New Patient Packets

Manatee Gynecology, LLC

Please correct the errors described below.

List all surgeries, procedures and hospitalizations

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List all prescription and over-the-counter drugs

(including vitamins, supplements, herbs, inhalers)

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List all allergies to medications, latex, foods, and x-ray dyes

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Obstetrical History

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Gynecological History

Please provide the date and result of the MOST RECENT of the following tests:

Social History

Family History (Please indicate age of onset in the appropriate box)

Please indicate your preferred Pharmacy (Name, Location, Phone)

Please provide the first and last name of your current providers

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

Patient Information (Failure to disclose accurate information may result in the termination of your relationship with our physicians/office)

Emergency Contact Person

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If you are covered by an HMO/PPO requiring an authorization, it is your responsibility to obtain that authorization prior to your scheduled appointment. If you have any questions about authorizations, call your insurance carrier, member services department, or if applicable, your Primary Care Physician. Depending on the type of service you need, you may be required to make a deposit or payment agreement for the estimated charges prior to being seen. A service charge of $15.00 will be added to your account, if your estimated portion is not collected at the time of service.

I hereby authorize Manatee Gynecology, LLC to furnish information to insurance carriers concerning my illness and treatment and I hereby assign to the physician(s) all payments for medical services to myself or dependents. I understand that I am responsible for any amount not covered or authorized by my insurance carrier for all office or surgical charges. Any unpaid patient balance older than 90 days will be sent to a third-party collection agency and you will be billed a $50.00 service fee.

By law, we are required to make available to you a copy of our Notice of Privacy Practices (“Notice”). By signing below you acknowledge that you received, or have been offered and declined, a copy of the Notice. A current copy of the Notice is also posted in the office, on our website and is available to you upon request. If the Notice is revised, you may review and obtain the new version at any time. You may decline to sign this acknowledgement

Please help us to protect your privacy by answering the following questions:

6. Please list each person and indicate which permissions are allowed.
(NOTE: We will NOT release any information to anyone that is not listed here.)

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a complete copy of the “Notice of Privacy Practices.” This is to verify that I have read and understand the above information. By signing this statement, I am giving Manatee Gynecology Associates and its staff permission to release my personal information as described above.

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

For Patients Under Age 18
Written parental or legal guardian consent is needed to provide any type of medical care or to prescribe medically necessary medication to a minor. In addition to the above information, I authorize Manatee Gynecology, LLC to diagnose, provide medical treatment, and prescribe medications for:

We were unable to obtain this written acknowledgement

Appointments: Late Cancellation/Late Reschedule/No show fee

Our office policy is to charge a $25.00 fee to patients who fail to keep their appointment or cancel/reschedule with less than 48 business hours’ notice. When patients do not give adequate notice of cancellation, we are not able to use that time for other patients, who need to be seen. The fee will be billed to your account and must be paid before any appointments or surgeries will be scheduled. (We offer reminder calls as a courtesy to our patients. If you do not receive a reminder call that does not eliminate your responsibility to show for a scheduled appointment or constitute that the fee will be waived.)

Preventive/Annual Physical Exams

According to the CPT (Code Book) a Preventive Physical Exam is defined as an “age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the order of laboratory/diagnostic procedures.”

If an abnormality is encountered or a problem/preexisting problem is addressed in the process of performing this preventive medicine evaluation, and if the problem/abnormality is significant to require additional work to perform the key components of a problem-oriented services than the appropriate visit code shall be charged as well.

When you come to the office for your Preventive/Annual Physical Exam, if you are healthy and have no continuing medical conditions then only a Preventive Code will be charged. If you are insistent on only Preventive Code being charged then you will only have the Preventive Exam and will be asked to return to the office for a second visit to address the problems/conditions that you are having.

We are attempting to provide the most comprehensive care that is possible and must code the visits according to the appropriate level of care provided.

**Please keep in mind, some insurance carriers will not allow any abnormalities or problems to be addressed at a Preventive/Annual Physical Exam. Also, if your medical condition requires immediate attention, we will have no choice but address that condition and reschedule your Preventive/Annual Physical Exam.

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

Your information will be encrypted.

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