Registrationform(Pleaseprint)

REGISTRATIONFORM(PLEASEPRINT)

Primary Care/ReferringDoctor: / Today’s Date:
PATIENTINFORMATION
Patient’sLastName: First: Middle: / Age: / Male
Female / Date of Birth:
/ /
Street Address: / Social Security No.: / Best Contact Phone Number:
( )
City: / State: / ZIP Code: / SecondaryPhone Number:
( )
Ethnicity:
Hispanic or Latin
NotHispanic or Latin
RefusetoReport / Race:
AmericanIndian or Alaska Native White
Asian Hispanic
Native Hawaiian Other Race
Black or AfricanAmerican Other Pacific Islander
Primary Parent / GuardianName: / Email:
Social Security No.: / Date of Birth:
Employer: / Employer phone No.: ( )
Second Parent/ GuardianName: / Marital Status of Parents:Married Divorced Single
INSURANCEINFORMATION
Name of Primary Insurance: / Subscriber’s Name: / Birth Date:
/ / / Subscriber’s S.S. No.: / Policy No.: / Group No.:
Subscriber Address:
Ifdifferentthanabove / Patient’srelationship to subscriber:
Self SpouseChild Other
City: / State: / ZIP Code:
Name of Secondary Insurance: / Subscriber’s Name: / Birth Date:
/ / / Subscriber’s S.S. No.: / Policy No.: / Group No.:
Subscriber Address:
Ifdifferentthanabove / Patient’srelationship to subscriber:
Self SpouseChild Other
City: / State: / ZIP Code:
EMERGENCYCONTACT
LastName: First: Middle: / Home Phone Number :( )
Cell Phone Number: ( )
Street Address: / Relationship toPatient: / Email:
City: / State: / ZIP Code:
APPOINTMENTINFORMATION
Referred by(Full name): / Reason for today’s visit:

My signaturebelowaffirms mypatientregistrationinformationis completeandtrue.

Signed: Relationship: Date

Consentto Treat

I herebyconsenttoevaluation,diagnosticprocedures,testing,andtreatmentasdirectedmyphysicianorhis/herdesignee.

I give myconsentforthelicensedhealthcareprofessionalsofElevatePartnership,PLLC/AustinUrogynecologytoexaminemyperson, performmedicaldiagnosticstudiesandgive medicaltreatmentwhichisconsistentwiththestandardsofmedicalcare. I understandthat thisConsenttoTreatwillbevalidfor eachvisitI maketotheElevatePartnership,PLLC/AustinUrogynecologyuntilrevokedbymein writing.

Recalls

Recallsarea courtesyandnotguaranteedtobesentout.Itisthepatientorpatientguardian’sresponsibilitytosetupall followupand

yearlyappointments.

Contact/Releaseof Information

Intheeventthat ElevatePartnership,PLLC/Austin Urogynecologyneedtocontactyouregardinganappointment,labresult,medicationor foranyotherreason,it ispermissibleto:

Leavea messageonanansweringmachine/Voicemail  Speakwithspouse/significantother

Other: NameRelationshiptoPatient:_

Speakwithotherfamilymember

I acknowledgethat ElevatePartnership,PLLC/Austin Urogynecologymayreleasemyprotectedhealthinformationasnecessaryfor treatment, paymentandhealthcareoperationsandacknowledgethatElevatePartnership,PLLC/AustinUrologyInstitute/Austin Urogynecology’s NoticeofPrivacyPracticeprovidesinformationonhowmyprotectedhealthinformationmaybeusedand/ordisclosedfor thesepurposes.I understandthatprotectedhealthinformationpertainstomydiagnosisand/ortreatment,andincludes,butisnotlimited to,informationrelatedtomyhealthhistory,diagnosis,treatment,prognosis,mentalillness(excludingpsychotherapynotes), useofalcohol ordrugs,prescriptionsandlaboratorytestresults,includingHIVorthediagnosisofAIDS.

I understandthatuseordisclosureofmyprotectedhealthinformationmaybenecessarybeforemyinsurerwillpayforthecost ofmy medicaltreatmentandthatifI refusetoconsenttothisdisclosureI mayberequiredtopaytheentirecostof medicalcareprovidedbymy provider.

I acknowledgeandconsentto allowElevatePartnership,PLLC/AustinUrogynecologytousehealthinformationexchangesystemsto electronicallytransmit,receiveand/oraccessmymedicalinformation,whichmayinclude,butisnotlimitedto,treatments,prescriptions, labs,medicalandprescriptionhistoryandotherprotectedhealthinformation.I may“optout”andnothavemyprotectedhealth informationdisclosedthroughhealthinformationexchangesystemsbyprovidingthesignedElevatePartnership,PLLC/Austin Urogynecology“opt-out”formtothepracticelocationwhereI receivetreatment.

FinancialPolicy

I assignandtransfertoElevatePartnership,PLLC/AustinUrogynecologyallrights,titleandinterestinpaymentsfromthird-partypayors, includingbutnotlimitedto,healthplans,healthinsurers,PersonalInjuryProtection(PIP)/UninsuredMotorist/UnderInsured Motorist (UIM/UM),autoorhomeowner’sinsurance.I understandthatitismyresponsibilitytoknowmyinsurancebenefitsandwhetherornotthe servicesI receivearea coveredbenefit.I understandandagreethatI willberesponsibleforanydeductible,co-payorbalanceduethat ElevatePartnership,PLLC/AustinUrogynecologyareunabletocollectfrommythird-partypayorforwhateverreason.If myaccount becomesdelinquentanditis necessaryfortheaccounttobereferredtoattorneys’orcollectionagencies,orlawsuitfiled,I agreetopayall patientcharges,reasonableattorneysfeesandcollectionexpenses.

I authorizethereleaseallmedicalinformationnecessarytoprocessallclaimsandthereleaseofpaymentformedicalbenefitstomyphysician and ElevatePartnership,PLLC/AustinUrologyInstitute/AustinUrogynecology.I agreetopayanyoutstandingbalancefor servicesnotcoveredbyinsurance,applicablecopays,co-insurance,deductible,andreplacementcostsforitemsdamaged.

My signaturebelowaffirms mypatientregistrationinformationandacceptanceof the financial terms,responsibilities andconsents asstated herein.

Patients Name: Date of Birth:

Signature: Relationship: Date

InsuranceCardPolicy

PleasepresentyourcurrentInsuranceCardandPhotoIDatcheck-in.Botharerequiredtoprocessinsuranceclaims.Yourappointmentwill berescheduledtoournextavailableopeningifyoudonotbringthesedocumentsorifyoudonot obtaina referral,ifrequiredbyyour insurance.Youareresponsibleforobtaininga referralfromyourPCPifoneisrequired.

Medicare/Medicaid/InsuranceBenefits

IfI ameligibleforhealthcarebenefitsunderanyfederalorstateprogram,including,butnotlimitedtoMedicareorMedicaid,I certifythat theinformationgivenbymeinapplyingforpaymentunderanysuchprogramsiscorrect.I authorizeanyholderofmedicalorother informationaboutmetoreleasetotheSocialSecurityAdministrationorContractorsanyinformationneededforanyfederalor state programrelatedclaims.I requestthatpaymentorauthorizedbenefitsbemadeto ElevatePartnership,PLLC/AustinUrogynecologyonmy behalf.I understandthatI amfinanciallyresponsibleforanydeductible,co-payorbalancedueundertheseprograms.

AcknowledgementofReceiptof theNotice of PrivacyPractice

I acknowledgethatI haverevieweda copyofElevatePartnership,PLLC/AustinUrogynecologyNoticeofPrivacyPractices.I understandhow medicalinformationwillbeusedanddisclosed.I understanda copywillbegiventomeuponrequest.

GeneralOfficePolicies

-Thepracticedoesnotaccept“walk-in”patientsorappointments.

-Ifyouaremorethan15 minuteslate,thephysicianreservestherighttorescheduleyourappointment.

-Ifyouarelate,andthephysicianagreestoseeyou,youwillloseyourappointmentandbeseenafterthosepatientswhoarriveontime. Thismayresultina veryprolongedwaittime.

No Showpolicy

ElevatePartnership,PLLC/AustinUrogynecologyiscommittedtoprovidingthehighestqualitycaretoourpatients.Ourstaffwillworkhard togetyouanappointmentata convenienttime.

No-shows,ormissedappointments,havea greatimpactonourabilitytoprovidetimelyaccesstocare.Whena personfailstoshowupfor theirscheduledappointmentorfailstogiveusa 24hournoticetoeitherrescheduleorcanceltheirappointment,it leavesanemptytimein ourphysician’sschedulethatcouldhavebeenusedbya patientinneed.

Allscheduledappointmentsnotcancelled24hoursprior,aresubjecttoa $40.00fee.Ifyoumissorcancelmorethan2 consecutive appointmentswe willbeunabletoschedulefutureappointments.

Tocancelanappointment,callourofficeat512-973-8276

By signingbelow,youunderstandandagreetoallpolicies.

PatientPrintedName PatientDate ofBirth

Patient/ResponsiblePartySignature Date