premier obstetrics and gynecology - premier obgyn … 12/14 premier obstetrics and gynecology...

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Premier Obstetrics and Gynecology Central Tampa Westchase

2727 Martin Luther King Blvd., Suite 630 6911 Pistol Range Rd., Suite 102 B Tampa, FL 33607 Tampa, FL 33635

(813) 876-6000 (813) 814-9719

Paul Sporn, M.D. Luciano Martinez, M.D. Mark Davis, M.D Diplomats, American Board of Obstetrics and Gynecology

Patient General Information Name ______________________________ Birth date ______________________ Age _______ Social Security # ______________________ Drivers License _____________________________ Home # ___________________ Cell # ___________________ Work # ____________________ Street Address _________________________________________________________________ City _____________ State________ Zip Code ___________ Email Address _________________ Occupation __________________________ Employer _________________________________ Spouse’s Name ____________________________ Spouse’s Phone _______________________ Emergency Contact ____________________________ Phone # __________________________ Primary Care Physician ____________________________ Phone # _______________________ Pharmacy Name ______________________________ Pharmacy # _______________________ Primary Insurance ___________________________ Policy Holder ________________________ Policy Holder Date of Birth ______________ Policy Holder Social Security # ________________ Secondary Insurance _________________________ Policy Holder ________________________ Policy Holder Date of Birth ______________ Policy Holder Social Security # ________________ ____________________________________________ _________________________________ Patient or Guardian Signature Date

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Office Policy

Welcome to our office. Please read this policy carefully and feel free to ask questions regarding any part of this document. We believe that a clear definition of our office and financial policies will allow us to concentrate on the primary goal of restoring or maintaining your health. Our practice will strive to provide you with the finest quality obstetrics and gynecology care. If you have any questions regarding your treatment, please do not hesitate to ask. We welcome referrals and look forward to establishing an excellent doctor-‐‑patient relationship with you.

Appointments

If you are unable to keep an appointment, please call the office to reschedule at least 24 hours in advance. Patients with three missed appointments or three cancelled appointments may be asked to transfer their records to another doctor. Patients who are more than 15 minutes late may be asked to reschedule their appointment. Patients who are not compliant will be discharged from the office.

Leaving Messages

Our office policy is to leave generic information on answering machines. Please initial next to your preference: ________________ Please leave very little information. ________________ Please call number ___________________ and leave specific details. ________________ Please leave as much information as possible on the machine or with anyone who answers my phone.

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In order to be in compliance with all HIPAA regulations, we ask that you update the following information. Please sign the necessary authorizations and assignments which will allow the Premier physicians to provide your medical care. ________________________________________ __________________ _________________________ Name Date of birth Social Security Number ____________________________________________________________________________________________________________________ Address ____________________________________ ______________________ ____________________ ___________________________________ City State Zip Code Email Address _______________________________________ ___________________________________ ________________________________________ Home Phone Cell Phone Work Phone __________________________________________________________ _________________________________________________________ Insurance Company Telephone Number __________________________________________________________ _________________________________________________________ ID/Policy Number Group Number I hereby authorize Premier Ob/Gyn of Tampa, LLP to release my records to other healthcare professionals as well as to any corporation, person or agency that may be responsible for payment of outstanding charges. The following persons are authorized to have access to my personal medical and financial records: __________________________________________ ___________________________________ Name Relationship __________________________________________________________ ________________________________________________ Name Relationship I hereby assign all benefits from all payers to Premiere Ob/Gyn of Tampa, LLP. This assignment shall remain in effect until revoked by me in writing. _______________________________________ Initial

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Assignment of Benefits

Policy Number: _____________________________ Group Number: ________________________________ I hereby assign all medical and/or surgical benefits to which I am entitled including Medicare and other government sponsored programs, private insurance and other health plans to Premier Ob/Gyn. This assignment will remain in effect until revoked by me in writing. I hereby authorize said assignee to release all information necessary to secure the payment directly to the above doctor for their services as described herein. I understand that I am financially responsible for all charges whether or not paid by such insurance. Name (print): _______________________________________________ Name (signature): ____________________________________________ Date: _____________________________________________________

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Financial Responsibility I understand that I am financially responsible for all charges. By signing below I am authorizing treatment by Premier Ob/Gyn of Tampa, LLP physicians and staff. I acknowledge that information has been provided to me regarding the HIPAA laws. Name (print): _________________________________________ Name (signature): ______________________________________ Date: _______________________________________________

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Verification of Benefits

We may assist you at our discretion in verifying your insurance coverage in an effort to verify exactly what ObGyn coverage is available on your policy. This can only be done on the day of your appointment if time permits. You as the policy holder are primarily responsible to verify benefits. We cannot guarantee payment of the benefits and subsequently you may be responsible for any coinsurance, deductibles or fees for non-covered services that may result.

Referrals

If your insurance company requires a referral and/or preauthorization and/or precertification, you are responsible for obtaining it. We most likely will not be able to obtain a referral on the date of service. Options at that point will be to reschedule your appointment or to pay at the time of service. We suggest you call your primary doctor at least 48 hours in advance to confirm that your referral has been generated and faxed to our office. The most reliable method is to obtain the referral yourself.

Paperwork

Disability forms and/or other types of forms to be completed and signed by the doctor will have a charge associated with them of $25.00. Forms will not be faxed or returned to the patient until they are paid in full. Please allow 2 to 3 weeks for completion.

Outside Testing Facilities

Please be advised that this office maintains no financial relationship with any laboratory or radiology centers. All bills generated by those facilities are the sole responsibility of the patient. Name (print): __________________________________________ Name (signature): _______________________________________ Date: ________________________________________________

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Referral and Authorizations Office Policy

Any and all private or Medicaid HMO’s (ex. – Medipass, Molina, Prestige, Sunshine, Universal) will require a referral prior to all ob/gyn procedures. A referral will also be required prior to performing sonograms if you have any of these insurance companies: Humana, Blue Cross, Blue Shield or AvMed. If your insurance carrier requires a referral, pre-‐‑authorization or pre-‐‑certification, it is your responsibility to obtain the referral by the time of your appointment. We will NOT be able to obtain it for you and you will need to reschedule your appointment. We suggest you call your primary care doctor at least 48 hours in advance to confirm that your referral has been generated and faxed to our office. Patient or Guardian Signature: ______________________________________________ Date: ___________________________________________

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Transferring Records

If you wish to have copies of your records you must authorize us to include all relevant information including your payment history upon request. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information including your payment history. A fee of $1.00 per page will be charged. Please allow 3 to 6 weeks for copies of records.

Financial Policy

This is an agreement between Premier Ob/Gyn, LLP as creditor and the patient/doctor named on this form. In this agreement the words “you”, “your” and “yours” means the the patient/debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us” and “ours” refers to the office of Premier Ob/Gyn. By executing this agreement you are agreeing to pay all services rendered.

Insurance Insurance is a contract between you and your insurance company. We are not a party to this contract in most cases. We will bill your primary insurance company only if we are a contracted participating provider. We will accept secondary insurances for Medicare only as long as it is medigapped (automatic crossover). Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance.

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I, ____________________________________________, hereby acknowledge that virus HIV or AIDS test, its purpose, potential uses, limitations and the meaning of its results. I authorize and consent to the taking of blood from me for the purpose of conducting an HIV test. I understand that a second or confirmatory test may be necessary before any test results are released (whether positive or negative). I will be provided with an opportunity for a face-to-face counseling. Name: _________________________________________________ Date: __________________________________________________ Witness: _______________________________________________ Patient REFUSED to sign. Witness: ___________________________________ Date: ____________

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Ultrasound Consent

I understand that I will be having sonogram examinations performed by Premier ObGyn physicians and their employees during my pregnancy. I further understand that these sonograms are considered Level I exams as compared to the hospital sonograms which are much more detailed examinations. This essentially means that your office sonograms are performed primarily to determine fetal growth, assess the expected due date and to scan for any major fetal defects. Consequently it is important that you recognize and acknowledge that an office sonogram reported as normal will NOT guarantee your baby will be free of anomalies. Name (print): ___________________________________________ Name (signature): ________________________________________ Date: _________________________________________________ Witness: ______________________________________________

premier obstetrics and gynecology - premier obgyn … 12/14 premier obstetrics and gynecology...

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