Centura Health Physician Group

Welcome! We are pleased to be able to care for you. Your time is important to us. We appreciate the information that you are about to give us. If there is any information that you are not comfortable answering at this time, please leave the space blank. Single

Patient Information:

Married

Widowed

Divorced

Last name: _____________________________________________ First: _____________________ Middle initial: _____ Address: _____________________________________ City: _____________________ State: _____ Zip: ____________ Home phone: _______________________ Work phone: ______________________ Cell phone: ______________________ Date of birth: __________________ Employer: _________________________________

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Spouse/Parent/Guardian information: Last name: _____________________________________________ First: _____________________ Middle initial: _____ Date of birth: __________________ Employer: _________________________________

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Home phone: _______________________ Work phone: ______________________ Cell phone: ______________________ Policy Holder:

Self

Spouse

Parent/Guardian

Other ____________________________________________

Policy Holder Information (only if different from above): Last name: _____________________________________________ First: _____________________ Middle initial: _____ Date of birth: __________________ Employer: _________________________________

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Home phone: _______________________ Work phone: ______________________ Cell phone: ______________________ Emergency Contact (different from above): Last name: _____________________________________________ First: _____________________ Middle initial: _____ Home phone: _______________________ Work phone: ______________________ Cell phone: ______________________ Referred by:

Doctor _________________________________

Friend __________________________________

Nurse __________________________________

Other ___________________________________

Assignment of benefits: I hereby authorize insurance carrier to assign any benefits directly to RidgeGate OBGYN. Patient signature: _____________________________________________________ Date: ____________________________ Medical records release: I authorize the release of any medical or other information necessary to process my claims. Patient signature: _____________________________________________________ Date: ____________________________

www.ridgegateobgyn.com

Centura Health Physician Group

Name:_______________________________________________

Date:______________________

ALLERGIES Please list all of the medications, foods, environmental agents, etc that you are allergic to and the type of the reaction. Name of what you are allergic to

Type of reaction

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MEDICATIONS Please list all medications that you use on a regular basis, including birth control pills, vitamins, and over-the-counter medications, as well as any alternative/complementary treatments or herbs. Please include the dosage and frequency of each. Complete and accurate information is important to avoid adverse drug reactions. Name of Medication

Dosage

How often you take it

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www.ridgegateobgyn.com

Centura Health Physician Group

Name:____________________________________________

Date:___________________________

Thank you for choosing us to provide your OB/GYN care. We want to know about your health in detail. The information you give will allow us to help you better today and in the future. What brings you to our office today?__________________________________________________________________ _ ____________________________________________________________________ ____________________________________________________________________ Do you have any questions, problems, or concerns that you would like to discuss with us today? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Occupation: What is your occupation? ________________________________________________________________ Primary Care Physician:

__________________________________________________________________________

Medical History: Have you ever had any medical problems? Please add details in the space on the right. Please add any conditions not included on this list in the spaces at the end of the list. Yes No Heart problems__________________________________________________________________________ 1. Lung problems___________________________________________________________________________ 2. High blood pressure_______________________________________________________________________ 3. 4. Kidney problems_________________________________________________________________________ Diabetes_________________________________________________________________________________ 5. Bladder problems________________________________________________________________________ 6. Thyroid or endocrine problems______________________________________________________________ 7. Seizure or neurologic problems, including migraine______________________________________________ 8. Depression or psychiatric disorders__________________________________________________________ 9. Hepatitis or liver disorders_________________________________________________________________ 10. HIV___________________________________________________________________________________ 11. Tuberculosis____________________________________________________________________________ 12. Other infections (herpes, pelvic inflammatory disease, chlamydia, gonorrhea, syphilis, genital warts, etc.) 13. ______________________________________________________________________________________ 14. Stomach, bowel, gallbladder, or other intestinal disorder__________________________________________ Elevated cholesterol______________________________________________________________________ 15. Blood transfusion________________________________________________________________________ 16. Anemia or blood problems_________________________________________________________________ 17. Abnormal pap smears(describe any treatment)__________________________________________________ 18. Cancer _________________________________________________________________________________ 19. Sexual abuse or domestic violence___________________________________________________________ 20. Breast problems__________________________________________________________________________ 21. Infertility_______________________________________________________________________________ 22. Other female or sexual problems_____________________________________________________________ 23. Other: _________________________________________________________________________________ 24. Other: _________________________________________________________________________________ 25.

Name:____________________________________________

Date:___________________________

Surgeries and Hospitalizations: Please list all surgeries you have had. Include outpatient surgeries. Also, please list all serious illnesses you have had which have required hospitalization. Mo./ Year

Operation or Illness

Complications/Additional information

Additional comments: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Family History: Please specify affected family member (e.g. paternal grandfather) and add details in space on right. Yes No Heart problems_________________________________________________________________________ 1. Lung problems or tuberculosis______________________________________________________________ 2. High blood pressure_____________________________________________________________ _________ 3. Kidney problems________________________________________________________________________ 4. Diabetes____________________________________________________________________________ ____ 5. Bladder problems_______________________________________________________________________ 6. Thyroid or endocrine problems (please specify)___________________________________________ _____ 7. Seizure or neurologic problems, including migraine (please specify)________________________________ 8. Depression or psychiatric disorders__________________________________________________________ 9. Hepatitis or liver disorders________________________________________________________________ 10. 11. Elevated cholesterol______________________________________________________________________ Stomach, bowel, gallbladder, or other intestinal disorder (please specify)____________________________ 12. Cancer (specify type)______________________________________ _______________________________ 13. Breast problems_________________________________________________________________________ 14. Female problems________________________________________________________________________ 15. Anemia or blood problems________________________________________________________________ 16. Any other inherited condition ______________________________________________________________ 17. Other _________________________________________________________________________________ 18. Other _________________________________________________________________________________ 19. Health Screening Tests: 1. When was your last pap smear? (year) ______________ (Advised annually) 2. When was your last cholesterol level? (year) ______________ (Advised every 5 years) normal elevated don’t know Was the result: 3. When was your last mammogram? (year) ______________ (Advised annually) 4. When was your last tetanus shot? (year) ______________ (Advised every 10 years) 5. When was your last dental exam? (year) ______________ General Health Questions: Yes No Are you exercising? If yes, how often? What type?_____________________________________________ 1. _____________________________________________ 2. Do you have any questions about safer sex?

Name:____________________________________________ 3. 4. 5. 6. 7. 8. 9.

Date:___________________________

Do you smoke cigarettes? If yes, how many per day?_____________________ Do you use street or recreational drugs? Do you drink alcohol? If yes, how often? How much?___________________________________________ Do you always wear your seat belt when driving? Do you always wear a helmet when riding a bike? Not applicable Do you keep firearms in your home? If yes, what precautions do you take to prevent an accident? _____________________________________________________________________________________ Do you wear sunscreen when outdoors?

Pregnancy History: Please list all pregnancies that reached 20 weeks (four and one- half months) or more. Year

Baby’s Weight at birth

Type of delivery

Complications

Baby’s sex

Baby’s Name

Additional comments: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Pregnancy History: Please list all pregnancies that reached less than 20 weeks. Year

Type of Pregnancy: (miscarriage, abortion, tubal, other)

Procedure: (none, D&C, laparoscopy, other)

Complications/Additional Comments:

Menstrual History: 1. What was the date of the first day of your last menstrual period?________________________ Yes No Was this a normal period for you? 2. How far apart are your periods usually?(counting from the first day of one period to the first day of the next period)______________________________________________________________ 3. What is the longest time you have had between periods in the last 2 years, when not pregnant?__________________ 4. At what age did you begin having periods?____________ Not applicable 5. If applicable, at what age did you stop having periods?____________ 6. Please describe any recent changes in your periods that you are concerned about on the menstrual calendar below. Please record the two or three normal cycles that preceded the abnormal cycle(s), as well as the abnormal cycle(s).

Name:____________________________________________

Date:___________________________

The use of this chart allows us betterunderstand the nature of any abnormal bleeding. Please use the symbols that follow to describe the type of flow: Normal = N January February March April May June July August September October November December

7.

1

2

3

Exceptionally light = L 4

5

6

7

8

9

Exceptionally heavy = H

10 11 12 13 14 15 16 17 18 19 20

21 22 23

Spotting = S 24 25 26 27 28 29 30 31

breast pain/swelling bloating Please list any menstrually related symptoms that are bothersome to you: irritability depression other (please describe) ____________________________________________________________________________________________ ____________________________________________________________________________________________

Contraception: Yes No Do you and/or your partner use a method of contraception? If yes, what type(s)? 1. birth control pills diaphragm Vaginal (Nuva) ring natural family planning spermicide rhythm IUD tubal ligation condoms Depo-provera vasectomy Other:_________________________ Do you want information about birth control? 2. Have you ever had a complication from any method of birth control? If yes, please describe 3. ____________________________________________________________________________________________ Perimenopausal/Postmenopausal Symptoms: Yes No Hot flashes______________________________________________ ________________________________ 1. Vaginal dryness__________________________________________________________________________ 2. Sleep disturbance_________________________________________________________________________ 3. Mood changes___________________________________________________________________________ 4. Other_____________________________________________________________ _____________________ 5.

Centura Health Physician Group

ANNUAL WELL WOMAN EXAM WAIVER Dear Patient, You are scheduled for an annual well woman exam today in our office. Please be advised that this is the way your insurance will be billed. Many insurance companies recognize the need for regular exams and have incorporated this into their benefits. Their reimbursement is limited to the well exam only. Accordingly, we have established an office policy covering the examinations defined by your insurance companies. Please read this before your examination so you are fully prepared for today's visit. During your visit you will be given a pelvic exam, a pap smear, breast exam and brief physical examination. We may take a urine sample and test a small sample of blood. We may order other lab work when indicated. Lab, pap and pathology charges are separate from today's office charges. The institutions performing the services will bill them. We will be unable to treat other illnesses during this appointment. We would like to schedule a subsequent appointment for any illnesses or problems needing further evaluation and treatment. Today’s examination is especially for your well woman checkup. If your insurance does not cover routine benefits, you will be expected to pay the balance in full today or within thirty days of notification from our office that the bill is your responsibility. We CANNOT bill your visit any other way when you schedule an annual well woman exam, due to chart audits with insurance companies. By signing, you acknowledge that you accept full responsibility for the charges if your insurance does not cover these services. Patient Name _______________________________________ Date ________________ Patient Signature _______________________________________

www.ridgegateobgyn.com

Centura Health Physician Group

FINANCIAL POLICY AGREEMENT

We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. There are always ongoing changes in the health industry, and these changes may affect you in the services that are covered by your insurance carrier, or in services that are determined to be due and payable directly by you. When we verify insurance benefits we will go by the information that is provided. We want you to be aware that any quote of benefits given by your insurance company, is not a guarantee of benefits or payment. Payment is due at time of service; this includes deductibles, co-insurance, and co-pays . All balances and current payments will be collected when you arrive at check in, unless co-insurance needs to be calculated, and then you will pay in check out. • Procedures done in office will be checked by our staff, and payment is due at time of service. Surgery deposits are due on your pre- op date. • Not all insurance plans cover all services. In the event that your insurance plan determines a service to be “not covered”, or “pre-existing”, you are responsible to remit payment properly for services rendered. • Your financial responsibility to us will be your co-payments, your co-insurance, your deductibles and any claim denials from your insurance company for services provided. • Only after exhausting our own internal attempts for payment, will we send a delinquent account to our collection agency, after 90 days. You will then be responsible for all costs incurred in collecting the balance. Should this happen, you risk being discharged from RidgeGate OBGYN, and the acceptance back into the practice would only be considered after your account is paid in full. • We do offer 25% prompt pay discount for all patients without insurance or services that come back not covered by your insurance. I have read and understand the RidgeGate OBGYN at Centura Health FINANCIAL POLICY AGREEMENT and I agree to be bound by it terms. ______________________________________ Printed Patient Name _______________________________________ Signature (if minor responsible party)

www.ridgegateobgyn.com

___________________ Date

Centura Health Physician Group

No Show and Cancellation Policy We appreciate that you have chosen our practice for your gyn and OB/gyn needs. We are dedicated to providing the best possible care for you, from the time you enter the waiting room until you check out. We value your time and know that it is very important. Since we try to accommodate all patients to the best of our ability we want you to share our no show, re-schedule, and cancellation policy. As a patient it is your responsibility to contact RidgeGate OB/gyn in a timely manner to cancel or re-schedule your appointment so as to afford other patients the ability to schedule an appointment. At times the physicians’ schedules can get booked out quickly, and without proper notice we are not able to work those patients in that may need a sooner appointment. If you fail to cancel or re-schedule within 24 hours before your appointment, or no show for the appointment completely, a fee of $25 will be charged to your account. If you arrive late for your appointment, you may be asked to reschedule your appointment so others will not be seen late on account of your lateness. If you are asked to reschedule due to your late arrival, a $25 fee will apply as well. We want to provide an excellent experience for you while you are here, and getting you in on time for your appointment is very important to us. Any future appointments will not be scheduled until all late fees are paid in full.

___________________________________ Patient Name Printed __________________________________ Patient Signature

__________________ Date

www.ridgegateobgyn.com

Centura Health Physician Group

Notice and Acknowledgement Acknowledgement: I acknowledge that I have received the attached Notice of Privacy Practices. _______________________________________________ Print Patient or Personal Representative Name _______________________________________________ Patient or Personal Representative Signature

_________________________________________ Date

If Personal Representative’s signature appears above, please describe Personal Representative’s relationship to the patient:________________________________________________________________________ PATIENT CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION With this consent, your office may leave messages, as indicated below, with my confidential medical information to assist the practice in carrying out treatment, payment, and healthcare operations, such as appointment reminders, insurance items and any information pertaining to my clinical care, including laboratory and pathology results. I authorize the practice to disclose confidential medical information via: Home phone number (answering machine)

phone number _______________________________

Cell phone number (voice mail)

phone number ________________________________

Work phone number (voice mail)

phone number ________________________________

Other individual (please give details)

phone number ________________________________ phone number ________________________________

I may revoke my consent in writing at any time, except to the extent that the practice has already made disclosures in reliance upon my prior consent. _______________________________________________ Signature of Patient or Legal Guardian

_________________________________________ Date

_______________________________________________ Print Patient’s Name

_________________________________________ Print Name of Legal Guardian (if applicable)

www.ridgegateobgyn.com

HIPAA NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. If you have any questions about this notice, please contact: Central Privacy Office at (720) 344-4915 OUR OBLIGATIONS We are required by law to: • Maintain the privacy of protected health information. • Give you this notice of our legal duties and privacy practices regarding health information about you. • Follow the terms of our notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION Described as follows are the ways we may use and disclose health information that identifies you (“Health Information”). Except for the following purposes, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice’s privacy officer. TREATMENT. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. PAYMENT. We may use and disclose Health Information so that others or we may bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give your health plan information so that they will pay for your treatment. HEALTH CARE OPERATIONS. We may use and disclose Health Information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetric or gynecologic care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

APPOINTMENT REMINDERS,TREATMENT ALTERNATIVES, AND HEALTH RELATED BENEFITS AND SERVICES. We may use and disclose Heath Information to contact you and to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health related benefits and services that may be of interest to you. INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. RESEARCH. Under certain circumstances, we may use and disclose Health Information for research. For example, a re search project may involve comparing the health of patients who received one treatment to those who received another for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.

SPECIAL SITUATIONS As Required by Law. We will disclose Health when required to do so by international, federal, state, or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat. Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your Information.

and are not allowed to use or disclose any information other than as specified in our contract. Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation; and transplantation. Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation. We may release Health Information for workers’ compensation or .similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury, or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government -programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: 1) in response

to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises; and 6) in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime. Coroners, Medical Examiners, and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties. National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state, or to conduct special investigations. Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be made if necessary: 1) for the institution to provide you with health care, 2) to protect your health and safety or the health and safety of others, or 3) for the safety and security of the correctional institution.

YOUR RIGHTS You have the following rights regarding Health Information we have about you: Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to the address shown below. Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to the address shown below. Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to the address shown below.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the address shown below. We are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communication, you must make your request, in writing, to the address shown below. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

You must make all requests in writing: Elise Chu, M.D., John Stallworth, M.D., David Wagar, M.D., Melissa Zart, M.D., Kathryn Reed, M.S., N.P.

(Be sure to include your physician’s name.)