NEW PATIENT REGISTRATION FORM 1 James W. Douglas, M.D. Board Certified Reproductive Endocrinology Obstetrics Gynecology Patient Information Spouse Information First Name: _____________________________ Last Name: ______________________________ SSN: ___________________________________ DOB: ___________________________________ Email: __________________________________ I prefer to be called: ______________________ Address: ________________________________ City: ______________ State: ________ Zip_____ Phone: ________________Cell: _____________ Employer: _______________________________ Work Phone: ____________________________ Ok to contact at work? Yes No Referred By:______________________________ DL#:____________________________________ Nearest relative:__________________________ Relative’s Phone: _________________________ Section II: Responsible Party/Insurance In order to control your cost, charges or co‐pays for office visits are to be paid at the time of service. Will you be paying by: ___ Check ___ Cash ___ Charge Are you covered by Medicare? Yes No Medicaid Yes No Private insurance? Yes No Through your work? Yes No Name of Insurance_______________________________________________ Responsible Party Relationship to Patient: Self Spouse Parent Other Address of Insurance _________________________________________________________________ Group Number __________________________ I.D. Number________________________________ Insurance Phone Number _____________________________________________________________ I am legally responsible for payment of bills made by myself or my dependants for medical care by James W. Douglas, MD, PA. Printed Name________________________________________________Date __________________ Signature__________________________________________________________________________ First Name: _______________________________ Last Name: _______________________________ SSN: ____________________________________ DOB: ___________________________________ Email: ___________________________________ I prefer to be called: ________________________ Address: ________________________________ City: ______________State: _____ Zip:_________ Phone _____________Cell: __________________ Employer: ________________________________ Work Phone:______________________________ Ok to contact at work? Yes No DL#:_____________________________________
Transcript
NEW PATIENT REGISTRATION FORM
1
James W. Douglas, M.D. Board Certified
Reproductive Endocrinology Obstetrics Gynecology
Patient Information Spouse Information First Name: _____________________________ Last Name: ______________________________ SSN: ___________________________________ DOB: ___________________________________ Email: __________________________________ I prefer to be called: ______________________ Address: ________________________________ City: ______________ State: ________ Zip_____ Phone: ________________Cell: _____________ Employer: _______________________________ Work Phone: ____________________________ Ok to contact at work? Yes No Referred By:______________________________ DL#:____________________________________ Nearest relative:__________________________ Relative’s Phone: _________________________
Section II: Responsible Party/Insurance In order to control your cost, charges or co‐pays for office visits are to be paid at the time of service.
Will you be paying by: ___ Check ___ Cash ___ Charge
Are you covered by Medicare? Yes No Medicaid Yes No
Private insurance? Yes No Through your work? Yes No
Name of Insurance_______________________________________________
Responsible Party Relationship to Patient: Self Spouse Parent Other
Address of Insurance _________________________________________________________________
Group Number __________________________ I.D. Number________________________________
Insurance Phone Number _____________________________________________________________
I am legally responsible for payment of bills made by myself or my dependants for medical care by James W. Douglas, MD, PA.
6300 W Parker Rd, Ste. G28 | Plano, TX 75093 | (972)612-2500 | (972)612-9601 Fax
www.ivfplano.com
Dear Patient, Our office is delighted to have the opportunity to serve you. We understand that your insurance coverage is a PPO/HMO. In order to begin our relationship in a manner which your managed care program dictates, this page outlines some of the financial and procedural steps required by your insurance plans. You must pay any co-payment or deductible at the time of service, unless other arrangements have been made previously with our office. We accept Cash, Checks, MasterCard or Visa. The remainder of your bill will be sent to your insurance company for direct payment to our office. Sometimes your insurance company will refuse payment of a claim to us for some of the following reasons:
1. This is a pre-existing condition which they do not cover. 2. You have not met your full calendar year deductible. 3. Infertility is not a covered benefit. 4. The insurance was not in effect at the time of service. 5. You have other insurance which must be filed first.
If your PPO/HMO insurance denied your claim for any of the above, or for any other reason, you will be responsible for your bill. Also, should your employer financially be unable to pay your insurance premiums then your become the responsible party. It is the responsibility of the patient to pay any denied charges in full. Most insurance plans must have pre-authorization for all infertility related services that are eligible. Referrals for visits and pre-certifications are the responsibility of the patient. It is your responsibility to provide a current referral prior to beginning any cycle. Also most insurance companies require their members to use certain laboratories for diagnostic tests. It is the patient’s responsibly to know and inform our office which laboratory is contracted with their insurance company. If any charges are denied because the wrong laboratory was used because you failed to inform us of your contracted laboratory, you will be responsible for the denied lab tests. If your insurance company requires you to use a specialty pharmacy for your infertility medications, please provide us with the appropriate paperwork or fax number to expedite your prescriptions. According to the rules of the Texas State Board of Medical Examiners the fee for Medical Records is $25.00 for the first twenty (20) pages of medical records then $ .15 per page thereafter. We will be happy to copy your records for a flat rate of $25.00. A Medical Record release form along with the fee must be completed prior to records being copied. After hours calls must be limited to emergencies only. Non-emergency issues such as prescriptions, instructions and test results must be taken care of during normal business hours. Non-emergency after hours calls will be subject to a $35.00 fee. This fee will not be waived or billed to your insurance.
James W. Douglas, M.D. Board Certified
Reproductive Endocrinology Obstetrics Gynecology
6300 W Parker Rd, Ste. G28 | Plano, TX 75093 | (972)612-2500 | (972)612-9601 Fax
www.ivfplano.com
Our primary mission is to provide you with quality, cost effective, medical care. Together we are trying to adapt to the changing way that healthcare is financed and delivered. Again, we value you as a patient and our first priority is to provide you with the best possible care. With this housekeeping chore complete, we are eager to serve you! Sincerely, James W. Douglas, M.D. and Staff
I HAVE READ THE ABOVE AND UNDERSTAND MY FINANCIAL OBLIGATIONS UNDER THIS PPO/HMO ARRANGEMENT AND WILL BE FULLY RESPONSIBLE FOR PAYMENT OF ANY AND ALL MEDICAL SERVICES DENIED BY MY INSURANCE COMPANY. _______________________________________________(PATIENT SIGNATURE) **Please print off this form and bring a signed copy to your first appointment**
6300 W Parker Rd, Ste. G28 | Plano, TX 75093 | (972)612-2500 | (972)612-9601 Faxwww.ivfplano.com
James W. Douglas, M.D.
Reproductive EndocrinologyObstetrics Gynecology
Revised: , 2002
Patient Consent and Acknowledgement of Receipt of Privacy Notice
I understand that as part of the provision of healthcare services, creates and maintains health records and other information describing among other things, my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.
I have been provided with a Notice of Privacy Practices that provides a more complete description of the uses and disclosures of certain health information. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their Notice and practices and prior to implementation will mail a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations (quality assessment and improvement activities, underwriting, premium rating, conducting or arranging for medical review, legal services, and auditing functions, etc.) and that the organization is not required to agree to the restrictions requested.
By signing this form, I consent to the use and disclosure of protected health information about me for the purposes of treatment, payment and health care operations. I have the right to revoke this consent, in writing, except where disclosures have already made in reliance on my prior consent.
This consent is given freely with the understanding that:
1. Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed for reasons outside of treatment, payment or health care operations without my prior written authorization, except as otherwise provided by law.2. A photocopy or fax of this consent is as valid as this original.3. I have the right to request that the use of my Protected Health Information, which is used or disclosed for the purposes of treatment, payment or health care operations be restricted. I also understand that the Practice and I must:agree to any restriction in writing that I request on the use and disclosure of my Protected Health Information; andagree to terminate any restrictions in writing on the use and disclosure of my Protected Health Information which have
(PATIENT'S NAME PRINTED) DATE
PATIENT'S SIGNATURE (OR GUARDIAN, IF A MINOR) SOCIAL SECURITY NUMBER (FOR IDENTIFICATION PURPOSES ONLY)
WITNESS (Optional) DATE
James W. Douglas, M.D., P.A.
James W. Douglas, M.D., P.A.
James W. Douglas, M.D.
Board Certified
Reproductive Endocrinology
Obstetrics Gynecology
6300 W Parker Rd, Ste. G28 | Plano, TX 75093 | (972)612-2500 | (972)612-9601 Fax
www.ivfplano.com
NOTICE TO ALL PATIENTS
Occasionally, you may require weekend or holiday services.
The fee for weekend/holiday services is $30 per visit. Your
insurance may not cover this charge. If you are seen on a
weekend or holiday and your insurance does not cover the
charge, you will be responsible for the fee.
There may be a fee for any non-emergency phone calls after
hours, on weekends and holidays. If you call is passed through
to the doctor or nurse this fee will be applied to your account.
Medical Information: FEMALE EVALUATION Name _______________________________________________ Age_______ Height____ Weight ____ Allergies_________________________________________________ Current Medications__________________________________________________________________ Occupation__________________________________________________________________________ Smoke Yes No _______/PPD Alcohol Yes No ______/WK Marital Status: Single Married Divorced Separated Other Duration of marriage ___________________years Last pap smear _________________ History of abnormal pap? Yes No Cryosurgery on cervix? Yes No Age of first menses? _____ Date of last menses? (First day) __________ Usual menses interval _____ Usual duration of bleeding _____ Cramps? Yes No Severity of cramping? minimal moderate severe Are cramps always present? Yes No Usual frequency of sexual intercourse ______ Lubricant used? Yes No Specify ____________ Duration of infertility ___________ Do you know your blood type? Yes No Specify ________ Have you ever been evaluated or treated for infertility before? Yes No If yes, who was your physician? ___________________________ Diagnosis?___________________ What drugs have you taken for infertility? Mark all that apply: Clomiphene (Clomid, Serophene) HMG (Menopur, Bravelle, Gonal‐F, Follistim, Repronex) Glucophage (metformin) Femara (letrozole) HCG (Pregnyl, Profasi, Novarel, Ovidrel) Parlodel (bromocriptine) I was referred by: physician friend insurance internet
other _________________________________________________________
NEW PATIENT MEDICAL HISTORY FORM
2
James W. Douglas, M.D. Board Certified
Reproductive Endocrinology Obstetrics Gynecology
Which of the following tests have you had performed? Give the results, if known, for all that apply: Serum Progesterone Results___________________________________________________ Hormonal assays Results___________________________________________________ (FSH, LH, Prolactin, DHEA, Testosterone, Thyroid) HSG Results___________________________________________________ Post‐coital test Results___________________________________________________ (Sims‐ Huhner) Sperm penetration test Results___________________________________________________ (Hamster Test) Ultrasound Results___________________________________________________ Laparoscopy Results___________________________________________________ Hysteroscopy Results___________________________________________________
PAST MEDICAL HISTORY Have you ever had any pelvic surgery or infertility surgery? Yes No If yes, specify _______________________________________________ Have you ever had any tubal or ovarian infections? Yes No Have you ever been diagnosed with a sexually transmitted disease? Yes No Have you ever had hepatitis? Yes No Have you ever undergone artificial insemination or in‐vitro fertilization? Yes No Is your partner being evaluated for infertility? Yes No Is your partner taking any medication or seeing a physician regularly? Yes No If yes, specify________________________________________________
NEW PATIENT MEDICAL HISTORY FORM
3
James W. Douglas, M.D. Board Certified
Reproductive Endocrinology Obstetrics Gynecology
Medical Information: MALE EVALUATION Name___________________________________________ Age_________ Height____ Weight ____ Allergies_____________________________________ Smoke Yes No _______/PPD Alcohol Yes No ______/WK Occupation______________________________________ Are you currently taking Testosterone?_________________________
MALE PAST MEDICAL HISTORY Current Medications___________________________________________________________________ I have had the following conditions or procedures to my penis, testicles or pelvic area Surgery _______________________________ Infection_______________________________ Injury _________________________________ Other _________________________________
Which of the following tests have you had performed? Give the results, if known, for all that apply: Semen Analysis Results___________________________________________________ Other Results___________________________________________________
Referring ObGyn PHYSICIAN INFORMATION Name: _____________________________________________________
