note: if you have medicaid insurance, you will be required to ......2020/04/04 · annually) or a...
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![Page 1: Note: If you have Medicaid insurance, you will be required to ......2020/04/04 · annually) or a minimum fee of $3.00. If an account is left unpaid the undersigned agrees to pay](https://reader036.vdocuments.us/reader036/viewer/2022062607/6027592b7a6ac209d7173ee4/html5/thumbnails/1.jpg)
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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
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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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