CHEYENNE OBSTETRICS & GYNECOLOGY, INC, PC 2301 House Ave – Suite 400 Cheyenne, WY 82001 NP - PT CHART #: ________________________ (307) 634.5216 PROVIDER: ____________________________________ DATE & CKD: ___________/_________ PATIENT’S FULL LEGAL NAME: (Please PRINT Front & Back Completely) __________________________________________________________________________ PH #: ( ) _____________________

FIRST MI MAIDEN LAST HOME

MAILING ADDRESS: _________________________________________________________ PH #: ( ) _____________________ STREET APT # CELL __________________________________________________________________________ PH #: ( ) _____________________ CITY STATE ZIP WORK SSN:______-_____-______ DATE of BIRTH: ____-____-____ AGE: _____ EMPLOYER: ______________________________ MARITAL STATUS: Single - Married - Separated - Divorced - Widowed ______________________________________________________ DOB: _____________ EMPLOYER: _______________________ SPOUSE -or- SIGNIFICANT OTHER –or- PARENT/GUARDIAN PH #: ( ) ____________________ PH #: ( ) __________________________ PH #: ( ) _____________________ HOME CELL WORK EMERGENCY CONTACT: NAME: __________________________________________________________________ RELATIONSHIP: ___________________ PH #: ( ) ____________________ PH #: ( ) __________________________ PH #: ( ) _____________________

HOME CELL WORK INSURANCE INFORMATION SUMMARY: Must be Completed by Patient + Bring Insurance Card(s) + Picture ID PRIMARY INS: ________________________________________ SECONDARY INS: ________________________________________ ID#: ____________________ GROUP#: ___________________ ID#: ____________________ GROUP#: ____________________ SUBSCRIBER: ________________________________________ SUBSCRIBER: __________________________________________ SSN: ______-____-______ Date of Birth: _____-_____-_____ SSN: _______-_____-_______ Date of Birth:_____-_____-____ EMPLOYER: __________________________________________ EMPLOYER: ____________________________________________ RELATIONSHIP to PATIENT: _____________________________ RELATIONSHIP to PATIENT: ______________________________ FINANCIAL POLICY:

• I request that payment of authorized medical benefits be made on my behalf to Cheyenne Obstetrics & Gynecology, Inc, PC, for any services furnished by that group.

• I authorize any holder of medical information about me to release to my insurance company and its agents, any information needed to determine these benefits or the benefits payable for related services.

• The responsibility for the payment of all account balances belongs to the individual identified as the Patient/Guarantor –or- Legal Guardian/Guarantor, without exception.

SIGNATURE OF PATIENT/GUARANTOR: _________________________________________ DATE: ___________________ SIGNATURE OF LEGAL GUARDIAN/GUARANTOR: ___________________________________ DATE: ___________________ 04/04/12/cnh

Cheyenne Obstetr ics and Gynecology

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Patient Privacy Practices The privacy provisions of federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), apply to health information created and maintained by the practice. The Department of Health and Human Services (HHS) has issued the regulation, “Standards for Privacy of Individually Identifiable Health Information”, applicable to entities covered by HIPAA. The Office of Civil Rights (OCR) is the departmental component responsible for implementing and enforcing the privacy regulation. The privacy standards are designed to provide basic, federal protections for an individual’s protected health information. Each state has existing privacy laws that may still apply and to which the practice is already complying. Cheyenne Obstetrics and Gynecology (COG) is required by law to maintain the privacy of your health information and to provide you with a description of our legal duties and privacy practices regarding your health information. The current notice is given to each patient at their initial consultation and an additional copy is available upon request. I acknowledge that I have been informed of, inspected, and/or obtained a copy of the “Notice of Privacy Practices” Printed Name Patient # Signature of Guardian Date Signature Date Identifiers: last 4 digits SS ________ Mother’s Middle Name ____________________ (Patient registration/Contact Info (II) I authorize the following person(s) to receive or review correspondence regarding my private health information: Name Relationship Name Relationship I authorize test results or appointment reminders to be left on my answering machine at: Home: yes / no Cell: yes / no Work: yes / no Additional information needed: Race: American Indian or Alaskan Asian Black Caucasian Other Race Declined Ethnicity: Hispanic Non-Hispanic Declined Primary Language: _____________________________________________________

Cheyenne Obstetrics and Gynecology

Financial and Referral Responsibility

The insurance representative at COG is available to help you better understand your insurance coverage and assist in some authorizations. You, as the patient, have the final responsibility of understanding your insurance coverage. Along with speaking to the insurance representative at COG, you should call your insurance company and clarify your benefits with them. Most insurance companies also offer benefits “handbooks” or a copy of benefits. This will help us in obtaining payment from your insurance company.

• COG will not be held responsible for any misinformation given to you and/or COG regarding your insurance coverage.

• If at ANY TIME your insurance company/policy changes, you are responsible to inform COG. We will not be held responsible for any miscommunication.

• If you have no insurance coverage for treatment, you will be considered self pay and will be required to pay in advance for any testing and/or treatment. Financing options are available, if needed.

• You are responsible for obtaining all referrals from your primary care physician (PCP). Referrals are obtained by simply calling your PCP and making this request. We recommend that a minimum of a 6 visit referral be obtained. More referrals can be requested if needed as treatment continues.

• Authorization for treatment is necessary for all Tricare and HMO policies. Your insurance company may require that certain testing be completed before an authorization is issued. The insurance representative at COG will communicate with your insurance company and supply the information necessary for them to make a decision for treatment.

• You have the right to appeal any denials made by your insurance company and the representative at COG will be happy to assist in this process as best we can.

Please understand that we at COG are sensitive to the fact that you want to start treatment. However, we must abide by your insurance company’s guidelines and obtain proper authorization, which at times can take a few days. By signing this agreement you are stating that you have read and understand al l above statements and agree to f inancial responsibi l ity in the case that your insurance company does not pay for services rendered: _______________________________________________ __________________ Patient Signature Date _______________________________________________ Printed Name _______________________________________________ __________________ Partner Signature Date _______________________________________________ Printed Name