Patient Packet

Verbal communication with family and others involved in your care

Name

Date of Birth

This form does not cover access to a release of medical records. This form may be used to document those individuals you want to communicate with providers and staff at Rose Women’s Health, Inc., in person or on the phone, in regards to the coordination or payment of your care. For access to copy the records to one of the individuals you designate, you must complete an authorization for disclosure of protected health information for each separate disclosure or have an effective Advanced Healthcare Directive or other valid legal document on file.

Please list any family members or others who may be involved in coordinating your care or payment for care. Also, indicate what kind of information may be shared with each individual.

Add Family Member or Other

Please describe any specific instructions or limitations

We will continue to rely on the information on this form when communicating with family members or others involved in your care unless you request change so Please promptly notify your physician's office if you wish to alter the designations 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.

Signature of patient or representative

Date

Relationship to patient

To revoke this authorization, please send a written request with a copy of this form to the health information services department/release of information at the address below.

Rose Women's Health

289 W. Huntington Dr.

Suite 305

Arcadia, CA 91007

Financial Responsibility

Patient Name

MRN

Costs:

It is understood that price quotes are based upon available information at the time of the quote. Additional charges may be added to the final billing according to the level of visit, additional diagnostic testing, medication or other services ordered. The undersigned agrees that any deposits made will be applied toward charges for services rendered. Payment arrangements are available to patients; please ask for any patient business services representative

No insurance patients:

Our goal is to great patients without regards to their financial status. If the doctor orders tests, medication, or supplies and you’re concerned about the price, please don’t hesitate to ask prior to receiving the service.

Co-payment policy:

Co-payments are due at the time of service. $25 statement processing fee will be charged for any unpaid co-payments for each visit.

No-show policy:

The office may use an automated reminder system to help remind patients of their upcoming appointments. However, timely cancellation of appointments remains the responsibility of our patients. If an appointment is cancelled with less than 24-hours’ notice, a no-show fee of $25 will be charged.

Nonsufficient funds fee:

Return check fee of $25 will be added to your account when your bank returns your check unpaid for any reason. We do not waive this bank fee.

Fee for forms:

Completion of forms not directly related to patient care is not routinely covered by clinical visit fees or by insurance. Because these take a significant amount of physician time, we find it necessary to charge a fee for completion of such forms.

Fees for medical records:

A reasonable fee will be charged for providing copies of patient health information, including costs of copying, postage, and for preparation of any summary or explanation if agree.

Fee for non-covered services:

There may be instances where your insurance does not cover certain injectable medications, immunizations, and medical supplies. Charges for those services are the responsibility of the patient. Patients are responsible for their coverage. If you have any questions, please contact your insurance.

Assignment of benefits

The undersigned authorizes, whether he/she signs as agent or the patient, direct payment of insurance benefits (otherwise payable to or on behalf of the patient) to the clinic. I understand my insurance carrier may not approve or reimburse my medical services in full due to the usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or medical necessary necessity. I understand I am responsible for fees not paid in full, co-payments, and policy deductible and co-insurance except where my liability is limited by contract or state or federal law. It is understood by the undersigned that he/she is financially responsible for charges not paid pursuant to this assignment.

Patient’s balance:

Payment of any balance due is expected within 10-days after receipt of your statement. Should the account be referred to an attorney or collection agency for collection, the undersigned shall pay the actual attorney’s fees and collection expenses. All delinquent accounts shall bear interest at the legal rage. Patient will not be allowed to see the physician unless the total current balance with the collection agency is paid in full.

The undersigned agrees, whether he/she signs as agent or the patient, to pay the account in accordance with the regular rates and terms of the office.

Patient / Guardian Signature

Patient / Guardian Name

Date

Acknowledgement of Receipt of Notice

I hereby acknowledge that I received a copy of this medical practice’s Notice of Privacy Practices.

Select One

Yes No

I would like to receive a copy of any amended Notice of Privacy Practices by e-mail at:

Signed

Date

Print Name

Phone

If not signed by the patient, please indicate your relationship to the patient:

parent or guardian of minor patient

guardian or conservator of an incompetent patient

beneficiary of personal representative of deceased patient

Name of Patient

For Office Use Only

signed form received by

acknowledgment refused

Efforts to obtain

Reasons for refusal

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article I: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure Section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below: Effective as of the date of first medical services.

Patient’s or Patient Representative’s Initials:

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

By:

Patient's or Patient Representative's Signature

Date

By:

Physician’s or Authorized Representative’s Signature

Date

By:

Print Patient’s Name

Print or Stamp of Physician, Medical Group, or Association Name

(If Representative, Print Name and Relationship to Patient)

A signed copy of this document is to be given to the Patient. Original is to be filed in Patient's medical records. 02012 J8577B 2/12

Your information will be encrypted.