Patient Intake Form for Women

 

Your Personal Information

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  • FEMALE *
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Health Insurance Information (Primary Care) *A copy of your insurance card(s) is required



Secondary Health Insurance Information; if applicable *A copy of your insurance card(s) is required

 

Please list all past medical history:



Screening History

Date of Last Screening Hitory of Abnormal Findings? Explain
Last Pap Smear
Lat Mammogram
Last Bone Density
Last Colonoscopy

Please list past medical history for first-degree family and relationships

Medical Issues Relationship Side of Family

Social History






 

Please list all past surgical history:




OB History; if applicable



Total Pregnancies

Gynecological History

Check all that are applicable
  • STD
  • Urinary Tract Infections
  • Problems with Bowel Movements
  • Heavy Menses
  • Painful Menstruation
  • Menopause
  • Sexually Active
  • Ovarian Cysts
Please list all medications AND dosage you are currently taking:
Medication Name Dosage and Directions
Please list all any hormones you have previously taken:


List any known allergies:

 

Health Assessment for Women

Sypmtoms Never Mild Moderate Severe
Depressive Mood
Memory Loss
Mental Confusion
Decreased Sex Drive/Libido
Sleep Problems
Mood Changes/Irritability
Tension
Migrane/Severe Headaches
Difficult to Climax Sexually
Bloating
Weight Gain
Breast Tenderness
Vaginal Dryness
Hot Flashes
Night Sweats
Dry and Wrinkled Skin
Hair Falling Out
Cold All the Time
Swelling All Over the Body
Joint Pain


Family History

NO YES
Heart Disease
Diabetes
Osteoporosis
Alzheimer's Disease
Breast Cancer





HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

  I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.



Insurance Disclaimer

Bio-identical hormone replacement is a unique practice and is considered a form of alternative medicine. Although many board certified medical providers offer bio-identical hormone replacement therapy to their patients, in most cases, insurance companies do not recognize it as a medical necessity.

BioEnve is not contracted with any insurance company. BioEnve will not contact any insurance company directly to seek prior-authorization, benefit details, or reimbursement for the bio-identical pellets and/or supplements.

Payment will be required at the time of service. Upon request, we will gladly provide a detailed receipt (f you wish to seek insurance reimbursement directly.

For Health Savings account holders, you may choose to payfor bio-identical pellets and supplements with your health savings credit/debit card. Please be aware however; that your insurance company may seek reimbursement from you if it is determined not to be an eligible benefit.

   By checking this box I certify that I have read the above information. My signature also certifies my understanding of and agreement with the above terms and I understand I am responsible for all charges with BioEnve.



Privacy Practices and Agreement

Dear Patient:
Physicians have always protected the confidentiality of our patient's health information by securing medical records away from open access and refusing to reveal information. Additionally, State and Federal laws set security standards to ensure the confidentiality of this sensitive information.

The federal government published regulations designed to protect the privacy of your health information. The "Privacy Rule" protects health information that is maintained by hospital, health care providers, and health plans. Physicians, as of April 13,2003, must comply with the federal government's regulations privacy rule's standard for protecting the confidentiality of your health information.

This new regulation protects virtually all patients regardless of where they live or where they receive their health care. Every time you see a physician, are admitted to a hospital, fill a prescription, or send a claim, your health care provider will need to comply with the privacy rules. All health information including paper, oral, or electronic are protected by the privacy rule.

The privacy rule also provides your certain rights, such as the right to have access to your medical records. However, they are exceptions. We also take precautions in our office to safeguard your health information, such as training our employees and employing computer security measures.

In the reception room, we have placed copies of our NOTICE OF PRIVACY PRACTICES. This notice contains very important information about how you can exercise your rights with regard to your protected health information. We request that you take the time to review the privacy practices of the office before you see the medical providers.

You may request, from the receptionist, a copy of the NOTICE OF PRIVACY PRACTICES, to take with you for further review. Federal regulations require that we document that the patient has been advised of our privacy practices and offered a copy of the notice. Additionally, we must receive documentation of the patient's authorization for communication. We require that you complete the attached form to serve as the formal documentation for both the notice and consent for communication. If you have any question regarding our privacy practices, you may schedule a meeting with the privacy officer for further details and review.

Thank you for your patience and assistance.

ACKNOWLEDGEMENT OF REVIEW OF NOTICE OF PRIVACY PRACTICES

I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of the document.

By checking the boxes below, I authorize my physician and his/her staff, to contact me by the designated means noted below.

  • home phone/answering machine/voice mail
  • office/workplace/voicemail
  • cell phone/text (standard text messaging costs from your carrier may apply)
  • fax

I authorize my physician and her staff to communicate information regarding my appointment, medical results, and billing issues to:

  • spouse
  • other
  • other

   By checking this box I understand that this consent/authorization shall remain in force from this time forward until revoked in writing, attention of Privacy Officer and I acknowledge and agree to the Privacy Practices of Dr. McCain's office.



General Practices and Agreement

Check In

Your time is important to us. The first step in keeping your appointment on time is being prepared. This includes filling out all required paperwork prior to your first appointment. It is extremely important that you provide each piece of Information that Is requested on both the Patient Information and Medical History Questionnaire. This will avoid delays in creating your chart and account at your visit. Please arrive at least 15 minutes prior to your scheduled time so that all information can be verified.

Missed Appointments, Late Cancellations, Late Arrivals, and Non-Compliance

We require a 24 hour advance notice if you must cancel or reschedule your appointment. We offer appointment reminder calls prior to your appointment which will allow you to cancel or reschedule. However, it is ultimately your responsibility to keep track of you appointment whether you receive a reminder call or not. Patients with multiple cancellations or missed appointments may be discharged from our practice. Please note that noncompliance with treatment plans (including medications and/or lab work) and abusive/inappropriate behavior towards staff and/or patients will result in immediate dismissal of your care from our practice.

Nurse Practitioners

Dr. McCain has two Nurse Practitioners on staff to assist in the delivery of medical care. Stacy Hammond, FNP-C and Ann Ellison, FNP•C are both advanced practice nurses who have completed a graduate level education and training in the diagnosis and management of medical conditions.

Forms of Payment

We accept payment in the form of cash, Debit Cards, or Credit cards. Prior approval is needed in order to pay by check. In the event the check is returned as non-sufficient or for any other reason you will be charged a $30 fee.

Collection Fees

All office visit charges are due at the time of service. This will include any co-pays or co-insurance amounts. If for some reason it is not collected at the time of service or if the Insurance company does not pay the expected amount a statement will be sent and the balance due upon receipt of the statement. We will send a maximum of3 statements then your account will be turned over to a collection agency. If your account is turned over to a collection agency, you will be discharged from the practice.

  I have read, understand and agree to the above office and financial policies of Dr. Stefanie Mccain. I hereby attest that I have given and agree to provide current demographic and insurance Information and authorize release of information necessary for insurance filing by checking this box. Checking this box states my agreement and understanding of Dr. Stefanie Mccain's office and financial policies and also serves as a request and consent for treatment. I authorize and assign all benefits to be made directly to Dr. Stefanie McCain.

Quick Contact Info.

1038 Early Blvd.
Early, Texas 76802
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PH: (325) 646-4800
FAX: (325) 646-4806

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