PATIENT REGISTRATION FORM williamgrovesmd com

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1890 W Gauthier Rd Ste 130,Lake Charles LA 70605,P 337 480 5530 F 337 480 5531. www williamgrovesmd com,PATIENT RECORD OF DISCLOSURES. In general the HIPPA privacy rule gives the individual the right to request a restriction on uses and disclosures of their protected health. information PHI The individual has the right to request confidential communication or communication by alternate means such as. sending correspondence to the individual s office instead of home. PATIENT S NAME,I WISH TO BE CONTACTED IN THE FOLLOWING MANNER. Home Telephone,OK to leave a message with detailed information. Leave message with call back number only,Work Telephone.
OK to leave a message with detailed information,Leave message with call back number only. Cell Telephone,OK to leave a message with detailed information. Leave message with call back number only,PATIENT OR LEGAL GUARDIAN SIGNATURE DATE. IT IS OUR GOAL AS YOUR MEDICAL PROVIDER TO CALL YOU WITH RESULTS OF ANY TEST ORDERED BY OUR OFFICE WITHIN 1 2. WEEKS DEPENDING ON THE PARTICULAR TEST PERFORMED IF FOR SOME REASON YOU DO NOT RECEIVE A CALL WITH YOUR. RESULTS DURING THIS TIME FRAME PLEASE CONTACT OUR OFFICE. PATIENT OR LEGAL GUARDIAN SIGNATURE DATE, I authorize the release of any medical or other information necessary to process claims I also request payment of benefits either to. myself to myself or to the party who accepts assignment on said claims I authorize J William Groves Jr M D to release medical. records and reports to the referring physician or any other physicians or health care providers that need access to these records for my. medical care I also authorize any other physician laboratory hospital or other provider to release all medical records and X rays. necessary for my care to J William Groves Jr M D,PATIENT OR LEGAL GUARDIAN SIGNATURE DATE.
REVISED 7 23 18,1890 W Gauthier Rd Ste 130,Lake Charles LA 70605. P 337 480 5530 F 337 480 5531,www williamgrovesmd com. Patient Consent Form, Use of this form is optional and not required under the HIPAA privacy rule. I hereby give my consent for J William Groves Jr M D to use and disclose protected health information. PHI about me to carry out treatment payment and health care operations TPO The Notice of Privacy. Practices provided by describes such uses and disclosures more completely. I have the right to review The Notice of Privacy practices prior to signing this consent J William. Groves Jr M D reserves the right to revise its Notice of Privacy practices at any time A revised. Notice of Privacy practices may be obtained by forwarding a written request to J William Groves. Jr M D 1890 W Gauthier Rd Ste 130 Lake Charles LA 70605. With this consent J William Groves Jr M D may call my home or other alternative location and leave a. message on voicemail or in person in reference to any items that assist the practice in carrying out TPO. such as appointment reminders insurance items and any calls pertaining to my clinical care including. laboratory test results among others, With this consent J William Groves Jr M D may mail to my home or other alternative location any items. that assist the practice in carrying out TPO such as appointment reminder cards and patient statements as. long as they are marked Personal and Confidential, With this consent J William Groves Jr M D may email to my home or other alternative location any items.
that assist the practice in carrying out TPO such as appointment reminder cards and patient statements I. have the right to request that J William Groves Jr M D restricts how the practice uses or discloses my. PIH to carry out TPO The practice is not required to agree to my requested restrictions but if it does it is. bound by this agreement, By signing this form I am consenting to allow J William Groves Jr M D to use and disclose my PHI to. carry out TPO, I may revoke my consent in writing except to the extent that the practice has already made disclosures in. reliance upon my prior consent If I do not sign this consent or later revoke it J William Groves Jr M D. may decline to provide treatment to me,Signature of Patient or Legal Guardian. Print Patient s Name Legal Guardian if applicable Date. REVISED 7 23 18,1890 W Gauthier Rd Ste 130,Lake Charles LA 70605. P 337 480 5530 F 337 480 5531,www williamgrovesmd com.
PATIENT DATE,MEDICATION LIST, PLEASE LIST ALL MEDICATIONS INCLUDING STRENGTH AND FREQUENCY INCLUDE VITAMINS. SUPPLEMENTS AND ALL OVER THE COUNTER MEDICATIONS TAKEN REGULARLY. MEDICATION STRENGTH FREQUENCY,J William Groves Jr MD. REVISED 7 23 18,GYNECOLOGIC INTAKE HISTORY,Address Birth Date. City Home Tel,State Zip Work Tel,Employer Insurance. Name of Spouse Partner Referred by, REVIEW OF SYSTEMS Please check any boxes that apply to you now or have applied in the past.
1 Constitutional Currently Past Notes,Weight loss,Weight gain. Double vision,Spots before eyes,Vision changes,3 Ears Nose Throat Mouth. Ringing in ears,Sinus problems,Sore throat,Mouth sores. Dental problems,4 Cardiovascular,Painful breathing. Chest pain,Difficult breathing on exertion,Swelling of legs.
Palpitations of heart,5 Respiratory,Spitting up blood. Shortness of breath,Chronic cough,6 Gastrointestinal. Frequent diarrhea,Blood stool,Nausea vomiting,Constipation. 7 Genitourinary,Blood in urine,Pain with urination. Frequency of urination,Incomplete emptying,Stress incontinence.
Abnormal periods,Painful intercourse,8 Musculoskeletal. Muscle weakness,9 Skin Breast,Pain in breast,MD Initials. REVIEW OF SYSTEMS CONTINUED Please check any boxes that apply to you now or have applied in the past. 10 Neurological Currently Past Notes,Trouble walking. 11 Psychiatric,Depression,Frequent crying,12 Endocrine. Abnormal thirst,Hot flashes,13 Hematologic Lymphatic.
Frequent bruises,Cuts that do not stop bleeding,Enlarged lymph nodes. 14 Allergic Immunologic,Drug allergy, PERSONAL PAST HISTORY Please check any boxes that apply to you now or have applied in the past. Major Illnesses YES NO Major Illnesses YES NO,Asthma Cancer. Pneumonia Ulcers,Chronic lung disease Depression anxiety. Kidney infections stones Anemia blood transfusions. Tuberculosis Seizures convulsions epilepsy,Venereal disease Bowel trouble.
Heart trouble murmur Glaucoma,Diabetes Arthritis joint pain. High blood pressure Fracture,Stroke Hepatitis yellow jaundice. Rheumatic fever Thyroid disease, OPERATIONS HOSPITALIZATIONS Describe reason for operation hospitalization. INJURIES CHRONIC ILLNESSES Describe type of injury illness. OBSTETRIC HISTORY,Number Number,Births Elective abortions. Miscarriages Ectopics Living children,Patient Name MD Initials.
ALLERGIES Drug or other including iodine and latex. FAMILY HISTORY Please check yes if a family member has or had one of these illnesses. Illness Yes No Family Member Illness Yes No Family Member. Diabetes Osteoporosis with fracture,Stroke Breast cancer. Heart disease Colon cancer,High blood pressure Ovarian cancer. Bleeding or blood clotting disorder Other cancer,SOCIAL HISTORY Personal Habits. Smoking Packs per day Years,Alcohol Drinks per day Drinks per week. Seat belt use,Regular exercise,PERSONAL PROFILE, Marital status Married Single Widowed Divorced Separated.
Sexual orientation Heterosexual Other,Number of living children. Number of people in household, School completed High school College Graduate school Other. Current or most recent job,PERSONAL SAFETY Yes No, Has anyone close to you ever threatened to hurt you. Has anyone ever hit kicked choked or hurt you physically. Has anyone including your partner ever forced you to have sex. Are you ever afraid of your partner, GYN HISTORY Please check if you have ever been treated for any of the following infections. Herpes Genital warts Chlamydia,Trichomonas Gonorrhea Syphilis.
Have you had a Pap smear in the last 7 years, Have you ever had an abnormal Pap smear test If so when. Did you begin sexual activity before you were 16 years old. Have you had more than 5 sexual partners in your lifetime. Have you ever tested positive for the HIV virus, Did your mother take the drug DES when she was pregnant with you. Completed by Patient Office nurse Physician,Signature of patient. Date reviewed by physician with patient,Physician signature. MD Initials,1890 W Gauthier Rd Ste 130,Lake Charles LA 70605.
P 337 480 5530 F 337 480 5531,www williamgrovesmd com. Appointment Cancellation No Show Policy We make every effort to provide a reminder call of your upcoming. appointment however it is your responsibility to remember your appointment cancel or change if needed Please call the. office at least THE DAY BEFORE YOUR SCHEDULED APPOINTMENT to reschedule IT IS ACCEPTABLE TO LEAVE A. VOICE MESSAGE IF IT IS OUTSIDE NORMAL OFFICE HOURS We reserve the right to charge a missed appointment fee of. 25 00 to patients who do not show up to a scheduled appointment or who cancel the same day as their appointment This. allows our office to offer the appointment time to other patients needing immediate care This fee is your responsibility since. insurance will not cover this assessment must be paid before any additional appointments can be scheduled In the event a. patient has 3 or more missed appointments or same day cancellations we reserve the right to terminate future care. Late Policy We are committed to prompt service and will work very hard barring emergencies to stay on time Admittedly this. can be difficult in an obstetric surgery practice but we value your time We may ask you to reschedule if you arrive for your. appointment more than 15 minutes after your scheduled appointment Always arrive at least 10 minutes early for an. appointment to complete any necessary paperwork, Non Sufficient Funds Fee There will be a 25 00 fee for any returned checks This will be applied to your account and you. will be placed on a cash or credit card only basis for all future payments. Delinquent Accounts We reserve the right to refer any delinquent account s to a collection agency and report them to the. credit bureau, Completion of Forms There is a 10 00 fee for completion of forms. Participating Insurances We participate with most insurance companies Copays or deductibles are DUE AT THE TIME OF. SERVICE Non participating insurances self pay payment IN FULL is required at the time of service for any gynecological. care an optional payment plan will be designed for obstetrical care for SELF PAY patients only For ALL insurances Please. review your benefit listings summary Well Woman or Annual Exams are usually considered preventative care and sometimes. covered at 100 by insurance plans For Medicare Based on certain criteria there is coverage for breast pelvic exam pap. smears We require a copy of all insurance cards ask that you present them at each visit along with your driver s license All. new patients must complete our patient information before services are rendered The forms of payments we accept are the. following cash check Visa MasterCard Discover, I understand agree that health insurance coverage is an agreement between an insurance carrier and me I understand that. this office will prepare any necessary reports forms to assist me in making collections from the insurance company that any. amounts authorized be paid directly to this office However I clearly understand agree that all services rendered to me are. charged directly to me, Lab Results I understand that it is my responsibility to call and check on any results regarding any test s performed Dr.
Groves or staff normally will make an effort to contact patient with results Ultimately it is my responsibility to obtain results from. the office, We reserve the right to terminate treatment to any patient with three or more missed appointments or same. day cancellations, I print name have read agreed to and received a copy of Dr William Groves. Financial Policy Appointment Cancellation No Show Late NSF Fee Policies of the practice. Patient Consent Form Use of this form is optional and not required under the HIPAA privacy rule I hereby give my consent for J William Groves Jr M D to use and disclose protected health information

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