note: if you have medicaid insurance, you will be required to ......2020/04/04  · annually) or a...

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Congratulationsonyourpregnancy!Weareexcitedtobeapartofyourjourneyandwouldliketogiveyousomeinformationregardingourbillingpolicies.Thisagreementistoinformyouofanticipatedfees,whichmaybeacquiredduringthecourseofyourpregnancy.Unlikeothertypesofservices,insurancecompaniesrequireustobillyourprenatalcareanddeliveryglobally.Ourexperiencewithinsurancecompaniesisthattherewillbeaportionoftheglobalfeethatwillbeyourresponsibilityalongwithanydeductibleandco-insuranceiftheyapply.Afteryourinitialvisitwithus,ourOBbenefitspecialistwillcallyoutoreviewyourbenefitsandanticipatedcosts.Theywillalsosetupamonthlypaymentplanwithyouatthattime.CVWCrequiresthatanyestimatedpatientresponsibilitybepaidinfullbeforedelivery.Estimatesgivenbyyourinsurancecompanyarenotaguaranteeofpayment.Finaldeterminationwillbemadebyyourinsuranceafterclaimshavebeensubmitted.Anydifferencebetweenquotedamountsandamountsactuallyowedwillbetheresponsibilityofthepatient.Duringyourpregnancy,physiciansmayorderbloodwork,labs,ultrasounds,ornon-stresstestsasneeded.Theseserviceswillbebilledtoyourinsuranceatthetimeoftheservice,andarenotincludedintheglobaldeliveryfee.Additionally,ifyouareseenforanyproblemorconditionunrelatedtoyourpregnancy,wearerequiredtobillfortheofficevisit.Yourresponsibilityfortheseserviceswillbedeterminedbyyourcontractwithyourinsurancecompany.Shouldyouhaveachangeininsurancecoverage,pleasenotifyusimmediately.Anydelayscouldresultinadditionalout-of-pocketexpensesordeniedclaims.Note:IfyouhaveMedicaidinsurance,youwillberequiredtobringyourcurrentcardwithyoutoeachappointment.IfMedicaidcoveragelapses,youwillberequiredtopay$300permonthofnon-coverage.Ifyoudonothaveinsurance,pleasecontactourbillingdepartmentpriortoyournurseconsultvisit.Pleasecheckwithyourinsurancecompanytodetermineyourglobalmaternitybenefitsandcompletetheinformationbelow:Insurance:____________________________________Deductible:__________________________________________Outofpocket:_________________________________Co-Insuranceafterdeductible:___________________________PatientSignature DateofBirthPrintName DatePLEASENOTETHISISFORPHYSICIANSERVICESONLY.FACILITYSERVICESAREBILLEDSEPARATELYBYLOGANREGIONALHOSPITAL.Ifyouhaveanyquestionsregardingtheaboveinformationpleasecontactourbillingdepartmentat435-753-9999

Page2of13PATIENTINFORMATION Date ___________________________________

Name:_______________________________________________________________________________ Last First MiddleMailingAddress_______________________________________________________________________ City State ZipHomePhone(___)___-_____CellPhone(___)___-_____EmailAddress__________________

DateofBirth___________________________Age___________Sex:¨M¨F

Race___________________________Ethnicity___________________PrimaryLanguage___________

MaritalStatus:

Single

Married

Divorced

EmploymentStatus:

FullTime

PartTime

EmployerName(ifapplicable) ___________________________________________________________

PartnerName(ifapplicable)________________________ DOB _______________________________

Partner'sEmployerName_______________________________________________________________

INSURANCEINFORMATION

(Primary)InsuranceCompany____________________________________________________________

Employer_____________________________________________________________________________

SubscriberName______________________________________________________________________

Policy#_________________________Group# _____________________________________________

PolicyHolderDOB______________________________________________________________________

(Secondary)InsuranceCompany__________________________________________________________

Employer_____________________________________________________________________________

SubscriberName______________________________________________________________________

Policy#_________________________Group# _____________________________________________

PolicyHolderDOB______________________________________________________________________

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EMERGENCYINFORMATION

Name:_______________________________________________________________________________ Name Phone#Name:_______________________________________________________________________________ Name Phone#

Dowehavepermissiontoleaveappointment

informationonavoicemailorviatext?

Yes

No

Dowehavepermissiontoleavetestresultson

onavoicemailorviatext?

Yes

No

Iauthorizethereleaseofanymedicalinformationnecessarytoprocessanyclaim.Ipermitacopyofthe

authorizationtobeusedinplaceoftheoriginal.Thisauthorizationmayberevokedbymeormy

insurancecompanyatanygiventimeinwriting.Ialsoauthorizepaymenttobemadedirectlytothe

doctorfrommyinsurancecompany.

Signature _______________________________________Date________________________________

*WehaveupdatedourHIPAANoticeofPrivacyPractices.Pleasevisitourwebsite(cvwomenscenter.com)andnavigatetothe

footer.Onceyouhavereadthenotice,pleaseinitialanddatehere:Initial_____________________Date__________________

Ifyouareunabletoreadthisonline,orwouldlikeacopyofthisnotice,pleasecontactourofficeat435-753-9999

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OFFICEFINANCIALPOLICY

CacheValleyWomen’sCenterprovidesservicestoyou,notyourinsurancecompany.Becauseofthis

factyouareresponsibleforpaymentofanybillincurredinthisoffice.Wecannotprovideservices

assumingtheinsurancecompanywillcomethroughwithpayment.Althoughasacourtesytoyouwe

willbillyourprimaryandsecondary(ifapplicable)insurancecompanies.Ifwehavenotreceived

paymentfromyourinsurancecompanywithin60days,wewillexpectyoutopaythebalanceinfull.It

willthenbeyourresponsibilitytocollectfromtheinsurancecompany.Youareresponsibleforall

deductiblesandchargesnotcoveredbyinsurance.Pleaseunderstandthatwecannot,asathirdparty,

becomeinvolvedinprolongedinsurancenegotiations,thatisyourresponsibility.Pleasecontactyour

insurancecompanytoinquireifweareaproviderforyourinsurance.

Allcopaymentsand/orpercentagesthatyourinsurancerequiredyoutopaymustbemadeatthetime

ofvisit.Weacceptcash,personalchecks,andmostmajorcards.

Oftenourpatientsfindthemselveswithoutanyinsurancecoverage.Itisourpolicythatpaymentistobe

madeinfullatthetimeofserviceunlesspriorarrangementshavebeenmade.

Anyaccountthathasbeenleftunpaidafter30dayswillbechargedaninterestrateof2%monthly(24%

annually)oraminimumfeeof$3.00.Ifanaccountisleftunpaidtheundersignedagreestopaycosts

chargedbyourcollectionagency(50%oftheunpaidbalance)andalllimitedreasonableattorney’sfees.

Thankyoufortakingthetimetoreadourfinancialpolicy.Ifyouhaveanyfurtherquestionsorconcerns,

pleasecalltheoffice.

Iagreetoandunderstandtheabovefinancialpolicy.

Signature _______________________________________________Date_________________________

Amended

Signature _______________________________________________Date_________________________

Signature _______________________________________________Date_________________________

Signature _______________________________________________Date_________________________

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OB/GYNINTAKEHISTORYDate_____________________________

Name:__________________________________________ DOB _______________________________

Nameofspouseorpartner_______________________________Numberinhousehold ___________

Allergies__________________________________ReferredBy_______________________________

REVIEWOFSYMPTOMS:

PersonalCURRENTHistory

¨Abdominalpain¨Abnormalperiods¨Anxiety¨Asthma¨Bloating¨Bloodinurine¨Bloodystool¨Bruisingeasilyoroften¨Chestpain¨Constipation¨Coughingblood¨Cryingoften¨Depression¨Diarrhea¨Dizziness¨Dryskinorrashes¨Earachesorringing¨Enlargedlymphnodes

¨Excessivethirst¨Fatigue¨Headaches,type ________¨Hotflashes¨Incompleteemptying¨Incontinence¨Jointpainorstiffness¨Nausea¨Nightsweats¨Painwithurination¨Painfulintercourse¨Painfulperiods¨Palpitationsor"heartracing"¨Premenstrualsyndrome¨Refluxorheartburn¨Seizures

¨Sexualconcernsorquestions¨Shortnessofbreath¨Sinusproblems¨Sleepingproblems¨Sorethroat¨Sore(s)thatwon’theal¨Urgency¨Urinaryfrequency¨Vaginaldischarge¨Vaginaldryness¨Vaginalirritation¨Visionchanges¨Vomiting¨Weightgain¨Weightloss¨ ______________________

PersonalPASTHistory

¨Anemia¨Anorexia¨Anxiety¨Asthma¨BloodClot¨Bloodtransfusion¨Boweltrouble¨Bulimia¨Cancer,type¨Celiacdisease¨Depression¨FractureWhichbone___________¨Graves'Disease

¨Hashimoto’s¨Hearttrouble¨Hepatitis¨HerpesType______________¨Highbloodpressure¨HIV¨HPV¨Hyperthyroid¨Hypothyroid¨Insomnia¨Jaundice¨Jointpain¨Kidneyinfections

¨Kidneystones¨Migraines¨Murmur¨Osteoarthritis¨Pneumonia¨RheumatoidArthritis¨Seizures/epilepsy¨Staphinfection¨Stroke¨TypeIDiabetes¨TypeIIDiabetes¨Ulcers

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Name:_______________________________________________________________________________

CurrentMedications

MedicationName Dosage Howoften?

Surgeries:

Surgery Reason DateofSurgery

OB/GYNHistory

Numberofpregnancies___________________

Numberofchildren______________________

Abortions ______________________________

Miscarriages____________________________

Full-termdeliveries ______________________

BirthControltype________________________

DateoflastMenstrualPeriod______________

Menseslastsapproximately___________(days)

Aremenses¨Regular¨Irregular

FamilyHistory(Pleaselistuptoyourmaternalandpaternalgrandparents)

Illness Yes Who AgeatdiagnosisBreastCancer ColonCancer OtherCancer OvarianCancer Depression Anxiety

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AlcoholicDependence DrugAddiction TypeIDiabetes TypeIIDiabetes Stroke BloodClots HeartDisease HighBloodPressure HighCholesterol ThyroidProblems

PersonalSocialHistory

Yes No Never Currentlyusingtobacco Packsperday

HowmanyyearsUsedtobaccointhelastfiveyears

Ifyes,whendidyouquit?

Alcohol DrinksperdayDrinksperweek

RecreationalDrugs NameHowoften?

RegularExercise HoursperdayHoursperweek

Caffeine OuncesperdayNameofdrinks

SexuallyActive

Haveyoueverbeentouchedinappropriately?Pleaseexplain___________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Doyoufeelsafeathome?Ifno,pleaseexplain_______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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PersonalProfile

MaritalStatus

Married

Single

Widowed

Divorced

Separated

Significantother

HighestEducationLevel

HighSchool

College

Graduatedegree

Other

CurrentJob(ifapplicable):_______________________________________________________________

Full-time

Part-time

IntakeHistoryCompletedby:

Patient

RN/MA

MD/PA

PatientSignature____________________________________________Date ____________________

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PRENATALGENETICSCREENING

• Willyoube35yearsorolderwhenthebabyisdue?

Yes

No

GeneticDiseasesCommontoCertainEthnicGroups

• Areyouorthebaby'sfatherofAfrican

descent?

Yes

No

• Ifyes,haveeitherofyoubeenscreen

forsicklecelltrait?

Yes

No

• Areyouorthebaby'sfatherofEastern

EuropeanJewishdescent(Ashkenazi)?

Yes

No

• Doyouoryourpartnerhaveanyclose

relativesfromItaly,Greece,oranother

Mediterraneancountry?

Yes

No

• Doyouorthebaby'sfatherhaveanyclose

relativesfromthePhilippinesorSoutheast

Asia?

Yes

No

PersonalandFamilyGeneticHistory

Haveyou,thebaby'sfather,oranymemberofyourrespectivefamilieseverhadanyofthefollowing

disorders:

Yes WhoCongenitalheartdefect Hemophilia DownsSyndrome OtherChromosomalabnormality MuscularDystrophy CysticFibrosis SpinaBifida Geneticdisordernotlistedabove

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Doyouorthebaby'sfatherhaveabirthdefect?

Yes

No

Haveyouhadapreviousstillbirthwithabirthdefect?

Yes

No

Haveyouhadthreeormorelossesinthefirsttrimester(first12weeks)?

Yes

No

Doyouorthebaby'sfatherhaveanyrelativeswithmentalretardation?

Yes

No

Excludingironorvitamins,haveyoutakenanymedicationsorrecreationaldrugs(alcohol,cocaine,

cannabis,speed,meth,LSD,etc.)duringthepregnancy?

Yes

No

Ifyes,pleaselist: ______________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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PRE-TERMLABORQUESTIONNAIRE

PatientName _________________________________________________________________________PatientDateofBirth ______________________EstimatedDeliveryDate_________________________

Doyouhaveahistoryof:

Yes Miscarriagebeforethreemonths Howmany?Miscarriageafterthreemonths Howmany?Previouspre-termlabor(20-37weeks) Previouspre-termdelivery(20-37weeks) Ifyes,why?

Pre-termlabor Prematureruptureofmembranes Medicallyindicatedinduction

Conebiopsy Uterineanomaly(fibrisincluded) Cervicalcerclage PositiveB-strepfromvaginalculture AreyouadaughterofDESexposure?

WiththispregnancyONLY,haveyou

experiencedanyofthefollowing?

YesBleedingafter12weeks Illnesswithincreasedtemperature Kidneyinfection? Urinarytractinfection? Cigarettesmoking Sexuallytransmittedinfection Alcoholuse Druguse AreyouadaughterofDESexposure?

GestationalDiabetesScreening.Doanyofthe

followingapplytoyou?

YesDeliveredababyweighing9lbsormoreatbirth

Familymemberwithdiabetes Gestationaldiabetesinapreviouspregnancy

Iamcurrentlydiabetic Ihavedeliveredastillbornchild Ihavedeliveredachildwithaphysicalabnormality

Ihavehadthreeormoreconsecutivemiscarriages

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HOMEDELIVERYPOLICY

ThephysiciansandprovidersoftheCacheValleyWomen'sCenterdonotaffiliatewithorbackupany

plannedhomedeliveries.Ifyouareplanningonahomedeliverywithamidwifeordoula,pleasebe

awarethatthiswillseverourpatient/physicianrelationship,whichwillautomaticallyresultinyour

dismissalfromourpractice.

Iagreetoandunderstandtheinformationprovidedabove.

Signature _______________________________________________Date_________________________

PrintedName_________________________________________________________________________

WitnessSignature ________________________________________Date_________________________

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