Patricia Giuffre, M.D. Kristine A. Eule, M.D.

Gynecology • Obstetrics • Infertility

To Our Patients:

Please note that we strive to provide high quality healthcare. As part of this, certain lab tests may be ordered based on each woman’s individual health history and exam.

Possible recommended tests:

• An annual pap smear (sent to Metropath ) • Human Papilloma Virus (sent to Metropath) • Sexually Transmitted Disease screening (Chlamydia, Gonorrhea,

etc...sent to Metropath) • Blood work (Cholesterol screening, HIV, TSH, etc…)

Most insurance companies cover an annual exam, but not all the lab tests. It is your responsibility to know if these tests are covered by your insurance company. You should also be aware that you could be responsible if you have a deductible or coinsurance. Should your insurance company not cover these tests, you will receive a bill from the lab.

Please sign below informing us that you are aware of your responsibilities.

Patient signature Date

Kristine A. Eule, M.D.

Gynecology • Obstetrics • Infertility

CONSENT TO USE AND DISCLOSE HEALTH INFORMATION

By signing this form, you are granting consent to Kristine Eule, M.D. to use and disclose your protected health information for the purposes of treatment, payment and health care operations. Our Notice of Health Information Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Health Information Privacy Practices before you sign this consent and we encourage you to read it in full.

Our Notice of Health Information Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting us at 303-770-0665. You have a right to request that we restrict how we use and disclose your protected health information for the purposes of treatments, payment or health care operations. We are not required by law to grant your request. However if we do decide to grant your request, we are bound by our agreement.

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.

__________________________________________________ _____________________________

Signature Date

Kristine Eule, M.D.

8200 E. Belleview Ave, Suite 414-C, Greenwood Village CO 80111 O: 303-770-0665 F: 303-331-6171

Effective 9/1/2019….. We will now require all patients leave a Credit Card or Debit Card on file with our office.

Questions / Answers about leaving a Credit Card on File.

1) Why do you have a credit card on file? This is a convenience for our patients and a policy we have

implemented to streamline patient billing.

2) When will my card be charged?

a) We bill your insurance first, wait for payment from your insurance company. If any balance is owed,

b) Then we bill you, how you request: credit card, debit card, cash, or check.

c) We bill when it’s convenient for you: When you call us with your consent, at each appointment, on a

specific day of each month, or by mailed statements.

d) If TWO statements are unpaid and we are unable to contact you, your credit card on file will be

charged.

e) We will send any unpaid accounts to collections, and we will not be able to schedule you for any

further appointments or refill any prescriptions until all balances are paid in full.

f) Before any surgery and delivery of your child.

3) When would I be billed if I don’t choose one of the options? If you don’t choose an option, and do not pay

three months’ statements that are mailed to you after your insurance payments are received, we will call you to

make arrangements. If we are unable to contact you after five days, we will bill your credit card.

4) Can you accept a debit card? Yes.

5) Can you accept American Express? No

6) Can you accept HSA/HRA Cards? YES, however a 2nd credit / debit card must be on file.

7) How often do I need to provide my credit card information? Annually or whenever your card information

changes, i.e.; card number, expiration date, or card type.

Patient Name:_________________________________________ Date of Birth:___________________

Credit Card Number:____________________________________ Circle one: Visa / MC / Discover

Expiration Date:________________________________________ CVV:___________________________

Patient Signature:______________________________________ Date:__________________________

Kristine Eule, MD Confidential Patient Profile Date:

Patient Last Name First Name: Middle: Birthdate: Social Security# Race/Ethnicity (circle) Asian Black White Hispanic Other________ Marital Status (circle) Single Married Divorced Widowed

Address: City/State Zip

What is your primary phone number (circle) Home Work Cell E-Mail

Home Phone Work Phone Cell Phone Emergency Contact Information

Name: Phone Relationship (circle) Spouse Parent Other

GUARANTOR INFORMATION – Complete this section if patient is a minor or someone else is responsible for the bills Guarantor Last Name: Guarantor First Name:

Address:

Phone Number: Relationship to Patient:

PRIMARY INSURANCE INFORMATION

Insurance Name: Insurance Phone #: Primary Policy Holder: Relationship to Patient:

Primary Policy Holder’s Birthdate: Employer (for group policies)

Member ID: Group # Claims Address:

SECONDARY INSURANCE INFORMATION Insurance Name: Insurance Phone #:

Primary Policy Holder: Relationship to Patient:

Primary Policy Holder’s Birthdate: Employer (for group policies)

Member ID: Group #

Claims Address:

PREFERRED PHARMACY INFORMATION PHARMACY NAME Phone

ADDRESS CITY/STATE/ZIP

Authorization to file insurance claims and Financial Responsibilities: I hereby authorize payment of insurance benefits to Kristine Eule, MD and any assisting physicians for services rendered. I understand that I am financially responsible for payments of any charges that are not covered by my insurance company; including co-payments, deductibles, co-insurance and any service denied as non-covered or denials for any other reason by the insurance company. In the event of default, I will be held responsible for payment of all collection costs and an associated attorney fees.

Use of Protected Health Information (PHI) I understand that my protected health information will be shared for the purpose of treatment, payment and any health care related operations. By my signature below, I authorized the release of my protected health information. I agree that a photocopy of my signature shall be as valid as the original.

Laboratory and Pathology Services Laboratory and/or Pathology services are not rendered in our office; blood and/or tissue specimens will be sent to the laboratory or pathologist for evaluation and reporting. These services will be billed by the individual laboratory and/or pathologist and are NOT included in our fees. You may receive a separate bill from the laboratory and/or pathology company. I understand that I may be financially responsible for payment of such services in addit ion to the services rendered by Kristine Eule, MD.

PATIENT (OR RESPONSIBLE PARTY) SIGNATURE: DATE:

Kristine Eule, M.D.

8200 E. Belleview Ave, Suite 414-C, Greenwood Village, CO 80111 O: 303-770-0665 F: 303-331-6171

Financial Policy

In order to reduce confusion and misunderstanding between our patients and the practice we have adopted the

following financial policy. If you have any questions please discuss them with our billing staff. We are

dedicated to providing the best possible care and service to you and regard your complete understanding of our

financial policies as an essential element of your care and treatment.

Unless other arrangements have been made in advance by you on your health coverage carrier, full

payments for office services are due at the time of service. For your convenience we will accept VISA,

MasterCard, and Discover, as well as cash, or check.

About Health Insurance:

Your insurance policy is a contract with between you and your insurance company. As a courtesy, we

will file your insurance claim for you. It is your responsibility to provide accurate and timely insurance

information.

About Participating Health Plans:

We have made prior arrangements with many insurers and other health plans to accept an assignment of

benefits. We will bill those plans with which we have an agreement and will only require you to pay the

co-payment at the time of service.

All health plans are not the same and do not cover the same services. In the event your health plan

determines a service to be “not covered”, you will be responsible for the complete charge. Payment is

due upon receipt of statement from our office.

For all service rendered to minor patients we will look to the adult accompanying the patient and parent

or guardian with custody of payment.

It is your responsibility to verify that this office participates with your insurance. If we do not participate

with your insurance, you will be responsible for all charges out of pocket.

• WE DO NOT ACCEPT ANY DISCOUNT PLANS

• Co-payment is required at the time of service. You are responsible for paying your co-payment when

you check in.

• Self-Pay. Patients without insurance are expected to make payment in full on the day services are

rendered. If you are unable to pay in full, payment arrangements must be made in advance, prior to your

being seen by our providers.

• Patients are responsible for all charges that are not covered by their insurance plan. This includes

co-payments, deductibles, co-insurance, and services including lab tests that may not be covered.

Financial Policy

Kristine Eule, M.D.

8200 E. Belleview Ave, Suite 414-C, Greenwood Village, CO 80111 O: 303-770-0665 F: 303-331-6171

Financial Policy

• Obstetrical Patients. You are responsible for contacting your insurance company regarding the expected

financial expenses for pregnancy and delivery. This may be co-payments, lab fees, deductibles, co-

insurance, etc. The patient is expected to pay her portion prior to delivery. We request that your portion

be paid by the end of your 28th week of pregnancy. We will be verifying your insurance benefits and let

you know regarding your financial responsibility prior to delivery. If you do not have insurance, you are

expected to have your obstetrical fee paid in full by the 28th week of pregnancy.

• Routine and Non-Covered services. Not all insurance companies pay for all routine services. If you

have a service that is “Not a Covered Benefit” of your insurance, you will be financially responsible for

payment of those services. Claims will be filed in accordance with the documentation in the chart. We

advise that you check with your insurance carrier to see if your plan pays for any routine care; i.e., annual

exams, contraception, etc. This will help you avoid any unexpected charges.

• When you receive a bill from us, payment is expected within 30 days. If you need to make payment

arrangements, please contact our billing personnel at (303) 904-1444 before the 30 day period. Our office

requires for you to place a credit card on file with our office. Please see our credit card authorization

form for details.

• No Show and Short Notice Cancellation fee: You may be charged a $50 cancellation/no show fee.

• Patients are responsible for the cost of collection efforts. If payments are not received in accordance

with the above guidelines, the account will be turned over to a collection agency. The patient will be

responsible for any collection fees, attorney fees and costs involved in collecting on the debt.

• Lab fees. All lab services provided outside of our office are billed separately. Our office will send a

copy of the billing information on file with the specimen. We do not handle any of the lab billing. Some

insurance plans require that your lab work be performed at certain laboratories. It is your responsibility to

inform the staff if your insurance requires a specific laboratory. Please make sure we have your most

current insurance information. If you have any questions or concerns about the bill from the lab, you must

contact them directly.

By signing below,

I acknowledge that I have read and understood the financial policy of the practice and I agree to be bound by its

terms. I also understand and agree that such terms may be amended from time-to-time by the practice.

____________________________________________ _______________________

Signature Date

Kristine Eule, M.D.

8200 E. Belleview Ave, Suite 414-C, Greenwood Village, CO 80111 O: 303-770-0665 F: 303-331-6171

Name: ____________________________________ Date of Birth: ______________________

HOW CAN WE REACH YOU?

Phone Message Consent

In effort to protect your privacy we have developed a policy on leaving medical care messages.

Please check one.

Please do not leave a message with anyone except the patient or legal guardian.

Please do not leave any confidential information on an answering machine.

Please do not leave any message on a voicemail.

Please leave any test result on my voice mail. (Patient Name must be on Voicemail)

UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO.

Please read below and consider carefully whom you authorize to have access to protected information regarding

your care.

I, ______________________________give Dr. Kristine Eule and/or one she designates, my permission to

speak with and/or leave phone messages regarding my medical care, test results and or billing with the

following.

I fully understand that this consent will remain valid until revoked in writing.

My HOME voice mail #: ________________________________________ Initials: __________

My CELL voice mail #: _________________________________________ Initials: __________

My OFFICE/WORK voice mail #: ________________________________ Initials: __________

My spouse/guardian #: _________________________________________ Initials: __________

If other name: _________________________________________________ Initials: __________

____________________________________________________________ _________________ Signature: Date:

Kristine A. Eule, M.D. Gynecology • Obstetrics • Infertility

REQUEST FOR MEDICAL RECORDS

Patient Name: ________________________Birthdate:________________SS#_______________

I hereby authorize: Name_______________________________________________________

Address______________________________________________________

City, State, Zip_________________________________________________

Phone___________________________Fax__________________________

To release my medical records to: Dr. Kristine A. Eule 8200 E. Belleview Ave. #414-C Greenwood Village, CO 80111 Phone: (303) 770-0665 Fax: (303) 331-6171

Reason to release PHI: ___________________________________________________________

Type of access requested:

_____Progress Notes _____Ultrasound Results

_____Pap Smear Result _____Mammogram Result

_____Colposcopy Result _____Prenatal (OB) Records

_____Lab Result _____ER Notes

_____other:____________________

I acknowledge and hereby consent to such that the released information may contain alcohol,

drug abuse, psychiatric, HIV result of AIDS information.

This release is valid until twelve months from date of signing. All records will be used solely for

the purpose of patient treatment, and will not be disclosed to any unauthorized parties. You,

the patient, have the right to revoke this request at any time, and may do so by contacting this

office.

_____________________________________ ____________________________

Patient Signature Date