ESTABLISH PATIENT

NEW OB FORM

Name:

Date of Birth:

First Day of Last Period

On birth control?

How old were you when you first began menstruating?

Are they predictable?

How often?

Length of flow?

(days)

Date of Pregnancy test

Pregnancy weight current

Father of the baby's name

Have you had any vaginal spotting with this pregnancy?

Yes No

Have you had any nausea/vomiting?

Yes No

Date of last Pap smear:

Doctor who performed Pap smear:

Medications currently taking:

Drug Allergies:

OBSTETRIC HISTORY

Total # Pregnancies

Number

Full Term

Number

Premature (< 37 weeks)

Number

Abortions

Number

Living Children

Number

Miscarriages

Number

Please List Each Pregnancy Below:

First

No. Date

Sex

Weight

Weeks Pregnant

Anesthesia (Epidural)

Type of Delivery

(Vaginal/C-Section)

Complications

Second

Date

Sex

Weight

Weeks Pregnant

Anesthesia (Epidural)

Type of Delivery

(Vaginal/C-Section)

Complications

Third

Date

Sex

Weight

Weeks Pregnant

Anesthesia (Epidural)

Type of Delivery

(Vaginal/C-Section)

Complications

Have you/or the father of the baby been exposed to HIV, Herpes, or Tuberculosis?

Have you been sick or had a rash since your last period?

Have you/or the father of the baby ever had an STD?

Yes No

If yes, please explain:

If you have had any surgeries before, please describe below:

Date and Type of Surgeries

PERSONAL MEDICAL HISTORY

History

Seasonal, Food, Environmental Allergies

Yes No

Anemia

Yes No

Asthma

Yes No

Autoimmune Disorders

Yes No

Infertility

Yes No

Breast Disorders

Yes No

Psychiatric Disorder

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Hypertension

Yes No

Liver Problems

Yes No

Blood Transfusions

Yes No

Kidney Problems

Yes No

Thyroid Problems

Yes No

Abuse, molested, raped, or assaulted

Yes No

Uterine Abnormalities

Yes No

Blood Clots

Yes No

Abnormal Pap Smears

Yes No

Neurologic Problems

Yes No

Depression

Yes No

Do you have cats at home?

Yes No

Have you had the Chicken Pox?

Yes No

Is the father of the baby in good health?

Yes No

Do you drink alcohol?

Yes No

Amount per week?

Do you smoke?

Yes No

Amount per day?

How many years?

Has anyone in your family or the father of the baby’s family had any of these?

Disorder

Spina Bifida

Yes No

If yes, who?

Down Syndrome

Yes No

If yes, who?

Congenital Heart Defects

Yes No

If yes, who?

Cystic Fibrosis

Yes No

If yes, who?

Tay-Sachs

Yes No

If yes, who?

Thalassemia

Yes No

If yes, who?

Canavan Syndrome

Yes No

If yes, who?

Huntington's Chore

Yes No

If yes, who?

Autism

Yes No

If yes, who?

Mental Retardation

Yes No

If yes, who?

Muscular Dystrophy

Yes No

If yes, who?

Sickle cell disease/trait

Yes No

If yes, who?

Type 1 Diabetes/PKU

Yes No

If yes, who?

Recurrent Pregnancy Loss/Stillbirth

Yes No

If yes, who?

Hemophilia/Blood Disorder

Yes No

If yes, who?

Other Genetic Screening/Birth Defects

Yes No

If yes, who?

REMINDER

We would like to welcome you as a patient to Midland Women's Clinic. This form you are completing now will assist us in providing you with the best possible care. The scheduling and financial process can take up to 3-5 business days after receipt of this form. An additional email will be sent to you regarding your financial responsibility and estimation that will require a signature prior to your New OB appointment.
All patients and attending parties must arrive 10 minutes before their appointment. If you are late, you could be re-scheduled or moved to a different time. Visits that involve Sonograms will not wait for other parties to arrive.
Payment is required at check in. Your payment amount is based off of your benefits. Your appointment will be rescheduled if payment is not collected.
If you need tocancel orre-schedule your appointment, please call the office atleast 24 hours prior to your appointment toavoid being billed a $50.00 no-show fee.
We do not file Medicaid as a Primary or Secondary insurance carrier. Failure to present the correct insurance information claim denials and inaccurate calculation of payments due.

If you have any questions, please do not hesitate to call (432-699-2370 ext 205).
We look forward to starting your OB care with you!!

Cancellation/ No Show & New Patient Paperwork Policy

1. Cancellation/No Show Policy
We understand that there are times when you must miss an appointment due to an emergency or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit because the schedule seems “full”.

If an appointment is not cancelled at least 24 hrs. in advance, you will be charged a fifty-dollar ($50) no show fee; this will not be covered by your insurance company. A patient who no shows more than three times is dismissed from the practice.

2. Scheduled Appointments
We understand delays can happen however, we must try to keep the other patients and doctors on time; although sometimes our doctors do run behind, your timely arrival helps from adding to the delay.

If a patient is 15 minutes late past their appointment time, we reserve the right to reschedule the appointment(s).

3. New Patient Paperwork
We ask that all new patients have our new patient paperwork filled out and in our office at least one business day (24 hrs) prior to your appointment. Having this information ahead of time allows our staff to be able to give you the best care during your appointment.

If our clinic does not have your new patient paperwork at least one business day (24 hrs) before your appointment, we may have to reschedule your appointment.

I understand all the above policies and procedures.

Signature

Date

Release of Billing Information & Assignment of Benefits

Please take a few minutes to read the paragraphs below and sign in the indicated spaces:

1. I authorize my insurance carrier to release information regarding my coverage to Midland Women's Clinic. I also authorize agents of any hospital, treatment center or previous physicians to furnish Midland Women's Clinic copies of my medical history, services or treatments. I also authorize the release of any medical information and/or reports related to my treatment to any federal, state or accreditation agency, or any physician or insurance carrier as needed. I also agree to a review of my records for purposes of internal audits and quality assurance reviews within Midland Women's Clinic

Signed (Patient’s signature or Parent or Legal Guardian if Patient is a Minor – Under 18)

Date

2. My right to payment for all pharmaceuticals, procedures, tests, supplies and nursing/physician services including major medical benefits, are hereby assigned to Midland Women's Clinic. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or my representative, I will endorse such payments to Midland Women's Clinic within five business days.

Signed (Patient’s signature or Parent or Legal Guardian if Patient is a Minor – Under 18)

Date

3. I authorize Midland Women’s Clinic to obtain/have access to my medication history.

Signed

Date

Privacy Consent & Financial Agreement Form

Privacy Consent

In reference to the HIPAA Law,

Date of Birth:

I DO NOT authorize the discussion or release of my medical records to anyone other than myself

I DO authorize the discussion or release of my medical records to the following people:

Patient Record Sharing

By choosing this box you are Authorizing Midland Womens Clinic to allow any provider you have seen or currently seeing to review your records from Midland Womens Clinic.

I am also aware of this office's Notice of Privacy Practice and HIPAA/Privacy policy which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.

Signed

Date

Effective January 1, 2024, CMS (The Centers for Medicare and Medicaid Services) approved the use of CPT code 99459 to help with the ever-increasing costs of providing healthcare to women, specifically the costs associated with pelvic exams and the need for a chaperone for most of our exams.

Using CPT language, this code is considered a practice expense add-on code and is added to your Evaluation and Management (E&M) or problem visit, or your Well Women visit when a pelvic examis performed with a chaperone present. Based upon your benefits plan, this code may be paid at 100% or it may be subject to deductibles, co-pays, or co-insurance resulting in an out-of-pocket expense.

As you may be aware, the availability of quality women's healthcare has become more and more difficult to find. This issue, which is seen in most specialties, has been made worse by the high incidence of retirements following the public health emergency caused by Covid.

Our goal is to continue to serve you, our valued patients, despite ever decreasing Medicare reimbursement as well as double digit inflation. Please understand, while we are seeing this covered by the major commercial insurance carriers there could be patient responsibility.

Thank you.

Signature

Date

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