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Patient Information

Patient Name:________________--,-- ----=--::-:-;:-:-;last First Middle

Mailing Address:

City: _______________ State: ____ Zip Code: _______

Date of Birth: ____________ Age: ____

HomePhone: ______________ Cell Phone: ______________

TXDl#: ______________ Social Security: ______________

Employer: ______________ Phone: ________________

Nearest Relative: _____________ Phone: ______________

Nearest Friend: ______________ Phone: ______________

PCP Information: ________________ Phone: _____________

Pharmacy: ___________________ Phone: ______________

Patient E-mail: _________________________________

Primary Insurance:

Group #:

Phone:

INSURANCE INFORMATION

Member ID/Policy #:

--

Secondary Insurance:

Group #:

Phone:

Member ID/Policy #:

Medical Release Assignment

I hereby authorize Advantage Women's Care, Jennifer T. Nguyen, MD to furnish information to my insurance company concerning my illness and treatments. I hereby assign all of the benefits to be payable for the services

rendered for myself or my dependents. I understand I am responsible for any amount not covered by insurance.

This assignment is effective until revoked in writing by Advantage Women's Care, Jennifer T. Nguyen, MD any

photocopy or facsimile/electronic transmission of this document shall be considered as valid as the original.

Signature: _________________ Relation to Patient: _________

Witness: _________________ Date: _______________

________ _ Advantage Women's Care Patient's Name:

19740 1-45 North Spring, TX 77373 Ph: 281-537-5556

Consent jor Testing:. Acquired Immune Deficiency Syndrome (AIDS)

I. The Acquired Immune Deficiency Syndrome (AIDS) is a virallllne!ls that is spread by contact with the blood or body fluids of an infected person.

II. As part of your treatment, it may be requested that you be tested to determine if you have had previous contact with the AIDS virus. This might be done as part of a diagnosis work up or for hospital epidemiological (Infection control) reasons.

III. The test for AIDS is done on a blood specimen which will be drawn along with blood for other tests. The test may give a false positive result (the test is positive witlOut the AIDS virus being present). Therefore, a confirmatory test is done on all positive results.

IV. It is possible in1he very early stage of the illness (the first few weeks after contact with an infected person) that the test could be negative even though active Infection is present. Especially for individuals In high risk groups or their intimate contacts, a single negative test cannot establish with certainty that the infection is not present.

V. If my blood is found to be positive, .twlll be notified and provided with information regarding follow-up. VI. I have the opportunity to ask questions concerning this blood test and understand that I will be given

counseling concerning the meaning of the test results and Its Implications. VII. I understand that my test result will be kept confidential to full extent required by law. I understand that

particular care is being taken to maintain my records in a secure manner.

I am consenting to the test. I have read and I understand this Information.

Patient's Signature.. ~. Dote

..Parent or Guardian if Minor

Witness

Ifwe do not hear from your Insurance company: If we do not receive payment or rejection from your insurance company in a timely manner, we will transfer the balance to your responsibility. We request your assistance in following up with your insurance company to resolve any non~payment issue.

Our providen recommend care based on the patient's best interest, which is independent pf

insurance coverage issues.

Benefit coverage: We cannot know the benefits and exclusions of each patient's coverage. Contact your insurance company or employer for this information. When insurers provide infonnation to physicians they always includ~ a.statement indicating it is not a guarantee for payment. Therefore, it's usually best for the patient to 'contact their insurance company directly. .

Payment at the Time of Service: Please be prepared to pay, any co-payments and non-covered services at the time of each visit. We will also collect all previous outstanding balances during

check In visit.

Additional Cbargesand Fees

We request at least a 24 hour advance notice if you will be unable to keep your scheduled

appointment (please call 281-537-5556 as soon as possible). Our policy is "Failure to provide 24

hour notice to cancel your appointment will result in a No Show Fee of $20.00 cash." If you

.. contact us in advance we can reschedule your appointment and avoid a no show fee.

Completing disability insurance forms and employer forms Is not a medical service and Is not paid by

Insurance. There Is a $25.00 cash fee for completing a form. Please provide at least one week notice

or lead time for completion. Provide a pre addressed envelope for mailing or a FAX # If requested.

There is a $25.00 cash fee for copying medical records which complies with TX State law. A legal

release Is required.

We thank you for choosing our physicians, certified nurse practitioner and staff as a partner

for your healthcare needs. As always, provldln& high quality heatthcare to you remains our

primary purpose. If you have any questions about this Information, please feel free to ask your

~rovlder, a Patient Services Representative at Check-In/Check-Out, or call our Office Manager,

Judy Her~andez at 281-537-5556 for more Information.

Name: _____________________________________

Date: _~____________

' .

· Advantage Women's Care, P.A. .,_ Genera) Consent to TreatIPatient Autb for Release of InformatioWAssignment of Insurance

BenefitslReceipt of Notice of Privacy Practices/Personal Representative

The following are the conditions for services provided by Advantage Women's Care, P.A. for the patient whose name appears at the bottom of this page.

Consent for Medica! Treatment Uwe voluntarily consent to medica) treatment and diagnostic procedures provided by Advantage Women's Care and its associated physicians, clinicians and other personnel. I/we consent to the testing fer infectious diseases, such as, but not limited to syphilis, AIDS, hepatitis and testing for drugs if deemed advisable by my physician . I am, or we are aware that the practice of medicine and surgery is not an exact science and Uwe acknowledge that no guarantees have been made as to the result of treatments or examinations.

Autborizatiop for Release of Information The practice and physicians are authorized to rele8!e any medical information required in the proce~lIing of applications or submission of information for financial coverage, diS