Obstetrics & Gynecology of North Texas, LLP

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Patient's Name Please provide a name

State Issued ID Card

Patient's Address

Patient's City, State Zip

Patient's Primary Phone

Patient's Secondary Phone

Patient's Email

Preferred Communication

Date of Birth Please select a date

Social Security Number

Physician Please select a physician

Primary Care Physician


Marital Status	Single	Married	Separated	Divorced	Widowed

Employer/School Name

Employer/School Address

Employer/School City, State Zip

Preferred Pharmacy Name

Preferred Pharmacy Address

Preferred Pharmacy City, State Zip

Preferred Pharmacy Phone

Insurance Information

Insurance Card (Front)

Insurance Card (Back)

Insurance Name

Insurance Phone

Insurance Policy Holder Name

Insurance Policy Holder Employer

Insurance Policy Holder Date of Birth

Insurance ID Number

Insurance Group Number

I have secondary insurance I would like to provide.

Secondary Insurance Card (Front)

Secondary Insurance Card (Back)

Secondary Insurance Name

Secondary Insurance Phone

Secondary Insurance Policy Holder Name

Secondary Insurance Policy Holder Employer

Secondary Insurance Policy Holder Date of Birth

Secondary Insurance ID Number

Secondary Insurance Group Number

Emergency Contact Information

Emergency Contact Name

Relationship

Emergency Primary Phone

Emergency Secondary Phone

Emergency Address

Emergency City/State/Zip

Financial policy, authorization for treatment and assignment
**Our office files all charges for Managed Care Contracts in which we are participants. We file on indemnity plans only for hospital Inpatient and outpatient fees. Your portion will be determined by your insurance plan and our office will convey that Information to you. The estimated amount of non-insurance reimbursement will be required as a deposit in non-emergency cases. For obstetrical care, this estimated amount will be collected prior to your 32" week of pregnancy. Additional billing or refund may occur after insurance reimbursement is received.
**I authorize treatment and agree to pay all fees and charges for such treatment. I agree to pay all charges incurred by me and/or members of my family upon presentation of the statement for same, unless credit arrangements are agreed upon in writing. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within thirty days of billing date. I hereby assign to the above physicians all proceeds from my insurance carriers for services provided. I authorize release of all medical records required by my insurance carriers to obtain payment for services received. This authorization shall remain in effect until revoked by mein writing. (A copy of this assignment is valid as the original).
**Your portion of payment for all office services Is due at the time of service. We accept VISA, MasterCard, American Express, Discover, CareCredit, cash, or check. All benefit quotes or prices given are only an estimate and are subject to change based on your insurance carrier determination You may have and additional balance due.
**I understand there will be a twenty-five dollar ($25.00) charge for all non-emergency after hours phone calls. This is not reimbursable by insurance.
NOTICE: Do not sign this agreement before you read.

I agree to the above financial policy.

Acknowledgment
Patient/Responsible Party
Today's Date

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Treatment Agreement
I promise full cooperation with my treating physician whether by surgical or non-surgical means. I understand that if I do not follow my doctor's instructions concerning my care and treatment, including any necessary medications, the outcome of my care and treatment could be put into jeopardy and less than optimal results may occur.
Release of Information
I allow Obstetrics & Gynecology of North Texas to release my Private Health Information to any and all my insurance carriers, their third-party payors and claim reviewer, until the claim is resolved. For the purpose of treatment, I also allow the above listed practice to release my information or contact any and all my treating physicians. Please list any additional individuals you wish to have access to your medical information:
Name/Entity	Phone Number	Relationship



Appointment Reminders
For the purpose of appointments, Obstetrics & Gynecology of North Texas utilizes Vital Interactions to contact patients by phone, text, or email on our behalf.
Photography/Video
To ensure patient privacy and HIPAA compliance, our office does not allow any photography/videography anywhere in the office.
Doctors Invested in Your Care
Many of our physicians at Obstetrics and Gynecology of North Texas have financial interests in facilities/medical companies in North Texas. These facilities and our physicians are committed to providing clinical excellence to our patients in a safe high-quality environment. Their financial interest in the facilities often provides them a voice in administration and in clinical and operational policies. This involvement helps to ensure the highest level of patient care and customer service. The following is a list of facilities/medical companies one or more of our physicians have a financial interest in: Baylor Surgicare at Grapevine; Methodist Southlake Hospital.
Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that a copy of the HIPAA Notice of Privacy Practices had been made available and that I have read (or had the opportunity to read if I so chose) and understand the notice.
Patient Financial Policy
You must provide personal (address, phone number, etc.) and/or insurance changes (carriers, networks, ID numbers, etc.) to the office. In the event the office is not informed, you will be responsible for any charges denied.
You are responsible for all authorizations/referrals/prior authorizations needed to seek treatment with Obstetrics and Gynecology of North Texas physicians. If you are unsure, please check with a staff member.
Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you with an assignment of benefits. You are agreeing to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within 60 days, the patient or guardian seeking care for a minor, will be responsible for payment of services. Please contact our office with any questions.
Please honor our 24 hour reschedule notice, as there may be a charge for appointments broken or cancelled without 24 hours advanced notice. Repetitive broken or cancelled appointments may also result in a charge.
We have made prior arrangements with insurers and other health plans to accept assignment of benefits. We will bill those plans with which we have an agreement and will require you to pay the co-pay/co-insurance/deductible at the time of service. Your upfront portion will be calculated based on your insurance benefit/limits and our negotiated fee agreement with your carrier. If you are seeing our physicians on an "out-of-network" basis, you will be subject to out of network rates. Once the claims are processed by your insurance, there may be an additional balance. We will bill you for this amount.
Not all services are a "covered" benefit in all insurance policies; some plans even impose a waiting period before covering services. In the event your health plan determines a service to be "not covered/pre-existing," or you do not have an authorization, you will be responsible for all charges. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their insurance carrier for clarification of benefits prior to services rendered.
Our office does not file to tertiary insurance. For all other insurances, we will provide an itemized statement upon your request. If you possess two insurance plans, you must notify our office of your designated primary policy.
Pre-scheduled surgical procedures require pre-payment/estimated deposit. Your deductible/co-insurance/co-pay for this procedure is due at the pre-operative appointment. For other services provided in the hospital by our physicians, our office will bill your insurance carrier. Any balance due is your responsibility.
We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, please contact our office promptly for assistance in managing repayment of balances due and payment options. Any payment exceptions will be agreed upon in writing.
Past due accounts are subject to collection proceedings including the credit bureaus. All fees including but not limited to collection fees, attorney fees, and/or court fees shall become your responsibility in addition to the balance due to our office.
There is a service fee of $35 for all returned checks. Upon an NSF or CLOSED ACCOUNT occurrence, all future remittances will need to be in another form of payment. Restitution of "theft-by-check" will be requested from the District Attorney's Office.
Medical Records and X-rays are the property of Obstetrics & Gynecology of North Texas. You may request a copy of medical records with a 30-day notice and a fee of $25 for the first 25 pages and $.50/per page thereafter. These fees are not covered by insurance and all requests must be in writing.
Disability/FMLA forms needing to be completed by Obstetrics & Gynecology of North Texas will incur a charge of $25 per form occurrence.
Minor patients must be accompanied by a parent/legal guardian with a signed consent form.
Authorization of Payment
I hereby assign all medical benefits directly to Obstetrics & Gynecology of North Texas for the payment of any services rendered. I also authorize release of medical records necessary to process my health claims. I fully understand that in the event my insurance provider does not pay for services I received; I will be financially responsible for all balances.
On Call Sharing Practice
I understand that another physician may be involved in my care in the event that my personal physician is not available. I further understand and accept that the on-call physician caring for the patient may male or female.
Minor Policy
Any patient under 18 years of age (unless married or pregnant) must bring a parent or legal guardian to the office to sign consent for treatment.
I (we), being the parent/legal guardian, give the office of Obstetrics & Gynecology of North Texas permission to treat the minor patient.
We will provide the best possible care and service to you and regard your complete understanding of our policies as an essential element of your care/treatment. Should you have any questions, please discuss them with a staff member or supervisor/manager.