PATIENT INFORMATION

PATIENT INFORMATION
Name*

First NameLast Name
NAME (Last, First Middle)*
SSN#
BIRTHDATE*

MonthDayYear
Date
LANGUAGE
SEX*
PRIMARY ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
SECONDARY ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
RACE
ETHNICITY
HOME PHONE*
SECONDARY PHONE NUMBER
PRIMARY CARE PHYSICIAN
REFERRING PHYSICIAN
EMERGENCY CONTACT NAME
CONTACT'S PHONE NUMBER
PRIMARY EMPLOYER
EMPLOYER'S ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
PRIMARY WORK PHONE NUMBER
SECONDARY EMPLOYER (if Applicable)
Address

Street Address

Street Address Line 2

CityState

Zip Code
SECONDARY EMPLOYER'S PHONE NUMBER
RESPONSIBLE PARTY

PATIENTOTHER

PRIMARY INSURANCE
NAME OF INSURANCE COMPANY
POLICY#
NAME OF INSURED
GROUP#
RELATIONSHIP TO PATIENT
SECONDARY INSURANCE (if Applicable)
NAME OF INSURANCE COMPANY
POLICY#
NAME OF INSURED
GROUP#
RELATIONSHIP TO PATIENT
I authorize payment of medical benefits to be made directly to my provider. I agree to pay my portion including co-payments, co-insurance, deductibles and non-covered services at the time services are rendered. I understand my visit will be billed to my insurnce if I have provided all appropriate insurance information on this form and copies of my insurance cards. I understand and agree (regardless of my insurance status) that I am ultimately responsible for payment of all professional services rendered by my provider. I also understand a finance charge will be added to each charge on my account that is not paid within 90 days. Finance charges will not be added to charges awaiting payment from insurance
DATE

MonthDayYear
Date
SIGNATURE OF PATIENT/GUARDIAN*

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	ALLERGY/REACTION
1.
2.
3.

SWAN HIPAA ACKNOWLEDGEMENT

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
SIGNATURE OF PATIENT/REPRESENTIVE*

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Date

MonthDayYear
Date
RELATIONSHIP TO PATIENT: RELATIONSHIP . PATIENT UNABLE TO SIGN DUE TO: REASON PATIENT UNABLE TO SIGN .
HOW I PREFER TO BE CONTACTED

I MAY BE CONTACTED IN THE FOLLOWING MANNER (CHECK ALL THAT APPLY):

	HOME	WORK	CELL
OK TO LEAVE DETAILED INFORMATION
LEAVE MESSAGE WITH CALL BACK INFO ONLY

WRITTEN COMMUNICATION:

	HOME	WORK	FAX
OK TO MAIL TO:

FAX NUMBER
Please enter a valid phone number.
MY MEDICAL INFORMATION MAY BE RELEASED TO THE FOLLOWING PEOPLE: SEPARATE NAMES WITH A COMMA.

Surgery and Procedure Reschedule, Cancellation, and No-Show Policy
RESHEDULING OR CANCELLING

It is important that when you schedule your surgery/procedure you have thoroughly checked your personal calendar to make sure that your scheduled date is ideal for you. Cancelling or rescheduling your surgery/procedure requires multiple phone calls to the hospital or outpatient facility, insurance company, and patient. We understand that a situation may arise that could force you to reschedule, postpone or cancel your surgery/procedure. Swan Urogynecology will reschedule a surgery/procedure one time at no charge. Beyond that, there will be a $50 charge each time a surgery/procedure is rescheduled. After three reschedules, we will not be able to reschedule your surgery. This fee will not be applied toward your surgery/procedure and will be added as a charge to your account, not billable to insurance. This fee must be paid to Swan Urogynecology prior to surgery/procedure being rescheduled.

NO-SHOW POLICY

If you cancel your surgery or procedure within 24 hours of your surgery or procedure there will be a $100 charge added to your account. This fee will not be applied toward your surgery/procedure and will be added as a charge to your account, not billable to insurance. This fee must be paid to Swan Urogynecology prior to surgery/procedure being rescheduled.

If you do not show up for a scheduled surgery/procedure you will be charged the FULL amount your surgery or procedure cost. This applies to surgeries and procedures that are scheduled in the office, surgery center or hospital.

We appreciate your understanding of the above stated policy and thank you for your cooperation.
Signature*

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Date

MonthDayYear
Date

SWAN FINANCIAL POLICY
REGARDING INSURANCE:

As a courtesy to our patients, we gladly file your insurance claims for you. However, per our contract with your insurance company, all co-payments and deductibles are due at the time of service. The balance is your responsibility whether your insurance company pays or not. If your insurance company has not paid your account in full within 45 days, the balance will be automatically due and will expect payment from you in full at that time. We will continue to re-file and work with you and your insurance company to get the payment due and reimburse you, if needed.

Collection Charges, Legal Fees, Finance Charges:

In the event your account is placed with an outside agency for collection, you agree to pay all collection cost, court cost and attorney fees incurred to collect your account. Carrying a balance with this office constitutes a credit transaction and as such, you authorize us, or our agent, to report credit activity to the credit bureaus. I also authorize you or your agent to check for address and employment should that be necessary to effect collection.

Any account that has fallen to bad debt must be cleared before any additional services are rendered and will from that point forward be on a cash or credit card payment system from then forward. We will gladly provide you with the forms to file any insurance claims with your carrier.

All patient accounts must be in good standing with the office in order to continue care from the providers of Swan Urogynecology, PC.

Cancellation Policy/No Show Policy

A fee of $25.00 will be issued to your account if an appointment is not cancelled within 24 hours of the schedule time. A fee of $100 will be issued to your account if a surgery, urodynamic, hysteroscopy or cystoscopy is not cancelled within 24 hours of the scheduled procedure. These fees are not paid by commercial insurance or Medicare and are the patient's responsibility. This fee will need to be paid before you will be able to be seen by a provider.

The state of TN does not allow Tenncare patients to be billed for late cancellations or no shows. Therefore, after 3 violations of the above policy the patient will be terminated from the practice and given 14 days of emergency care to allow time to become established with a new provider.

Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns.

I have read the Financial Policy and I agree with the above and understand my part.
Signature*

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Date

MonthDayYear
Date

PRIOR AUTHORIZATION POLICY
HORMONE REPLACEMENT THERAPY MEDICATION

Due to Medicare not providing coverage for hormone replacement therapy, please understand that a prior authorization for a hormone replacement medication will not be completed if you have a Medicare insurance plan.

ALL OTHER MEDICATIONS

For all other medications, a prior authorization will be completed if necessary and based on failed therapies. An appeal will be completed once, if necessary. If the medication is still not covered after the initial prior authorization and appeal is completed, it will be up to the patient to discuss coverage with the insurance or a change in medication will be offered if deemed medically safe and appropriate.

We appreciate your understanding of the above stated policy and thank you for your

I have read the above policy and I agree with the above and understand my part.
Signature*

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Date

MonthDayYear
Date
Should be Empty:

	CURRENT USE?	HOW MUCH?	LAST TIME USED?
ALCOHOL
TOBACCO
STREET DRUGS

	HEALTH PROBLEM 1	HEALTH PROBLEM 2	HEALTH PROBLEM 3
FATHER
MOTHER
SIBLINGS
CHILDREN
OTHER FAMILY
OTHER FAMILY

	NAME OF PHARMACY	PHARMACY PHONE NUMBER
PRIMARY PHARMACY
SECONDARY PHARMACY
MAIL ORDER

PATIENT INFORMATION

PRIMARY INSURANCE

PATIENT HISTORY

CURRENT MEDICAL CONCERNS

PAST MEDICAL HISTORY

SWAN HIPAA ACKNOWLEDGEMENT

HOW I PREFER TO BE CONTACTED

Surgery and Procedure Reschedule, Cancellation, and No-Show Policy

SWAN FINANCIAL POLICY

PRIOR AUTHORIZATION POLICY

	NAME OF DRUG	DOSAGE	DAILY OR AS NEEDED
1.
2.
3.
4.
5.