Please Send Completed Forms to in Advance of Your First Appointment

Please send completed forms to in advance of your first appointment.

Patient Information

Name: ______Address:______

Apt:______City:______Zip Code:______

Home Phone: ______Cell Phone:______Work Phone:______

Social Security#:______Date of Birth:______Age:______

Marital Status: __Married ___Single____Divorced _____Widowed Ethnicity:______Race:______

Employment Status: ❑Employed ❑Retired ❑Student Other:______

Employer: ______Address:______

How may we contact you? Text____Phone_____Email_____ I have received a pin number to register for Boardwalk Portal for Patient ______intials

E-Mail Address:______Phone to text______

Insurance Information

Insurance Company ______Policy# ______Group #______

Subscriber’s Name:______Date of Birth: ______Relationship: ______

Secondary Insurance Information

Insurance Company ______Policy# ______Group #______

Subscriber’s Name:______Date of Birth: ______Relationship: ______

Pharmacy Information

Pharmacy Name ______Phone Number ______

Address ______

NAME: ______

Emergency Contact

Name:______Phone#: ______Relationship:______

AUTHORIZATION TO RELEASE MEDICAL INFORMATION TO ABOVE MENTIONED PERSON

My signature below serves as authorization to release private and protected medical information to the above said person in the manner marked:

VERBALLY____ MESSAGE VIA PHONE______RECEIVE MEDICAL RECORDS ON MY BEHALF______

DO NOT RELEASE MEDICAL INFORMATION TO ANYONE OTHER THAN MYSELF ______

SIGNATURE______DATE:______

ASSIGNMENT OF BENEFITS

I hereby assign all of my rights, tides, interests, and payment of any medical or surgical reimbursement benefits to which I am entitled (by my insurance policy, including Medicare, Private transfer, or any third party) to BOARDWALK OB/GYN ASSOCIATES. I request that payment for such be made directly to BOARDWALK OB GYN ASSOCIATES. I authorize this office and its employees the right to release and disclose all or part of my medical information to any entity which is liable for charges. I authorize this office and its employees the right to send such records via fax or any other form of secured electronic means for assistance in payment of charges and to provide the patient with the most appropriate medical care. This authorization will remain valid until revoked by written notice. A photocopy of this agreement is to be valid as an original. The signature furnished below shall suffice for all insurance forms on a continuing basis.

Signature: ______Date: ______

NAME:______

AGREEMENT TO PAY

IN THE EVENT THAT MY INSURANCE DETERMINES THAT A SERVICE OR PROCEDURE IS A NON COVERED SERVICE OR NOT MEDICALLY NECESSARY, THIS FORM SHALL SERVE AS AN ADVANCE WRITTEN NOTICE THAT I WILL BE BILLED FOR THE NON COVERED SERVICES.

I ALSO UNDERSTAND THAT IT IS MY RESPONSIBILITY TO KNOW THE BENEFITS OF MY POLICY. I UNDERSTAND THAT THE PROVIDER RENDERING CHARGES IS NOT RESPONSIBLE FOR OBTAINING MY BENEFITS. I UNDERSTAND THAT ANY BENEFITS OR COVERAGE INFORMATION PROVIDED TO ME IS NOT A GUARANTEE OF BENEFITS NOR VERIFICATION OF ELIGIBILITY. I AM SOLEY RESPONSIBLE FOR ALL COPAYS, DEDUCTIBLES, COINSURANCE AND ANY NON COVERED OR NON PAYABLE SERVICES.

I ACKNOWLEDGE THIS DISCLOSURE AND AGREE IN WRITING TO ACCEPT THE NON COVERED SERVICES AS BILLABLE TO ME AND ACCEPT FINANCIAL RESPONSIBILITY FOR SUCH CHARGES.

SIGNATURE: ______DATE______

I further understand and agree that if my account is turned over to a collection agency, I am financially responsible for all additional charges. These include a 27% fee for accounts less than a year old and 45% for accounts older than a year, leaving me responsible for a total made up of the balance and the collection fee.

Signature: ______Date: ______

GENERAL CONSENT

By signing this form, I consent to give Boardwalk OB GYN and its associated staff the authorization to perform and render any and all necessary medical care during my office visits and to fulfill the orders of the physicians and staff associated with Boardwalk Ob/Gyn.

By signing this form, I consent to authorize Boardwalk Ob/Gyn and associated staff the right to disclose treatment illness (except for psychotherapy notes), use of alcohol or drugs, communicable diseases such as Human Immunodeficiency Virus (HIV), and Acquired Immune Deficiency Syndrome (AIDS) for treatment, payment, healthcare operations, and as otherwise allowed by law.

The duration of this consent is indefinite and continues until revoked in writing.

NAME: ______DATE______

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I ______acknowledge that I have received a

(Name of Patient)

copy of BOARDWALK OB/GYN ASSOCIATES ‘Notice of Privacy Practices’.

This Notice describes how BOARDWALK OB/GYN ASSOCIATES may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

I also acknowledge that I have been afforded the opportunity to read the notice of Privacy Practices and ask questions.

______

(Signature of Patient, or Personal Representative) (Date)

______

(Relationship to Patient)

NAME: ______

Laboratory Services

Please be advised that the majority of laboratory services performed in our facility are processed through an outside laboratory. The laboratories that we currently use are Quest Diagnostics and LabCorp; these may be subject to change. Our office will collect the specimen here and forward them to the contracted laboratory along with your billing and insurance information. We determine where your specimens will be sent based upon your insurance companies’ contract with each facility. Based upon your insurance policy, your benefits may vary for laboratory services. All billing of laboratory services will be handled by the specific laboratory used. For any out-of-pocket expenses or billing disputes, please contact the laboratory directly.

Normally when Pap Smears are read at a laboratory, they are read by a Cytotechnologist. If there are any abnormalities found in the review of the Pap Smear, it may be forwarded to a physician who then reviews and interprets the Pap Smear again. This ensures that a precise reading had been performed and that the results are as accurate as possible. If a laboratory physician is required to review your Pap Smear, there will be an additional charge of $16.00 to $20.00 added to your account that may not be reimbursable based on your insurance plan. In the event that you are charged this additional fee, you will receive a bill from our office or from the laboratory.

By signing below, you state that you understand the above statements and agree to pay the laboratory bill to them separately.

______

Patient SignatureDate

Consent to Treat a Minor

______, (Minor Child) has an appointment at Boardwalk OB/GYN, on ______(Date) for an examination and treatment.

I, ______(Parent/Guardian) give Boardwalk OB/GYN my permission to examine and treat the above named child.

Name:______

HIPAA PRIVACY ACT INFORMATION FORM

Please check one of the boxes below for release of medical information:

Release information only to me:□ Yes □ No

Where may we call to verbally communicate medical information: cell______home______work______

Where may we leave a message: cell______home ______work______none______

What can we leave on the message: call back______leave medical info______do not leave message______

Release information to my spouse/partner/other:□ Yes □ No

What information to release: verbal ______copies of records______

Spouse’s Full Name: ______cell______home______work______

Other Person: ______cell ______home ______work______

Where may we call to verbally communicate medical information: spouse_____ cell______home______work______

Other ______cell______home______work______

Where may we leave a message: spouse_____ cell______home______work______

Other ______cell______home______work______

What can we leave on the message: spouse call back______leave medical info______do not leave message______

: spouse call back______leave medical info______do not leave message______

Acknowledgement of Receipt of Communication Policies

Your signature confirms approval of the HIPPA communication of information preferences. You may change your preferences at any time, but this must be done by completing a new form.

Signature______Date______

Patient Name:______Date of Birth______

Reason for Visit

What brings you in today?______What other concerns would like to address?

______

______

______

Current Medications □ No medicationsAllergies□ No Known Drug Allergies

What medications are you taking?______Are you allergic to: □ Tape □ Latex □ Iodine

______

Name Dose FrequencyName Reaction

______

Name Dose FrequencyName Reaction

______

Name Dose FrequencyName Reaction

______

Name Dose FrequencyName Reaction

Past Medical History □ I have no known medical problems

□ Alcoholism

□ Allergies

□ Anemia

□ Anxiety

□ Asthma

□ AIDS/HIV

□ Autoimmune Disorders

□ Back problems

□ Bleeding

□ Blood Disorders

□ Blood Transfusion

□ Breast Cancer

□ Clotting Disorder

□ Colon Cancer

□ Diabetes

□ Depression

□ Eating Disorders

□ Ear Problems

□ Epilepsy

□ Glaucoma

□ Gout

□ Heart Disease

□ Heart Defects

□ Hepatitis A,B, or C

□ High Blood Pressure

□ High Cholesterol

□ Liver Disorder

□ Kidney Disorder

□ Joint Disorder

□ Lung Disorder

□ Measles

□ Migraines

□ Osteoporosis

□ Pneumonia

□ Polio

□ Psychiatric Illness

□ Rheumatic Fever

□ Stroke

□ Thyroid Disorder

□ Stomach Ulcer

□ Substance Abuse

□ Skin Disorder

□ Tuberculosis

□ Sexually Transmitted Disease

Other details:______

______

______

Patient Name:______Date of Birth______

Family Medical History □ No Family Medical Problems

□ Alcoholism

□ Allergies

□ Anemia

□ Anxiety

□ Asthma

□ AIDS/HIV

□ Autoimmune Disorders

□ Back problems

□ Bleeding

□ Blood Disorders

□ Blood Transfusion

□ Breast Cancer

□ Clotting Disorder

□ Colon Cancer

□ Diabetes

□ Depression

□ Eating Disorders

□ Ear Problems

□ Epilepsy

□ Glaucoma

□ Gout

□ Heart Disease

□ Heart Defects

□ Hepatitis A,B, or C

□ High Blood Pressure

□ High Cholesterol

□ Liver Disorder

□ Kidney Disorder

□ Joint Disorder

□ Lung Disorder

□ Measles

□ Migraines

□ Osteoporosis

□ Pneumonia

□ Polio

□ Psychiatric Illness

□ Rheumatic Fever

□ Stroke

□ Thyroid Disorder

□ Stomach Ulcer

□ Substance Abuse

□ Skin Disorder

□ Tuberculosis

□ Sexually Transmitted Disease

Other details:______

______

______

Past Surgical History □ I have never had surgery

______

SurgeryDateWhere Performed

______

SurgeryDateWhere Performed

______

SurgeryDateWhere Performed

______

SurgeryDateWhere Performed

______

SurgeryDateWhere Performed

Lifestyle

Are you sexually active?□ Yes□ NoHow many partners? (past year)______(total lifetime)______

If not currently active, have you ever been sexually active?□ Yes□ No

Sexual Partner(s) is/are:□ Male□ Female □ Both

Would you like to be checked for sexually transmitted diseases?□ Yes□ No

Has anyone in your home physically or verbally hurt you?□ Yes□ No

Do you smoke? □ Yes □ No packs/day______Have you ever smoked? □ Yes □ No Quit Date______

Do you use recreational drugs? □ Yes □ No What types/Frequency______

How much alcohol do drink per week?______

How much caffeine do you drink per day?______

How many times per week do you exercise?______

Patient Name:______Date of Birth______

Pregnancy History □ I have never been pregnant

______

# pregnancies#term#preterm#miscarriages#abortions

Date #Weeks Type of Delivery M/F Weight Living Complications

______

______

______

______

______

______

Are you currently pregnant? □ Yes □ No

Are you trying to become pregnant? □ Yes □ No

What is your current method of birth control? □ None □ Abstinence □ Condoms

□ Intrauterine Device □ Implanon/Nexplanon □ Vaginal Ring (Nuva Ring) □ Contraceptive Patch

□ Spermicide □ Natural Family Planning/Rhythm Method □ Withdrawal □ Diapragm/cervical cap

□ Oral contraceptive Pills: (name)______□ Other:______

Menstrual HistoryHealth Maintenance

Age at first period?______Last pap smear ______□ never had one

Date of last period?______Last mammogram ______□ never had one

Frequency of periods?______Last colonoscopy ______□ never had one

Length of period?______Last bone density ______□ never had one

Are your periods regular? □ Yes □ No Last general health checkup ______

Age at menopause?______□ N/AImmunizations up to date? □ Yes □ No

OB/GYN History - □ I do not have any OBGYN problems

□ Abnormal vaginal bleeding

□ Abnormal pap smear

□ Bleeding between periods

□ Breast Lump/Mass

□ Breast Cancer

□ Breast Surgery

□ Cervical Cancer

□ Cervical Dysplasia

□ Chlamydia

□ Colposcopy previously

□ Cryosurgery

□ DES exposure

□ Fecal/Flatus Incontinence

□ Fibroids

□ Genital Warts

□ Gonorrhea

□ Herpes

□ Hot Flashes

□ HPV (Human Papilloma Virus)

□ Infertility

□ Irregular Periods

□ Menstrual Pain

□ Nipple Discharge

□ Ovarian cysts

□ Ovarian Cancer

□ Painful Intercourse

□ Pelvic Inflammatory Disease

□ Uterine Cancer

□ Uterine Hyperplasia

□ Urinary Incontinence

□ UTI – frequent

□ Vaginitis (BV) – frequent

□ Yeast - frequent