New Patient Forms

OB/GYN OF HOUSTON

Please correct the errors described below.

New Patient Registration Information

Primary Insurance

Secondary Insurance

Assignment of Benefits

This medical practice works with the patient to minimize difficulty in the payment of fees for service, Upon leaving from your appointment, you will be asked to pay those minimal unmet deductible amounts and co-insurance amounts that your insurance company authorizes to be collected. Please insure that the primary and secondary information above is correct. Authorization of Benefits: I the undersigned hereby authorize OB/GYN of Houston to release all information pertaining to the patient's treatment to his/her insurance company or companies and to any other physician or healthcare provider to whom the undersigned may be referred. Assignment of Benefits: I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance, and other health plan to: OB/GYN of Houston. Financial Responsibility: I understand that I am financially responsible for all services received, regardless of my insurance coverage.

DISCLAIMER: 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.

Financial Statement

PATIElNT RESPONSIBILITIES In order to receive proper care, patients must accept certain responsibilities. You are responsible for providing accurate and complete information regarding your Insurance policy (ies). You are responsible for your financial obligation.

FINANCIAL TREATMENT In consideration of the services to be rendered to the patient and/or the legally responsible person signing this Consent assumes full financial responsibility for the payment of the patient's account. If the account is referred to an attorney or collection agency, the same person agrees to pay actual attorney's fees and collection expense. If charity services are required, eligibility determination should be requested upon first visit or receipt of itemized bill or statement.

IRREVOCABLE ASSIGNMENT OF INSlJRA1'\CE BENEFITS I hereby authorize and direct all Insurance company (ies) under which I am insured to pay directly to OB/GYN of Houston for all charges incurred, or alternatively, for all charges in excess of the sums actually paid by the said policy (ies). Each person signing the Consent is financially responsible for charges not collected by this assignment.

RELEASE OF INFORMATION To the extent necessary to determine liability for payment and to obtain reimbursement, I Authorize OB/GYN of Houston to disclose my health care information to any person, Social Security Administration, Insurance or benefit payor, health benefit plan or worker's compensation carrier which is, or may be, liable for all or a portion of the physician's charges, and to complete claim forms on behalf of the patient. I understand that OB/GYN of Houston may disclose my health care information without my written authorization to: members of audit, quality assurance, applicable State and Federal agencies; or to a court pursuant to a court order or Subpoena. I also understand that my health care information will not be provided to any person including next to kin, close personal friends, florists, delivery personnel or physicians who are not currently treating me without my written authorization.

FOR MEDICARE PATIENTS ADVANCE BENEFICIARY NOTICE THAT MEDICARE WILL NOT PAY Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits. Some items and services are not Medicare, benefits and Medicare will not pay for them. When you receive and item or service that is not covered, you are responsible to pay for it, personally or through any other insurance that you may have.

DECLARATION I have read and understand the above agreements, authorizations, and irrevocable assignments. The terms and consequences of this document have been fully explained to me and I have signed it freely an without inducement other than the rendition of services. All questions have been fully answered. ! do understand the above agreements, authorizations, and irrevocable assignments. The terms and consequences of this document have been fully explained to me and I have signed it freely an without inducement other than the rendition of services. All questions have been fully answered. I do understand that I am responsible for any amount not covered by Insurance.

DISCLAIMER: 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.

HIPPA Privacy

Acknowledgment of Receipt of Privacy Notice

By signing this acknowledgment of Receipt of Notice of Privacy Practices (the "Notice"); I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that the Company may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, health exam information and/or type of products provided) to another party to permit the Company to perform its administrative duties, provide me with health care services and products, process my health benefit claims and communicate with me regarding health care services provided by the Company (for example, mailings of health reminders or information about services/products provided by the Company). I can be assured that this Company does not sell my persona! health information of any kind to a third party for such party's own use. I authorize the Company to submit my health benefit claims to my plan sponsor or health plan to receive reimbursement directly for the health services and products that I have received from the Company.

DISCLAIMER: 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.

Refusal of Acknowledgment (For Office Use Only)

For Company Use ONLY: This section is to be completed by the Company only if unable to obtain the patient or patient's legal representatives written acknowledgment of receipt the Notice of Privacy Practices for the following reasons:

NOTE: PLACE THIS FORM IN THE PATIENT'S FILE, AND RETAIN INDEFINITELY.

Review of Systems

Please check each box for every "yes" answer to the following questions. Use the space at the bottom of this form to write in any explanations or other information you would like us to know. Have you had any of the following conditions or medical problems?

DISCLAIMER: 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.

Health History

Family History

Father

Mother

Brothers

Sisters

Children

ALLERGIES or side effects from medications (list name of medications / type of reaction):

Add Another Medication/Reaction

Any immediate family members with the following?

Personal History

Medications

(Please include birth control pills and any other over-the-counter, nonprescription drugs!)

Add Another Medication

Hospitalizations and Surgeries

Add Another Hospitalization or Procedure

Health Maintenance

Women

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