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  • 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
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Page 1 of 13 Congratulations on your pregnancy! We are excited to be a part of your journey and would like to give you some information regarding our billing policies. This agreement is to inform you of anticipated fees, which may be acquired during the course of your pregnancy. Unlike other types of services, insurance companies require us to bill your prenatal care and delivery globally. Our experience with insurance companies is that there will be a portion of the global fee that will be your responsibility along with any deductible and co-insurance if they apply. After your initial visit with us, our OB benefit specialist will call you to review your benefits and anticipated costs. They will also set up a monthly payment plan with you at that time. CVWC requires that any estimated patient responsibility be paid in full before delivery. Estimates given by your insurance company are not a guarantee of payment. Final determination will be made by your insurance after claims have been submitted. Any difference between quoted amounts and amounts actually owed will be the responsibility of the patient. During your pregnancy, physicians may order blood work, labs, ultrasounds, or non-stress tests as needed. These services will be billed to your insurance at the time of the service, and are not included in the global delivery fee. Additionally, if you are seen for any problem or condition unrelated to your pregnancy, we are required to bill for the office visit. Your responsibility for these services will be determined by your contract with your insurance company. Should you have a change in insurance coverage, please notify us immediately. Any delays could result in additional out- of-pocket expenses or denied claims. Note: If you have Medicaid insurance, you will be required to bring your current card with you to each appointment. If Medicaid coverage lapses, you will be required to pay $300 per month of non-coverage. If you do not have insurance, please contact our billing department prior to your nurse consult visit. Please check with your insurance company to determine your global maternity benefits and complete the information below: Insurance:____________________________________Deductible:__________________________________________ Out of pocket:_________________________________Co-Insurance after deductible:___________________________ Patient Signature Date of Birth Print Name Date PLEASE NOTE THIS IS FOR PHYSICIAN SERVICES ONLY. FACILITY SERVICES ARE BILLED SEPARATELY BY LOGAN REGIONAL HOSPITAL. If you have any questions regarding the above information please contact our billing department at 435-753-9999

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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

Page1of13

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

Page 2: 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

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

Page 4: 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

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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

Page 6: 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

Page6of13

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

Page 7: 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

Page7of13

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_______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Page 8: 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

Page8of13

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 ____________________

Page 9: 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

Page9of13

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

Page 10: 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

Page10of13

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: ______________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Page 11: 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

Page11of13

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

Page 12: 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

Page12of13

HOMEDELIVERYPOLICY

ThephysiciansandprovidersoftheCacheValleyWomen'sCenterdonotaffiliatewithorbackupany

plannedhomedeliveries.Ifyouareplanningonahomedeliverywithamidwifeordoula,pleasebe

awarethatthiswillseverourpatient/physicianrelationship,whichwillautomaticallyresultinyour

dismissalfromourpractice.

Iagreetoandunderstandtheinformationprovidedabove.

Signature _______________________________________________Date_________________________

PrintedName_________________________________________________________________________

WitnessSignature ________________________________________Date_________________________

Page 13: 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

Page13of13


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