PATIENT REGISTRATION

PLEASE READ AND INITIAL EACH SECTION:

INSURANCE AUTHORIZATION AND FINANCIAL AGREEMENT:
I acknowledge that payment for all services is due at the time services are rendered. I understand that it is my responsibility to verify and understand my insurance coverage, including applicable copayments, deductibles, and coinsurance obligations. I further understand that if additional services or procedures are performed during my visit, I may incur additional financial responsibility in accordance with my insurance plan.

If I am unable to present a valid and current insurance card at the time of service, I will be classified as a self-pay patient. Payment in full for services rendered will be required at the time of service. I certify that all information provided regarding my insurance coverage is accurate and complete, and I agree to present updated insurance information at each visit.

I understand that any pre-payment estimates provided by Greensboro OBGYN Associates prior to an appointment, procedure, and/or ultrasound are based on the information available at that time and are not a guarantee of final patient responsibility. Following claim submission and adjudication by my insurance carrier, I may be responsible for additional amounts or may be entitled to a refund.

I hereby authorize Greensboro OBGYN Associates to file claims on my behalf and assign all applicable insurance benefits directly to the practice. I further authorize the release of any medical or other information necessary to process such claims.

I understand that there is a $15.00 fee for the release of medical records.

I understand that completion of FMLA and/or Short-Term Disability forms is subject to a fee ranging from $10.00 to $25.00 per packet.
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NO SHOW POLICY
I understand that if I need to cancel or reschedule an appointment, I must do so within the required timeframes to avoid a missed appointment fee. The required notice and associated fees are as follows:

Office Appointments: $25 fee for cancellations with less than 24 hours’ notice
Procedure Appointments: $50 fee for cancellations with less than 24 hours’ notice
Mobile Anesthesia Procedure Appointments: $75 fee for cancellations made after 12:00 PM on the Friday prior to the scheduled appointment
Hospital Surgery Appointments: $100 fee for cancellations with less than 72 hours’ notice

I acknowledge that missed appointment fees are my sole financial responsibility and must be paid in full prior to scheduling a new appointment. Should I need a more in-depth description of this policy, I am aware it can be found on Greensboro OBGYN Associate’s website, or a printed copy can be given upon request.
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CELL PHONE AND RECORDING POLICY
I understand that the use of cell phones, video recording devices, or any form of recording equipment is strictly prohibited within the office; including in lobby, waiting areas, hallways, and exam rooms. Failure to comply with this policy may result in immediate termination of the appointment.
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CREDIT CARD ON FILE AGREEMENT
Greensboro OBGYN Associates utilizes Credit Card Plus/Elavon to securely maintain credit card information on file. By agreeing to a credit card on file, I authorize the practice to charge my card for any outstanding balances after my insurance claim has been processed.

I understand that I will receive an email notification at least five (5) days prior to any charge being processed, which will include contact information for the office should I have questions or wish to dispute the charge.

I further authorize the use of the card on file for payment of copayments, deductibles, coinsurance, pre-payments, and any outstanding balances related to future services.
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ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have been informed that the Notice of Privacy Practices is available on the Greensboro OBGYN Associates website or upon request in the office. This Notice describes how my protected health information may be used and disclosed, as well as my rights regarding such information.

I understand that this Notice may be revised at any time and that I may request a current copy at any time.
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CONSENT FOR HEALTHCARE AND RELEASE OF MEDICAL INFORMATION
I voluntarily consent to receive medical care and treatment from the providers and staff of Greensboro OBGYN Associates. I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made regarding the outcome of any treatment or procedure.

I consent to the use and disclosure of my protected health information for purposes of treatment, payment, and healthcare operations, as permitted by applicable law.
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CONSENT TO RECEIVE TEXT AND EMAIL COMMUNICATIONS
I understand that text messaging and email are not secure forms of communication and may carry a risk of unauthorized access or disclosure of my personal or health information.

I acknowledge that communications may include information such as my name, appointment date and time, provider name, and other relevant details. I understand that it is my responsibility to maintain accurate contact information with the practice.

I understand that NORMAL lab/test results may be left on my voicemail, unless I specifically request otherwise to a staff member.

I understand that I may opt out of text and/or email communications at any time by notifying the office.
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EXPLANATION OF PELVIC EXAM CODE AND HEMOGLOBIN TESTING
I understand that, effective January 2024, the American College of Obstetricians and Gynecologists (ACOG) established billing code 99459 for pelvic examinations. This fee reflects costs associated with equipment, chaperone services, sterilization, and related clinical supplies. While this charge is typically covered by insurance, it may be applied to my deductible or coinsurance if applicable. The patient responsibility for this charge generally ranges from $15.00 to $30.00.

I understand that hemoglobin testing may be performed during annual exams or other visits as clinically indicated. While often covered by insurance, any applicable patient responsibility (typically under $10.00) will be billed following insurance processing.
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