Patient Privacy and Individual Rights

Name*

First NameLast Name

Email*

example@example.com

Is it o.k that we call you (whether it is to remind you of an appointment, your insurance, test results, or any other reason necessary)?*

YesNo

Daytime Phone Number

Area CodePhone Number

Is it o.k that we leave messages on your answering machine?*

YesNo

Are you aware of what HIPAA means to you? If no, please see the receptionist when you come to the office and ask for a copy of our patient privacy practice sheet.*

YesNo

Is there anyone that you give us permission to discuss your health-related information?*

YesNo

If yes, please list name(s) and relation to you:

FINANCIAL POLICY
• If you do not have insurance, you must pay for your visit in full.
• If you do have insurance and we are a participating provider, we will file it for you.
• If we have filed your insurance twice, and they have not paid, you will be responsible for payment.
• There is a $35 fee for returned checks and redepositing a check.
• Anything that your insurance does not cover or denies, you will be responsible for.
• The parent and/or guardian bringing a minor patient in is responsible for making the payment that is due on the
patient’s account.
• Please give a 24 hour notice if you need to cancel or reschedule an appointment. Canceled appointments less than 24
hours and missed appointments will be subject to a $25 fee. A second missed appointment will be subject to a $50 fee and a
third missed appointment will result in dismissal from this practice.
I HAVE READ AND UNDERSTAND THE PATIENT PRIVACY ACT, THE FINANCIAL POLICY AND NOTICE OF PRIVACY PRACTICES OF WOMEN’S HEALTH ASSOCIATES. I CONSENT TO MEDICAL TREATMENT AND UNDERSTAND THAT THIS AGREEMENT IS IN EFFECT FOR ONE YEAR UNLESS REVOKED IN WRITING BY MYSELF.

Signature of Patient or Guardian*

Date*

Date

Name of Patient or Guardian*

First NameLast Name