History & Physical Information

Please correct the errors described below.

Welcome to Mansion Street Women’s Health. This form contains questions about your medical, obstetrical, family, and social histories. This information is vital to us. Please answer the questions to the best of your knowledge. We realize that some of our patients have previously filled out this information; however, we need this to update our records. Leave blank any questions you do not know. Your answers are kept confidential. Thank you very much!

SEXUAL HISTORY:

GYNECOLOGIC HISTORY

Please fill in the information requested for all pregnancies. Include abortions, miscarriages, and ectopics.

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Do you currently have a problem with any of the following?

Has any blood relative ever had (past or present) any of the following? If yes, please describe who has had the problem:

PATIENT INFORMATION

SPOUSE INFORMATION (or IF MINOR, legal parent / guardian):

Insurance

Add another insurance

Emergency Contact (DIFFERENT ADDRESS THAN ABOVE)

Assignment and Release: I hereby authorize that my insurance benefits be paid directly to the undersigned physician. I authorize the release of any medical information, about me, to other treating providers for evaluation, administration of claims for benefits, and for developing cost-effective managed care. I acknowledge that I am financially responsible for any non-covered services. I authorize MSWH to contact and speak to my emergency contact if deemed necessary.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient / Legal Guardian if under age 18.

FINANCIAL POLICY

Thank you for choosing Mansion Street Women’s Health, P.L.L.C. (MSWH) as your health care provider. We are committed to providing you with exceptional, quality healthcare. We would like you to understand your financial commitment for all services rendered in our office. The following is a statement of our Financial Policy that we ask that you read in its entirety and sign in that you agree.

For your convenience MSWH accepts the following methods of payment: Cash, Check, Money Order, Visa, Mastercard, Discover and American Express.

Insurance Claims (Participating): We have contracts with many insurance companies and will bill them as a courtesy service to you. As the patient of services rendered, you are responsible if your insurance company declines to make payment for any reason. All co-pays are due at the time of your appointment. Below is a partial list of insurance companies with which we are participating providers. If your insurance company is not listed here, please ask the front desk if we are currently a participating provider with your insurance.

  • Aetna
  • Blue Cross Traditional & PPO
  • Cofinity
  • Meridian Health Plan
  • Priority Health
  • Medicaid
  • Medicare
  • United Healthcare Community Plan
  • Healthscope Benefits
  • United Healthcare

You should know that your insurance policy is a contract between you and your insurance company. Please be aware that it is your responsibility as a patient to know which services (for example: tests, labs, etc.) are covered benefits of your plan. Also please note that some of the services we provide may be non-covered services under your own insurance plan and are not payable by your insurance policy. You will be financially responsible for these services. Secondary insurances will be billed as a courtesy to our patients. Deductibles, co-insurances and non-covered services are due upon receipt of your first patient statement.

Deductibles: If your insurance company has applied our charges for services rendered towards your deductible, then it is deemed your responsibility to make payment to our office. Insurance claims and deductibles are typically paid on a “first come first served/ processed” basis by the insurance company and are not always paid in “Date of Service” order. Deductibles are due upon receipt of your first patient statement.

Non-Participating Insurance Claims: For patients with an insurance plan that we are non-participating with, we will bill your insurance as a courtesy with the understanding that whatever charges come back as not being paid for are your responsibility as the patient.

Minor Patients: Parents or legal guardians of patients who are minors (under the age of 18) are responsible for full payment as described herein.

Records Fee: Copies of your medical records are available to you and are subject to the per page guidelines set fourth by the State of Michigan Department of Community Health. Please inquire with the receptionist for further information.

FMLA Forms: A $10.00 fee will be assessed for each form needing to be filled out and payment in full is required before this paperwork will be released.

Obstetrical Care Patients: Those patients who will be receiving obstetrical care with our office will be presented with additional information regarding your charges and payment options.

No-Show Fees: A no-show / late cancellation fee of $25.00 will automatically be assessed to any patient who does not cancel their appointment at least 24 hours in advance or neglects to show up. Three no-shows are considered non-compliance with scheduled appointments and may result in your dismissal from the practice. In addition, please note that if you show up for an appointment 15 minutes or more LATE, it is office policy that you will be rescheduled. Since many appointments are scheduled and booked months in advance, please be on-time as it may be extremely difficult to be rescheduled timely. Thank you! *Please note that due to the nature of our practice, our doctors are sometimes called to surgery and/or labor & delivery. If you are here for an appointment and your provider is not in the office, we will advise you at that time. We thank you in advance for your patience in the event this situation arises!

Returned Checks: A fee of $40.00 will be charged to your account for all returned checks to this office for any reason (insufficient funds, stop payment, account closed, etc). This fee is assessed in addition to the amount of the original payment. We will not send the check thru the bank more than one (1) time. If subsequent checks are returned to us, we will no longer be able to accept a personal check from you or any immediate family members. Other methods of payment for your account must be utilized at that time.

Non-Compliance: If for any reason you choose not to comply with the MSWH Financial Policy as outlined herein, your account will be reviewed and could result in being forwarded to our collection agency. Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or patient’s responsible party fully understands that MSWH will disclose all relevant personal and account information necessary to collect payment for services rendered. A collection fee of $50 shall be charged to your account if it is forwarded to our collection agency. Additional costs, such as court costs, attorney fees, and any interest charged will be the responsibility of said patient or signed representative acting on their behalf. Any patient sent to collections may also result in being dismissed from the practice.

By signing below, I acknowledge that I have fully read, understand and completely agree to the above financial policy as set forth by Mansion Street Women’s Health, P.L.L.C. This document may be scanned into an electronic format and such printed copy of the electronic record shall be deemed an original.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. We look forward to providing you with exceptional care throughout your visits with MSWH!

Automated Appointment Reminders

Dear Patient,

We would like to inform you that we have instituted a new automated reminder system, named AutoRemindTM, which is already in effect. This system, being one of the more advanced on the market, allows us to remind you of your appointments in the manner that is best suited to your needs and habits!

AutoRemind can send you appointment confirmation requests via email, text messages, and voice calls to your mobile / home telephone numbers.

PLEASE NOTE: The automated system will ask you to confirm your appointment at the end of the message, as well as inform you of our late cancellation / no-show fee policy. IT IS HIGHLY IMPORTANT THAT YOU LISTEN TO THE MESSAGE / READ THE EMAIL IN ITS ENTIRETY AND CONFIRM YOUR APPOINTMENT ACCORDINGLY. PLEASE ADD THIS ADDRESS TO YOUR CONTACTS/ADDRESS BOOK: NOREPLY@AUTOREMIND.US

We would also like to ask, on this occasion, that you update your contact information in our system for us to be able to deliver those reminders to you. Please fill out this registration form for MSWH & AutoRemind and we will implement your request right away.

From now on, there is no more reason to forget your appointments – just request an AutoReminder that’ll fit your needs!

Preferred reminder method

PLEASE ADD THIS ADDRESS TO YOUR CONTACTS/ADDRESS BOOK: NOREPLY@AUTOREMIND.US

Hereditary Cancer Questionnaire

Personal Information

Instructions: This is a screening tool for cancers that run in families. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. Next to each statement, please list the relationship(s) to you and age of diagnosis for each cancer in your family.

You and the following close blood relatives should be considered: You, Parents, Brothers, Sisters, Sons, Daughters, Grandparents, Grandchildren, Aunts, Uncles, Nephews, Nieces, Half-Siblings, First-Cousins, Great-Grandparents and Great-Grandchildren

YOU and YOUR FAMILY's Cancer History (Please be as thorough and accurate as possible)

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Authorization for Disclosure of Health Information

I hereby authorize the following people the designated information as marked below:

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By Signing this form I agree to the following:

I understand that authorizing the disclosure of this health information is voluntary. I also understand that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I understand I may revoke this authorization in writing at any time by giving written notice to the mansion street Women's Health, P.L.L.C., Office Manager, except to the extent that action has been taken in reliance on this authorization.

I have read the information provided on this release and do hereby acknowledge that I fully understand the terms and conditions of the authorization. This document may be scanned into an electronic format and such printed copy of the electronic record shall be deemed an original.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

WHAT EVERY PATIENT SHOULD KNOW.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY. If you have any questions about this Notice, please contact our Privacy Officer, Dr. Mark Walker at (269) 781-1183.

PROVIDERS COVERED BY THIS NOTICE

Mansion Street Women’s Health, PLLC is required by law to maintain the privacy of your health information, to provide you with this Notice of our legal duties and privacy practices, and to abide by the terms of this Notice currently in effect. We may share your health information for purposes of providing you with treatment, obtaining payment for medical services, and for health care operations. Examples of sharing information for purposes of treatment, payment, and health care operations are described below.

OUR PLEDGE TO YOU:

We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care, bill for your care, and comply with legal requirements. This Notice applies to all of the records of your care that we maintain, whether made by our staff, or by the physicians and other health care professionals working with us.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU.

Our doctors, nurses, and other health care professionals may use health information about you to provide you with health care treatment or services. We may also disclose health information about you to others who are involved in taking care of you. For example, we may send health information about you to a physician specialist as part of a referral. Or, we may share information with a local nursing home in order to continue your care. We may use and disclose health information about you to obtain payment for the treatment and services you receive from us or from the doctors and other health care professionals that treat you. For example, we may send billing information to your insurance company or Medicare. We may use and disclose health information about you to support our health care operations. For example, we may use health information to review the treatment and services we provide to you and to evaluate the performance of our staff in caring for you. Unless you object, we may disclose information to a family member or other person responsible for your care about your condition, status, and location. Unless you tell us otherwise, we will include your name, location, your general condition (good, fair, etc.), and religious affiliation in our patient directory and make this information available to anyone who asks for you by name. Unless you object, we may disclose this information to a member of the clergy. We may use and disclose health information to contact you for an appointment reminder, to tell you about healthrelated services or to recommend possible treatment options or alternatives that may be of interest to you. We may contact you about supporting our fund raising efforts. Subject to certain requirements, we may use or disclose health information about you without your prior authorization for other reasons:

We may give out health information about you for public health purposes; to report abuse or neglect; for health oversight reviews; in research studies, so long as provision is made for the protection of your health information; to medical examiners; for funeral arrangements and organ donation; in response to special law enforcement requests, valid judicial or administrative orders, or for authorized national security and intelligence activities; for workers’ compensation purposes; to avert a serious threat to your health or safety or those of the public or another person; and when required by law (for example, state law requires certain reports to cancer registries). If you are or were a member of the armed forces, we may release information about you as required by military command authorities or the Department of Veterans Affairs. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. We must also release your health information when required by the Department of Health and Human Services to investigate our compliance with the privacy laws. Both federal and state laws protect your health information. In situations where both laws apply, we will comply with the law that is most protective of your health information and/or gives you additional rights. For example, in some situations Michigan law gives more protection to information contained in mental health records. For any other purpose not covered by this Notice, we will ask for your written authorization before using or disclosing your health information. You may revoke this authorization at any time by notifying us in writing, except to the extent we have taken an action in reliance on your authorization.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU.

You have the right to request in writing that you inspect and obtain a copy of the health information we maintain. We may charge a fee for the costs of copying, mailing or other supplies and services associated with your request. In certain circumstances, we may deny your request. You may request that this denial be reviewed. If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend your health information. The request must be in writing, and should state the reason for the amendment and the specific information to be amended. You have the right to make a written request for a list of disclosures we have made of your health information. This list will not include disclosures made for treatment, payment, and health care operations, to your family, or those disclosures you authorized. You have the right to request a restriction on the health information we use or disclose about you, including a right to request restrictions on disclosures to family members or friends. You must submit this request in writing. We are not required to agree to your request for restrictions. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment, or we are otherwise required by law to make a disclosure. You have the right to request that confidential communications with you be made in an alternative manner or location. This request must be in writing, but you do not need to state the reason for your request. For example, you may ask us to send information to your work address instead of your home address, or in a blank envelope with no distinguishing marks. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

WRITTEN REQUESTS

All written requests should be submitted to our Privacy Officer, Dr. Mark Walker at 215 East Mansion Street, Suite 3D, Marshall, MI 49068.

COPIES OF NOTICE AND CHANGES

You have the right to obtain a paper copy of this Notice at any time, upon request, even if you have agreed to accept this Notice electronically. You may also obtain a copy of this Notice at our website, www.mansionstreetwh.com

We reserve the right to change this Notice, and to make the changed Notice effective for health information we already have about you as well as any information we receive in the future. Upon your request, we will provide you with any revised Notice. A revised Notice will also be posted in waiting areas throughout our facilities and at our website, www.mansionstreetwh.com

COMPLAINTS

If you are concerned that your privacy rights may have been violated or you disagree with a decision we make about your health information, you may file a complaint with our Privacy Officer, Dr. Mark Walker. You may also send a written complaint to the U.S. Department of Health and Human Services. Our Privacy Officer, Dr. Mark Walker can provide you with the address.

Under no circumstances will we ever ask you to waive your rights under this Notice or retaliate against you in any manner for filing a complaint.

EFFECTIVE DATE

This Notice was published and became effective on February 1, 2014.

Patient Rights--These rights apply to our patients and/or their legal representatives.

  1. Be informed of their rights prior to the institution or discontinuance of care.
  2. Receive information in a language that can be understood.
  3. Be given considerate and respectful care in a safe setting, without discrimination.
  4. Personal privacy in a confidential and secure environment, in accordance with HIPAA regulations.
  5. Exercise civil and religious liberties.
  6. Be informed of choices.
  7. Participate in the plan of care, make decisions regarding that care, and accept or refuse treatment, the risks, benefits, other options and prospects for recovery.
  8. Participate in ethical questions, conflict resolution, organ donation, withdrawal of life-sustaining treatment and withholding resuscitation.
  9. Effective pain management.
  10. The use of advance directives.
  11. Access personal medical records.
  12. Protective services.
  13. Be informed of and refuse to participate in human experimentation or other research.
  14. Charges and billing information.
  15. Be informed of unanticipated outcome.

Patient Responsibilities

  • A patient is responsible for following the office rules and regulations affecting patient care and conduct.
  • A patient is responsible for providing a complete and accurate medical history.
  • A patient is responsible for making it known whether he or she clearly comprehends a contemplated course of action, consents to it, and understands the actions expected.
  • A patient is responsible for following the recommendations and advice prescribed in a course of treatment by the physician.
  • A patient is responsible for providing information about unexpected complications that arise in an expected course of treatment.
  • A patient is responsible for being considerate of the rights of other patients and office personnel and property
  • A patient is responsible for providing the office with accurate and timely information concerning his or her sources of payment and ability to meet financial obligations.
  • A patient is responsible for any personal property brought into the office.

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE

By signing below, I acknowledge that I have received Mansion Street Women’s Health, P.L.L.C.’s Notice of Privacy Practices. This document may be scanned into an electronic format and such printed copy of the electronic record shall be deemed an original.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

PREGNANCY QUESTIONNAIRE

Welcome to Mansion Street Women’s Health. This form contains questions about your medical, obstetrical, family, and social histories. This information is vital to us. Please answer the questions to the best of your knowledge. We realize that some of our patients have previously filled out this information; however, we need this to update our records. Leave blank any questions you do not know. Your answers are kept confidential. Thank you very much!

Is there any family history on either sides of your families of:

Are you up to date on your vaccinations?

Previous OB history:

Your information will be encrypted.

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