PATIENT REGISTRATION FORMS

Patient Last Name:

Patient First Name:

Patient Middle Initial:

Street Address:

City:

State:

Zip Code:

Email address

Date of Birth:

Race:

Ethnicity:

Phone Number: HOME

Phone Number: CELL

EMERGENCY CONTACT

Name:

Relation:

Phone Number:

CELL

HOME

PRIMARY INSURANCE INFORMATION

Please make sure to fill out the highlighted information below.

Insurance Company Name:

Insurance Phone Number:

Street Address:

City:

State:

Zip Code:

Responsible Party Last Name:

Responsible Party First Name:

Relation:

Date of Birth:

Phone Number: CELL

Phone Number: HOME

Subscriber ID Number:

Group Number:

Specialist Copay:

Effective Date

Follow my Health Registration

Personal Account Access
Patient Ages 12+
(Photo ID required)

I am 12-17 years of age and request access to my own medical record information

I am 12-17 year of age and grant Read Only Access to my medical records to the authorized user listed below

1 am 12-17 years of age and grant Full Access to my medical records to the authorized user listed below

I am 18 years or older and request access to my own medical record information

I am 18 years or older and grant Read Only Access to my medical records to the authorized user listed below

Authorized User Access

Parent / Guardian for patients) under age 11
(Legal documents and photo ID required)

I am 18 years or older and request Read Only Access to a patient medical record

I am 18 years or older and request Full Access to a patient medical record

I have legal paperwork for POA/Guardian/Adoption/Ward of the State or County for this patient

I am the parent of a minor aged 11 or younger and possess their birth certificate

PATIENT INFORMATION

First Name:

Middle Name:

Last Name:

Patient DOB:

Phone Number:

Email address where patient portal messages will be sent:

I hereby authorize COMPLETE WOMEN'S HEALTHCARE to use/disclose individually identifiable health information to Follow My Health patient portal for my online access to COMPLETE WOMEN'S HEALTHCARE health care information.

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

Patient Signature:

Date:

Authorized User Information

Authorized User Name:

Authorized User DOB:

Relation to Patient:

Authorized user email address where portal messages will be sent:

Address:

Phone Number: Home

Phone Number: Cell

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

Authorized User signature:

Date:

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW CAREFULLY.

State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. It is our right to change our privacy practices as the laws permit. We will amend this Notice before any significant changes and will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date the changes were made.

You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer. Our office will promptly notify affected individual(s) in the event of a breach of their PHI.

TYPICAL USES AND DISCLOUSERES OF HEALTH INFORMATION

We will keep your health information confidential using it only for the following purposes

Treatment: We may use your health information to provide you with our professional services. We have established "minimum necessary" or "need to know" standards that limit various staff members' access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.
Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends, and/or other persons you choose to involve in your care, only if you consent that we may do so.
Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may be involved in the process of mailing statements and/or collecting unpaid balances.
Emergencies: We may use or disclose your health information to notify or assist in notification of a family member or anyone responsible for your care in the case of any emergency involving your care. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated, we will use our professional judgement to disclose only that information directly relevant to your care. We will also use our professional judgement to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays, or other similar forms of health information and/or supplies unless you have advised us otherwise.
Healthcare Operations: We will use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security intelligence and other State and Federal officials and/or if you are an inmate or otherwise under custody of law enforcement.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to our health and safety or that of others.
Public Health Responsibilities: we will disclose your health information to report problems with product reactions to medication, product recalls, and disease/infection exposure and to prevent and control disease, injury and/or disability.
Marketing Health-Related: WE will not use your health information for marketing purposes unless we have your written authorization to do so.
National Security: The health information of Armed Forces Personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence, or other national security actives, we may disclose it to authorized federal officials.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders including but not limited to voicemail messages, postcards, or letters.

YOUR PRIVACY RIGHTS AS OUR PATIENT

Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be $25.00. If you want copies mailed to you postage will also be charged. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for fee and/or explanation of our fee structure.
Amendment: You have the right to amend your healthcare information if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.
Non-routine disclosures: You have the right to receive a list of non-routine disclosures we have made to your healthcare information. When we make a routine disclosure of your information to a professional for treatment and/or pertinent purposes, we do not keep a record: therefore these are not available. You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can request no routine disclosures going back 6 years starting on April 14, 2003.
Information prior to that date would not have to be released.
Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement.
(Except in emergencies) Please contact our Privacy Officer if you want to further restrict access to your healthcare information. This request must be submitted in writing. You also have the right to request restrictions for services paid out-of-pocket.

HELATH INFORMATION EXCHANGE ADDENDUM

Generally, a HIE is an organization that regional providers participate in to exchange patient information in order to facilitate health care, avoid duplication of services (such as tests) and to reduce the likelihood that a medical error will occur. By participating in a HIE, the provider may share certain health information with other providers that participate in the HIE (each a "participating provider") or participants of other health information exchanges. All participating Providers of HIE agreed to a set of standards relating to their use and disclosures of health information available through the HIE. These standards are intended to comply with all applicable state and federal laws. This health information includes, but not limited to:

General laboratory results including microbiology
Pathology test results including biopsies, pap smears, etc.
Radiology results including x-rays, MRI's, CT Scans, etc.
Results of outpatient diagnostic testing including GI testing, cardiac testing, neurological testing, etc.
Health Maintenance documentation
Problem list documentation
Allergy list documentation
Immunization profiles
Medication lists
Progress notes
Consultation notes
Discharge instructions
Inpatient operative reports
Emergency Room visit discharge summary notes
Urgent Care visit progress notes

HIE "OPT OUT" OPTION

If you opt-out, your health information will no longer be accessible through the KlEs in which the provider participates, however, your opt-out does not affect health information that was disclosed through a GHIE prior to the time that you opted-out.
Regardless of whether you choose to opt-out, your health information will still be provided to the HiEs in which the provider participates, however if you choose to opt-out, the HiEs will not exchange your health information with other provider. Also, you cannot choose to have only certain providers access your health information.
All participating providers who provide services to you will have the ability to access your information, however, participating providers that do not provide services to you will not have access to your information.
Information available through a HIE may be provided to others as necessary for Referral, consultation, treatment and/or the provision of other treatment related healthcare services to you. This includes providers, pharmacies, laboratories, etc.
Your information may be disclosed for payment related activities associated with your treatment by a participating provider and your information may be used for healthcare operations related activities by participating providers.
You may opt-out at any time by notifying the provider. A form and a list of participating providers may be obtained at the front desk.

QUESTIONS AND COMPLAINTS

You have the right to file a complaint with us if you feel we have not complied with our privacy policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us in writing. Request a COMPLAINT FORM from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

CONTACT INFORMATION

Practice Name: COMPLETE WOMEN'S HEALTHCARE
Telephone: (770)622-9810 | Fax: (770)622-9811
Email: INFO@WOMENSCAREONLINE.COM
Website: WWW.WOMENSCAREONLINE.COM
Address: 634 Peachtree Parkway
Suite 200
Cumming, GA, 30041

RECEIPT OF NOTICE PRIVACY OF PRACTICES AND HIE WRITTEN ACKNOWLEDGE FORM

I have received a copy of the Complete Women's Healthcare Privacy Practices & HIE Notices

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

Patient (or responsible party) Signature

Date:

PATIENT CONSENT FORM

I, the undersigned, hereby consent to the following treatment:

Administration and performance of all treatments
Administration of any needed anesthetics
Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient
Use of prescribed medication
Performance of diagnostic procedures / tests and cultures
Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgement of the attending provider or their assigned designees

I fully understand this is given in advance of any specific diagnosis or treatment.

I intend this consent to be continuing in nature even after specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.

I understand that COMPLETE WOMEN'S HEALTHCARE will use and disclose my information for the purpose of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices.

A photocopy of this consent shall be considered as valid as the original.

I certify that I have read and fully understand the above statement and consent fully and voluntarily to its content.

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

Patient (or responsible party) Signature

Date:

MEDICARE PATIENTS: I authorize COMPLETE WOMEN'S HEALTHCARE to release information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to COMPLETE WOMEN'S HEALTHCARE.

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

Patient (or responsible party) Signature

Date:

FINANCIAL AND PAYMENT POLICY FORM

RETURN CHECK FEES

CHECKS returned for non-sufficient funds will be charged a $30.00 administration fee, in addition to the patient balance.

HMO, MANAGED CARE AND PPO PLANS

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COPY OF RECORDS / FORMS

COPY OF RECORDS requests require approximately TWO WEEKS to complete. A $25.00 charge is applied for each request. includes verification of pregnancy letters and/or forms for disability, return to work letter, etc. This is a one-time fee payable before forms are completed. This fee will not be submitted to your insurance.

MISSED APPOINTMENTS

If you are unable to keep your scheduled appointment please notify our office at least 24 hours in advance of your appointment time. Failure to do so will result in a $35.00 no show charge. After 3 no shows on your account you will be dismissed from the practice.

MISSED, CANCELLED, OR RESCHEDULED PELVIC FLOOR THERAPY APPOINTMENTS.

If you are unable to keep your scheduled appointment please notify our office at least 24 hours in advance of your appointment time. Failure to do so will result in a $50.00 no show charge. After 3 no shows on your account you will be dismissed from the practice.

CANCELLED SURGERIES

There is a $100 cancellation fee for scheduled surgeries that are cancelled less than 48 hours. We do not know what the hospital cancelation policy is, and therefore you may be required to pay more fees with them.

DEDUCTIBLE, CO-INSURANCE AND CO-PAYS

All deductibles and co=pays are due at the time of services. We accept cash, checks, Visa and MasterCard. If payment is not received on the date of service, a $20.00 administration fee may apply. All unpaid balances will accrue a monthly 5% late charge If not paid in fuil after 60 days or not set up on an acceptable payment plan. Complete Women's Healthcare will send all unpaid balances to a collections company after 90 days.

LABS

We use PATHGROUP for all laboratory services. All labs are billed SEPARATELY through PATHGROUP and you will receive a separate statement for any laboratory services not covered by your insurance. If your insurances requires a specific lab, it is YOUR RESPONSIBILITY to let us know at the time of visit.

Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Above is a statement of our financial policy that we would like you to read and sign as evidence of your agreement prior to any treatment.

We must emphasize that as your physician our relationship is with YOU, not your insurance company. We file the insurance claim as a courtesy to our patients, but all charges are your responsibility from the date rendered. Not every service is a covered benefit in all contracts. Some insurance companies arbitrarily select your health insurance policy and its requirements for coverage including pre-authorizations of services. We are not responsible for knowing the requirements of your specific plan.

It is your responsibility to contact your insurance carrier to confirm that our office participates in your plan. If you receive services from our office, and we are not on your plan, You will be responsible for payments in full for our fee(s).

If you are unable to provide us with current insurance information (a current insurance card or written documentation of coverage from your insurance carrier), or if you do not provide us with the correct insurance information and claims are denied, you will be required to pay for any services you receive. When you have provided us with the corrected insurance information, we will file a claim with your insurance carrier and reimburse you once we have received their payment. Please be aware, if too much time has passed your insurance may not cover your services and you will be required to pay for services.

COMPLETE WOMEN'S HEALTHCARE is not a participating provider of Medicaid, you will be responsible for payment in full if you are insured with them. Patient responsible balances are expected within 30 days. Failure to pay a balance will result in collection actions. If a patient's balance is turned over to a collection agency an additional 30% of the balance will be added to the account.

I have read and understand this financial agreement of COMPLETE WOMEN'S HEALTHCARE. I accept and acknowledge

this financial and payment policy by signing below.

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

Patient (or responsible party) Signature

Date:

Patient (or responsible party) Printed Name

Consent for Release of Personal and Health Information

Patient Name:

Date of Birth:

Phone Number

Address:

This consent form allows personal and health information to be shared via telephone call with the person being authorized. I authorize the use or disclosure of personal and health information by Complete Women's Healthcare as described below.
(Please check which one you agree to, and fill out the blanks if necessary.)

Any and all personal and health information Complete Women's Healthcare maintains

Personal and health information regarding the treatment for the following

condition:

Personai and health information covering the period of time

from:

to:

Personai and health information covering the period of time

This information may be disclosed to, and used by the following individuals or organizations (healthcare included)

Add Healthcare Provider

Add Name

I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and send my written revocation to Complete Women's Healthcare. I understand that the revocation will not apply to information that has already been released in response to this authorization.

I understand that I do not have to sign this authorization. I understand that once the information is disclosed the pursuant to this authorization, it may be re-disclosed by the recipient and the information may not be protected by federal privacy regulations

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

Patient (or responsible party) Signature

Date:

WELL WOMAN CONSENT FORM

Name:

Date of birth:

You have been scheduled to have a Well-Woman exam today. The annual well woman exam is an essential part of your ongoing health maintenance. Despite changes in recommendations for certain test such as the Pap test, a regular annual exam is strongly recommended. Most health insurance companies will cover most in full, if not all, of the charges associated with this type of visit. Please check with your insurance company to determine how your visit will be covered.

What things are normally considered to be part of the annual well-woman exam?

A clinical breast and pelvic exam, Pap smear but the frequency of these exams depends on your age, health, and risk factors for certain conditions.
Reproductive health concerns, birth control options, menstrual, menopause and sexual health
Breast cancer screening
Genetic screening for cancer for women with certain risk factors
Bone density screening
Screening for sexually transmitted infections (STI's)
Screening for depression, anxiety and other mental health problems

Any labs that are ordered for you today are billed separately by the lab company. The labs MAY or MAY NOT be covered by your insurance. Reminder you will received a separate invoice for the lab for any balance or test not covered by your insurance.

Important Note:

The intent of an annual well-woman visit is for routine health maintenance. The assumption is that you do not have any specific medical problems or conditions. If you discuss any problem-oriented issue with your provider (e.., back pain, breast pain, rashes, sleeping problems, yeast infections, medication adjustments, requesting additional labs other than your preventative routine labs), your insurance may be billed separately and in addition to your well-woman visit since problem-oriented visits usually necessitate a visit. Please review your insurance coverage for more information on what is covered as part of your visit.

Please sign below when you have read and understood this form.

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

Signature

Date:

NEW PATIENT MEDICAL HISTORY FORM

Please complete the following information as accurately as possible. Please note that ALL INFORMATION is required and needed for your visit. Your answers on this form will help your provider understand your medical concerns and conditions better. If vou cannot remember specific details, please give best estimates.

Name:

Date:

Date of Birth:

Name:

PRIMARY CARE PHYSICIAN:

PREFERRED LAB:

PREFERRED PHARMACY:

PHARMACY NUMBER

REASON FOR VISIT (please check one)

please check one

Annual - Well Woman Check Up

Problem Visit - please list:

(Examples: Menstrual problems, ovarian cysts, UTI, ect)

FEMALE GYNECOLOGY HISTORY:

Date of last menstrual period:

NONE due to:

Hysterectomy

Menopausal

Other

Age of first period:

How many days do you bleed:

How many days from one cycle to the next:

Any problems with your period?

YES NO

If yes, please explain:

CONTRACEPTION

Are you currently using a Contraceptive?

YES NO

Are you interested in discussing Contraception today?

YES NO

HORMONE EVALUATION

Are you in Menopause?

YES NO

Do you or have you ever used hormone therapy?

CURRENTLY NEVER PREVIOUSLY

Are you interested in Bio-Identical Hormone Therapy?

YES NO UNSURE

Do you have any menopausal symptoms?

YES NO

If yes, please list:

FEMALE GYNECOLOGY PROBLEMS (PAST AND PRESENT):

If Abnormal Pap Smear is select, Year:

If other, Specify:

If Cancer is select, Type:

ALLERGIES

Add Allergies

MEDICATIONS: Current and regularly taken prescribed medications by healthcare providers (if you have a list, please attach)

Add Medication

SUPPLEMENTS: Supplements, Vitamins, etc.

Add Supplements

FAMILY HISTORY: Place a check next to all that apply

Bleeding Disorder - Family Member

Blood Clotting Disorder - Family Member

Diabetes - Type 1 - Family Member

Diabetes - Type 2 - Family Member

Cancer - what type - Family Member

Heart Disease - Family Member

Hypertension/High Blood Pressure - Family Member

High Cholesterol - Family Member

Stroke - Family Member

Kidney Problems - Family Member

Mental Illness - Family Member

PAST SURGICAL HISTORY: Please list ALL surgical procedures with dates performed

Add new row

PREGNANCY HISTORY: Please include abortions or miscarriages

Number of times Pregnant:

Number of Miscarriages:

Number of Abortions:

Number of Premature Births:

Number of On-time Births:

Number of Living Children:

If any, is there anything you would like us to know about the adopted children?

Add new row

SEXUAL ACTIVITY

• How many partners in the last 12 months?

If so, which:

HPV

Cylamydia

Gonorrhea

HIV

Syphilis

Hepatitis B

***Deductibles or copays may apply to the laboratory when performing the test, Complete Women's Healthcare DOES NOT know your lab benefits

SOCIAL:

Your Occupation:

Your Employer:

Name of Spouse / Partner:

If yes, drinks:

per

drink(s) week month

If yes, type:

Cigarettes

E-Cigarettes

How many cigarettes a day:

How long:

Quit Date:

What kind:

If yes, cups:

per

drink(s) week month

How many days per week:

What kind of exercise:

Vegan

Vegetarian

Restrictions

Other

Restrictions:

Other:

Would you like to explain:

SAFETY

VACCINE HISTORY:

HEALTH MAINTENANCE AND MODIFIERS:

WHEN WAS YOUR LAST

Pap Smear

Mammogram

Colonoscopy

DEXA / Bone Scan

Cholesterol / Lipid Screen

Routine Lab Work

Add new row

REVIEW OF SYSTEMS: please indicate any recent problems or symptoms

General:

Excessive fatigue

night sweats

unexplained weight change - gain

unexplained weight change - loss

hot flashes

heat or cold intolerance

Breasts:

change in skin

breast pain

nipple discharge

lumps

Respiratory:

unexplained cough

shortness of breath

wheezing

Gastrointestinal:

vomiting (more than 2 weeks)

blood in stool

bloating (more than 2 weeks)

chronic diarrhea

chronic constipation

persistent nausea

Genital / Urinary:

vaginal discharge

leaking of urine

blood in urine

vaginal odor

pain with urination

urination urgency

Skin:

new or changing skin lesions

Neurologic:

intense headaches, new onset

Cognitive / Emotional:

depression

inability to concentrate

anxiety

poor sleep

lack of focus

Cardiovascular:

chest pain

palpitations

By signing this agreement, I certify that all of the above information is true to the best of my knowledge and beliefs.

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

Patient (or responsible party) Printed name

Date:

Patient (or responsible party) Signature

Your information will be encrypted.