheezing
GI: Nausea, vomiting, diarrhea, constipation, abdominal pain, blood in stools, loss of appetite, hemorrhoids
GU: Urgent or frequent urination, blood in urine, painful intercourse, vaginal discharge, genital sores
INTEGUMENT: Rash, new or growing moles, excessive hair growth, acne
NEURO: Muscular weakness, numbness, memory difficulties
MUSC: Joint pain, muscle pain, muscular weakness, back pain
ENDO: Heat or cold intolerance, excessive thirst, loss of hair
PSYCH: Anxiety, depression, difficulty sleeping
HEME/LYMPH: Easy bruising, easy bleeding


PAYMENT GUARANTEE

First and Last Name:

Which Doctor are you seeing?
Eva S. Arkin, M.D.
Laura W. Cummings, M.D.
Sujatha Reddy, M.D.
Jennifer B. Aqua, M.D.
Nadine A. Becker, M.D.
Jennifer M. Lyman, M.D.

If we participate in your insurance plan and provided you present your insurance card at time of service, we will collect your copayment and any other charge for services that we know are not covered by your insurance. We accept cash, check or credit card. The remainder of your charges today will be billed to your insurance company. Please follow up with your insurance company to ensure your claim is paid timely. Claims not paid by your insurance company within 60 days become patient responsibility. If you do not have insurance in which we participate or do not have your insurance card, all fees are due and payable at time of service.

We test for HPV on all women, with a cervix, over 30 years of age every three (3) years, which is the standard of care set forth by the American College of OB/GYN.

***I hereby certify that all insurance information provided is true and accurate and that I am responsible for keeping it updated. I hereby authorize Premier Care for Women to submit claims on my behalf to my insurance company and to accept payment from my insurance company on my behalf. I understand that the submission of a claim does not absolve me of my responsibility to ensure the claim is paid in full and that I may be responsible for any and all amounts not payable by my insurance company including non covered services, deductibles, coinsurance, services determined by the insurer as not medically necessary or any failure by my insurer to comply with all applicable laws. I authorize release of records to the insurance company as requested in order to facilitate claims payment.

I understand that rebilling fees of $10 per month are applied to my account if charges turned over to patient responsibility are not paid promptly and that failure to keep my account current may limit my access to the Practice and my physician until the balance has been paid in full or acceptable payment arrangements have been formalized. I understand that returned checks incur a fee of $25, must be repaid by cash or credit card including the $25 fee, and that Premier Care for Women may seek recovery using the means available to them under Georgia Law. I understand that Premier Care for Women utilizes the services of a collection agency as necessary. I further understand that access to the Practice and my physician may be limited if my account is sent to collections until the balance is paid. If I am sent to collections twice, I may be dismissed from the Practice. I have been made aware there is a $25 “No Show” Fee for all appointments not cancelled within 24 hours prior to the appointment.   Urogynecological appointments will incur a $50 fee if not cancelled within 24 hours prior to the appointment***

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby give consent for Premier Care for Women to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). I have the right to review and request a copy of the Notice of Privacy Practices at any time.

With this consent, Premier Care for Women may leave voice mail messages, mail correspondence or e-mail to my home or other alternative location or number that I have provided for appointment reminders, patient statements,  insurance or clinical care items.  Contact regarding issues of a sensitive nature will be made by personal phone call or letter from a member of Premier Care for Women.

I understand that I have the right to request, in writing, that Premier Care for Women restrict how it uses or discloses by PHI to carry out TPO , but the Practice is not required to agree to my requested restrictions. If it does, it is bound by this agreement. I may revoke my consent in writing, except to the extent that the Practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Premier Care for Women may decline to provide treatment to me.

**You will be asked to sign this form at time of your appointment**

 

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