Patient Registration - Legacy OB/GYN

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Reason for visit

Appt Date and Time

Patient Name

Social Security Number

Date of Birth

Marital Status

Spouse/Partner Name

Race

Ethnicity

Occupation

Telephone

Home

Work

Cell

Where would you like us to call you first?

Emergency Contact Information

Name

Phone

Relationship

Primary Care Physician

Referred By

Pharmacy Name

Address

City

Advance Directive Education

Do you have any of the following?

Living Will

Advance Directive

DNR

Power of Attorney

Would you like information on Living Wills and Advance Directives?

Yes

Insurance Information

Primary Insurance

Policy Number

Effective Date

Subscriber Name

DOB

Relationship

Secondary Insurance

Effective Date

I have declared all my current insurances and I understand I will be responsible for the bill for any outstanding balances.

Signature

Date

Collection Policy

It is the policy of this office, that if your account is sent to collections due to non-payment of services rendered, your status as our patient becomes inactive. It will remain inactive until the balance has been paid to our collection agency or to our office. It is our every hope that this is a last resort, but if the situation warrants the placement of the account into collections, it is the intent of this practice to collect any debt through the proper channels. Upon receipt of payment we will update the status of your participation with our practice.

Signature

Date

Rx History Consent

I give permission for my provider to access my pharmacy benefits data electronically through RxHub. This consent will enable my provider to: determine the pharmacy benefits and drug co pays for a patient’s health plan, check whether a prescribed medication is covered (in formulary) under a patient’s plan, display therapeutic alternatives with preference rank (if available) within a drug class for non-formulary medications, determine if a patient’s health plan allows electronic prescribing to Mail Order pharmacies, and if so, e-prescribe to these pharmacies, download a historic list of all medications prescribed for a patient by any provider.

Patient Signature

Date

Parent Signature

Date

Consent to Treat & Financial Authorization

I hereby authorize my provider to treat my symptoms and apply for benefits on my behalf for any services rendered by him or his order I request that payments of authorized benefits from Medicare/Insurance Company be made directly to my provider I authorize my provider to release any medical information about me to HCFA/my insurance and its agents, any information needed to determine these benefits or the benefits payable to related services. I authorize the use of this authorization for any of my insurance submissions I understand that I am responsible for any amount not covered by my insurance company(s). I certify the information that I have reported with regards to my insurance coverage is correct. I permit a copy of this authorization to be used in place of its original. This authorization may be retrieved by either me or my insurance company at any time in writing.

Patient Signature

Date

Parent Signature

Date

Rx History Consent

Patient Signature

Date

Parent Signature

Date

HIPAA Consent

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. We are committed to protecting the privacy of our patients’ personal and health information. All of our employees are required to sign confidentiality agreements and are required to comply with our confidentiality policies. We may use or disclose your protected health information for purpose of treatment, payment or practice operations only with your written consent. For example, we may contact another physician to coordinate your care, submit a claim to an insurer, or look at your file to perform internal quality monitoring. We must obtain your written authorization for any other use or disclosure. You may revoke your consent or authorization at any time in writing. This will not apply to information used or disclosed while the consent or authorization is in effect. We will provide access to your information, without your consent or authorization, when required to do so by law or regulation. Access may be granted to public health and law enforcement authorities, health care oversight agencies, government benefits programs, employers (in cases of work-related illness or injury), courts and administrative tribunals. We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services. You may want a friend or family member to discuss care with a physician(s), or staff member, take messages, and pick up prescriptions or other medically related communications.

Please indicate if there is a friend or family member to whom we are allowed to release medical information to:

Name

Phone

Relationship

Name

Phone

Relationship

You have the right to: access and amend your information, request an accounting of any disclosures, request restrictions on use and disclosure of your information, request a copy of this Notice, or receive confidential communications. If you request restrictions on the use and disclosure of your information, we are not required to grant your request. You may exercise your rights by contacting the individual identified at the conclusion of this Notice. We are required by law to maintain the privacy of protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. We are required to abide by the terms of the most current notice in effect. We reserve the right to change the terms of our notice and to make the new notice provisions effective for all protected health information that we maintain. We will provide you with a revised notice by mail. If you believe that your privacy rights have been violated, you may complain to us or to the Secretary of the U.S. Department of Health and Human Resources. We will not retaliate against you for filing a complaint. For more information, please contact us at: 313-271-0640 this notice is effective: 4/1/2024 The undersigned acknowledges that he/she has received a copy of this notice of privacy practices.

Patient Signature

Date

Permission to Communicate my Health Information Electronically

Our office is pleased to inform that we now participate in a health information exchange. As you may be aware, health information exchanges allow for electronic communication and access to your electronic medical record. This electronic access, in turn, supports opportunities for improved continuity of care by physicians and other healthcare personnel who are involved in your care. Most important is that health information exchanges create a means by which healthcare data may be accessed in a shorter period than has been traditionally the case with paper records. Participation in the health information exchange could give your healthcare provider access to critical information such as your home address, past medical history, surgical history, hospitalizations, family history, social history, vital signs, immunizations, allergies, chronic medical conditions, previous and current medications, laboratory and radiology test results. Of course, your privacy protections through HIPAA would remain and providers will be expected to access information consistent with these rules.

PLEASE INDICATE YOUR CHOICE TO PARTICIPATE OR NOT IN THE EXCHANGE AS PROVIDED FOR BELOW.

Print First and Last Name

Date of Birth

Signature of Patient or Representative

Date

Patient Portal

By providing us with your email address, you are granting us permission to contact you via email so you may obtain a protected user ID and password in order to create an account with our secure portal. By participating in our secure patient portal, this will allow communication between yourself and our office and obtain information such as lab results, prescription refills, etc. In any online communication, there are risks involved in sharing your information electronically; however it is the intent of this office to keep your information secure. I acknowledge that I have read and fully understand the Patient Portal Consent. I have read and understand the responsibilities and benefits of Patient Portal and understand the risks associated with online communications between me and my doctor’s office. I consent to the conditions outlined and I agree to keep my password confidential and notify the office if my email address changes at any time.

Email Address

Signature of Patient or Representative

Date

Patient Name

Date of Birth

If yes, please notify the office ahead of time so that we obtain records before your appointment. If we do not have records, your appointment may be rescheduled. The only hospital system we have access to is Corewell Health.

Medication List

Medication Name (include over the counter medication and vitamins)

Strength/Dose (mg)

Number of pills per dose

Number of times per day

Current/Past Medical History

Allergies

Drug / Non-Drug Allergy

Allergic Reaction

Patient Name

Date of Birth

Gynecological History

Age at first period

Number of days <b>between</b> periods

Date of last period

Any problems with periods

History of any STD

Use of birth control (condoms, pills, etc.)

Menopause (date)

Abnormal Pap Smears (dates)

Gardasil Vaccine (HPV)

Are you sexually active?

Obstetrical History

Total pregnancies

Total living children

Stillbirths

Ectopic pregnancies

Miscarriages

Abortions

C-sections

Vaginal Deliveries

Previous Hospitalizations and Surgeries

Which, if any

Year

Preventative Care

Which, if any

Year

Vaginal Deliveries

Colonoscopy

Pap Smear

Mammogram

Bone Density

Cholesterol

Blood Sugar

Other lab test

Family History

Father

Living

Deceased

Medical History (Diabetes, Stroke, Heart Disease, HX of blood clotting disorders)

Age

Age at Death

Mother

Living

Deceased

Medical History (Diabetes, Stroke, Heart Disease, HX of blood clotting disorders)

Age

Age at Death

Siblings

Brothers

Sisters

Medical History (Diabetes, Stroke, Heart Disease, HX of blood clotting disorders)

Children

Sons

Daughters

Medical History (Diabetes, Stroke, Heart Disease, HX of blood clotting disorders)

Patient Social History

Use of Tobacco

Never

Previously, but quit.

Current Packs/Day

When?

How many

Use of Drugs

Never

Yes

How often?

Type

Use of Alcohol

Never

Monthly or less

2 to 4/month

2 to 3/week

>4 /week