Patient Registration Packet

Patient Name

DOB

Social Security

Address

City

State

Zip

Patient Phone Number

Marital Status

Single Married Divorced Widowed Other

Employer / School

Employer / School Phone Number

Ethnicity

Caucasian African American / Black Hispanic/Latino Native American Asian Other

Spouse / Guardian

Name

DOB

Phone Number

Emergency Contact

Name

Phone Number

Relationship

Nearest Relative Not Living at Same Address

Name

Phone Number

Relationship

Primary Insurance Information

Insurance Co.

Policy #

Group #

Policy Holder Name

DOB

Relationship

Assignment of Insurance Benefits & Authorization to Release Information

I authorize payment of medical benefits to ELITE WOMEN'S CARE CENTER, PA for any and all services not paid in full at the time services are rendered.

I authorize ELITE WOMEN'S CARE CENTER, PA to release any medical information as necessary for the completion of my insurance claims to any insurance carrier, health, or hospital plan.

Patient/ Guardian Name (Print)

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/Guardian Name (Sign)

Date

PAYMENT POLICY

Payment arrangements must be made prior to appointment. Arrangements for payment require approval from management. If arrangements are defaulted, all arrangements will be voided and full payment will be due BEFORE any future services will be rendered.
Co-payments is due at time of service. No payment arrangements are made for co-pay amounts.
A Statement will be sent within 30 days of the rendered services(s) or immediately after payment from your insurance company is received.
A late fee of $35.00 will be applied to your account balance after EACH 60-day period until the balance is cleared.
Accounts will be sent to collections after 90 days. Patient will be responsible for collection fees in addition to office charges.
All major credit cards are accepted / no checks accepted
There will be a $25.00 charge to the patient for NO-SHOW office visit appointments.
There is also a $50.00 charge to the patient for NO-SHOW office procedures.
These charges are not payable by any insurance company. To avoid additional charges, please call within 24-hours to cancel appointment.
Patient requested paperwork (i.e. FMLA certification) completion is subject to a $25.00 service fee per form. Forms will not be released, by any means, until fee is paid. Please allow 5-7 businesss day for completion.
For OBSTETRICAL services, the full 100% is due by, no later than, 28 weeks of pregnancy.
Laboratory fees are separate from physician fees. Please contact the lab for any invoices received related to laboratory fees.
For elective circumcisions , there will be a $150.00 deposit due by 28th week of pregnancy. Deposit applied to charge if insurance does not pay. A statement will be issued to you, as this is only a deposit.This does not cover the full charge.
Proof of monthly payment is required for premium based insurance coverage.
Patients are responsible for services not covered by their health plan. (i.e. pre-existing medical necessity, non-coverage, etc.)

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.

Signature

It is the intent of Elite Women's Care Center, PA to ensure that our patients are wll informed of the office policies and procedures so that we may provide you with the best possible care. We appreciate your business and thank you for allowing us the opportunity to care for you.

Health Insurance Portability & Accountability Act Notice

In accordance with the Health Insurance Portability & Accountability Act (HIPAA), as of April 14, 2003 all health care providers are required to provide their patients with a "Notice of Privacy Practice" Statement

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE READ IT CAREFULLY

Elite Women's Care Center, PA is required by law to maintain the privacy and cinfidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practice with respect to your protected health information.

TREATMENT - We may disclose your health care information to other health care professionals within our practice for the purpose of treatment, payment, or health care operations. For example; It may be necessary to seek consultation regarding your condition from other health care provider's associated with Elite Women's Care Center, PA
PAYMENT - We may disclose your health information to your insurance provide for the purpose of payment or health care operations. For example: An itemized billing statement provided by EWCC to your insurance company may contain medical information including diagnosis, date of injury, condition, and codes that describe the services received.
WORKER'S COMPENSATION - We may disclose your health information as necessary to comply with State Worker's Compensation laws.
EMERGENCIES - We may disclose your health information to notify or assist in notifying a family member, or the individual responsible for your care about your medical condition in the event of an emergency or of your death.
PUBLIC HEALTH - As required by law, we may disclosed your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting medication, and reporting disease or infection exposure.
JUDICIAL PROCEEDINGS - We may disclose your health information in the course of judicial proceedings.
LAW ENFORCEMENT - We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness, missing persion, complying with a court order or subpeona, and other law enforcement purposes
DECEASED PERSONS - We may disclose you health information to coroners or medical examiners.
ORGAN DONATION - We may disclose your health information to organization involved in procuring, banking, or transplanting organs or tissues.
PUBLIC SAFETY - We may disclose you health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
SPECIALIZED GOVERMENT AGENCIES - We may disclose your health information for military, national security, prisoner, and goverment benefits purposes.
MARKETING - As a courtesy to our patients, we may contact you for the purpose of reminding you of an appointment date and time. If you are not available we may leave a message. No personal information will be disclosed during the attempt to contact you other than the date and time of your scheduled appointment in addition to a request to return the call to our office if you need to cancel or reschedule your appointment.

YOUR HEALTH INFORMATION RIGHTS

You have the right to request restrictions on certain uses and disclosures on your health information. Please be advise, however, that Elite Women's Care Center, PA is not required to agree to the restriction that you requested.
You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
You have the right to inspect and copy your health information.
you have a right to request that Elite Women's Care Center, PA amend your protected health information. Please be advised, however, that Elite Women's Care Center, PA is not required to agree to amend your protected health information. If you request to amend your health information has been denied, you will be provided with an explanation of denial reason(s).
You have the right to receive accounting of disclosures of you health information made by Elite Women's Care Center, PA
You have a right to a paper copy of this Notice of Privacy Practice at any time upon request.

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES

Elite Women's Care Center, PA reserves the right to amend this Notice of Privacy Practice at any time in the future, and will make the new provision effective for all information that it maintains. Until such amendment is made. Elite Women's Care Center, PA is required by law to comply with this notice. Elite Women's Care Center, PA is required by law to maintain the privacy of your health information and to provide you with this notice of its legal duties and privacy practice with respect to your health information. If you have questions about this notice. or if you would like more information about your privacy rights, please contact: Dr. Torri Pierce at Women's Care Center, PA at (281) 579-9900

COMPLAINTS - Complaints about your privacy rights or how Elite Women's Care Center, PA has handled your health information should be directed to Dr. Torri Pierce at Elite Women's Care Center, PA by calling this office at (281) 579-9900.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to the Department of Health & Human Services:

File Online at : www.hhs.gov/ocr/hipaa/
Or mail complaint to HIPAA Complaint, Office for Civil Rights, Region VI U.S. Dept Health & Human Services, 1301 Young St., Suite 1169 Dallas, TX 75202

THIS NOTICE IS EFFECTIVE AS OF 04/01/2010

I have read the Privacy Notice and understand my rights contained in this notice.

As indicated by my signature below , I provide Elite Women's Care Center, PA with my authorization and consent to use and disclose my protected health information for the purposes of treatment, payment, and health care operation as described in the Privacy Notice.

Patient's Name (Print)

Date

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's Signature

Date

AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO FAMILY MEMBER

Patient Name (Print)

DOB

I hereby authorize Elite Women's Care Center to discuss my protected health information with the following friend(s) and/or family member(s)

Name

Relation

DOB

Add new row

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 Signature

Date

Elite Women's Care, Center, PA

Well Woman Policy

You are scheduled for your yearly well woman exam/preventative health exam today.

(This is a routine checkup). Your insurance plan my only pay for the routine visit, testing of your preventative visit as defined by your plan.

*If you have new or chronic condition that requires additional attention, testing or treatment , there may be a co-pay, deductible, or an extra charge (s) for these services as per your plan.

*Some test may not be covered under your preventative benefit coverage which may result in a cost share to you.

*You may wish to consult your health plan regarding your benefits and your health plan reimbursement policies.

Thank you.

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's Signature

Date

Lab Consent

All laboratory services, cultures, and pathology are performed by a third party vendor. You are responsible for these services. Elite Women's Care Center is not responsible for any copays, deductibles, or non-covered lab services. If you have any questions, please contact your insurance company prior to any services rendered.

Patient's Name (Print)

Date

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's Signature

Date

PAST HISTORY (check all that applies)

Other Heart Disease

Other Kidney Disease

Infectious Disease (TB,HIV, ETC)

Other Lung Disease

Other Genetic/Inherited Disease

OBSTETRIC HISTORY

# of Pregnancies

# of Miscarriages

# of Living Children

# of Deliveries

# of Abortions

PLEASE LIST PREGNANCIES IN CHRONOLOGICAL ORDER:

PART 1 (do not forget filling up the part-2)

Birth Date

SEX

M F

Birth Weight

Add new row

PART 2 (continuation of part-1)

Anesthesia (If Any)

Complications

Doctor/Hospital

Add new row

Patient Name

Age

SURGICAL HISTORY

List all previous surgeries (type and approximate date) including plastic surgery, minor surgery and cesarean

Appendectomy

Yes No

Date

Complications

Surgeon/Hospital

Cervical Cone/Leep

Yes No

Date

Complications

Surgeon Hospital

Gall Bladder

Yes No

Date

Complications

Surgeon Hospital

Hysterectomy (Uterus)

Yes No

Date

Complications

Surgeon Hospital

Laparoscopy

Yes No

Date

Complications

Surgeon Hospital

Ovaries Removed

Yes No

Date

Complications

Surgeon Hospital

Tubal Ligation

Yes No

Date

Complications

Surgeon Hospital

Others (i.e Beast Biopsy etc.)

Yes No

Date

Complications

Surgeon Hospital

Will you permit a blood transfusion for medical reasons?

Yes No

Age of Onset of menses

When was your last pap smear

When was your last mammogram

Have you had a Hysterectomy?

Yes No

Do you still have your ovaries?

Yes No

If Menopausal, age of last menstrual period.

First day of last menstrual Cycle.

Patient Name

Age

How often do you get your period (Choose one)

Less than 20 Days Apart 21-35 Days Apart More than 36 Days Apart

How many days does your period last (Choose one)

Less than 2 Days 2-5 Days 5-7 Days 7-10 Days More than 10 Days

How many pads/tampons do you use on a heavy day?

Which form of Birth Control (if any) do you use?

Pill/Patch/Ring Depo Provera IUD Vasectomy Condom Tubal Ligation/Essure

Do you want to change birth control?

Yes No

What birth control options are you interested in?

Did your mother takes DES or other Hormones while pregnant with you?

Yes No

Regarding your Femail Organs: Choose any that apply

Abnormal Bleeding

Pelvic Infections

Chlamydia/Gonorrhea

Syphilis/Herpes

Tumor of the Uterus or Ovaries

Genital

LIST ALL CURRENTLY USED MEDICATIONS PRESCRIPTION, BIRTH CONTROL PILLS, OVER THE COUNTER, HERBAL AND NUTRITIONAL SUPPLEMENT)

Name

Dosage

Frequency

Add new row

Patient Name

Age

LIST ALLERGIES TO MEDICATION/FOOD

Are you allergic to latex?

Yes No

Medication/Food

Reaction

Add new row

What languages(s) do you speak, other than English?

SOCIAL HISTORY

Marital Status

Single Widowed Married Living Together Divorced Other

Are you sexually active

Yes No

Number of partners in the past year

Alcohol Use

Yes No

If Yes, Describe

Previously, but not now

Tobacco Use

Yes No

Pack(s) per day

Previously, but not now

Are you using any other drugs?

Yes No

If Yes, Type of drug(s)

FAMILY HISTORY

Cancer

Family Relation

High Cholesterol

Family Relation

Congenital Disease

Family Relation

Kidney Disease

Family Relation

Diabetes

Family Relation

Mental Retardation

Family Relation

Heart Disease

Family Relation

Osteoporosis

Family Relation

High Blood Pressure

Family Relation

Twins

Family Relation

Patient Name

Age

Have you ever had an abnormal Pap Smear?

Yes No

If yes, type of treatment

Are you sexually active?

Yes No

Do you have any concern(s) or discomfort

Yes No

If Yes, Explain

Date of last Pap Smear

Result

Date of last Mammogram

Result

Date of last Bone Density

Result

Reason for today's visit

What changes have there been in your life recently?

Pharmacy Name

Phone number

Do you need one month or 90 Day Prescription?

One Month 90-Day

How did you hear about us?

Katy Magazine

Internet

Primary Care/Specialist

Absolutely Katy

Friend/Relative

Prior Patient

Insurance Company

Patient Name

Age

Your information will be encrypted.