New Patient Information Form 2025

SWAN UROGYNECOLOGY, PC
PATIENT DEMOGRAPHICS
PATIENT NAME (Last First Middle)*
SEX*
BIRTHDATE*

MonthDayYear
Date
SSN*
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
PRIMARY PHONE NUMBER*
ALTERNATE PHONE NUMBER
EMAIL ADDRESS
example@example.com
LANGUAGE
ETHNICITY
RACE
MARITAL STATUS*
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE
EMPLOYER NAME
EMPLOYER PHONE NUMBER
PRIMARY CARE PROVIDER
PRIMARY CARE PROVIDER PHONE NUMBER
REFERRING PROVIDER NAME
REFERRING PROVIDER PHONE NUMBER
Please enter a valid phone number.
RESPONSIBLE PARTY (if different from above)
NAME (Last, First, Middle)
SEX
BIRTHDATE

MonthDayYear
Date
SSN
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
PRIMARY PHONE NUMBER
Alternate Phone Number
EMAIL ADDRESS
example@example.com
PRIMARY INSURANCE
NAME OF INSURANCE
POLICY NUMBER
NAME OF INSURED
GROUP NUMBER
BIRTHDATE OF INSURED

MonthDayYear
Date
RELATIONSHIP TO PATIENT
SECONDARY INSURANCE
NAME OF INSURANCE
POLICY NUMBER
NAME OF INSURED
GROUP NUMBER
BIRTHDATE OF INSURED

MonthDayYear
Date
RELATIONSHIP TO PATIENT
I authorize payment of medical benefits to be made directly to Swan Urogynecology, PC. I agree to pay my portion including co- payments, co-insurance, deductibles and non-covered services at the time of service. I understand that I will be asked to reschedule if I am not prepared to pay the above at the time of service. I understand my visit will be billed to my insurance if I have provided all appropriate insurance information at each visit with copies of my insurance cards. I understand that it is my responsibility to provide Swan Urogynecology, PC my updated demographic and insurance information at each visit. I understand and agree (regardless of insurance status) that I am ultimately responsible for payment of all professional services rendered by Swan Urogynecology, PC. I 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.
Signature of Patient or Guardian*

Clear
Date*

MonthDayYear
Date

MEDICAL HISTORY
TODAY'S DATE*

MonthDayYear
Date
PATIENT'S NAME*
DATE OF BIRTH*

MonthDayYear
Date
Briefly describe your present symptoms:
CURRENT MEDICATIONS
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:

Current Medications

	Name of Medication	Dosage	How long have you been taking this?
1
2
3
4
5

Do you have any drug allergies?*

NoYes
Name of Drug Allergy & Reaction
Name of Drug Allergy & Reaction
Name of Drug Allergy & Reaction
MEDICAL CONCERNS

	Enter an "X" if this applies to you. If not, do NOT enter antyhing in to this space.
Recent Weight Gain
Recent Weight Loss
Fatigue
Weakness
Fever
Urinary urgency w/out leakage
Urinary frequency ______/24hrs
Voiding more than 2 times at night
Unable to fully empty bladder
Painful urination
Blood in urine
Leak Urine
Urgency
Laugh, Cough, Sneeze
Recurrent UTI
Abnormal Pap
Irregular periods
Post menopausal bleeding
PMS
Previous Miscarriage _____
Pelvic Pain
Bulge in vagina
Pain with intercourse
Constipation
Birth control _________
Hormone replacement therapy
Stomach pain
Breast pain
Breast lumps
Abnormal mammogram
Ovarian cyst
Endometriosis
Uterine fibroids
Depression
Excessive worries
Difficulty falling asleep
Difficulty staying asleep
Difficulties with sexual arousal
Anxiety
Poor appetite
Food cravings
Frequent crying
Sensitivity
Thoughts of suicide / attempts
Stress
Irritability
Poor concentration
Mood swings
Racing thoughts
Hallucinations
Rapid speech
Guilty thoughts
Paranoia
STD

OTHER PROBLEMS
REPRODUCTIVE AND SURGICAL HISTORY

Please indicate whether or not you have had any of these procedures and the number where applicable.

	Type an "X" if Yes. IF NO LEAVE BLANK.	Number (if applicable)
Vaginal Births
Cesarean Section
Abortion
Tubal Ligation
D&C (due to miscarriage)
D&C (diagnostic)
Laparoscopy
Ablation
Hysterectomy (uterus/cervix/tubes/ovaries)
Hysterectomy (I still have my ovaries)
Prolapse Repair
Sling

Other Surgeries
PAST MEDICAL HISTORY

	If this applies to you, enter an "X" here. Otherwise, do not enter anything.
Diabetes
High Blood Pressure
High Cholesterol
Hypothyroidism
Cancer
Leukemia
Angina
Heart Problems
Heart Murmur
Pneumonia
Pulmonary Embolism
Asthma
Stroke
Epilepsy (Seizures)
Kidney Disease
Kidney Stones
Crohn's Disease
Depression
Anxiety
Anemia
Stomach or Peptic Ulcer
Rheumatic Fever
HIV/AIDS

Family History

	Health Problem 1	Health Problem 2	Health Problem 3
Father
Mother
Siblings
Children
Other Family

Lisat any other medical conditions in your family:

Social History

	Currently Using?	Not Currently Using
Alcohol
Tobacco
Street Drugs

If you currently drink alcohol, how much do you drink and when was the last time you drank?
If you currently use tobacco, how much do you use/smoke and when was the last time you used it?
If you currently use street drugs, how much do you use and when was the last time you used it?
PHARMACY
Primary Pharmacy
Address
Phone
Secondary Pharmacy
Address
Phone Number
Please enter a valid phone number.
Mail Order Pharmacy
Address
Phone

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy of Swan Urogynecology's notice of Privacy Practices. This notice describes how Swan Urogynecology may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.
Patient Name*
Signature of PatientPatient Representative*

Clear
Date*

MonthDayYear
Date

HOW I PREFER TO BE CONTACTED

I may be contacted in the following mannaer (check all that apply):
Ok to leave detailed information

HomeWorkCell
Leave message with callback information only

HomeWorkCell
Ok to mail to

HomeWorkFax
Fax number that is ok to fax to:
Please enter a valid phone number.
My medical information may be released to the following people
A copy of this authorization may be used in lieu of the original.
Signature of PatientPatient Representative*

Clear
Date*

MonthDayYear
Date

FINANCIAL POLICY
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, FMLA/Disability Paperwork:

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.

Leave of Absence, FMLA or disability paperwork completion will incur a $25 fee that is patient responsibility. This must be paid prior to paperwork completion.

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*

Clear
Print Name*
Date*

MonthDayYear
Date

MEDICATION PRESCRIBING AND REFILL POLICY
Outlined below is Dr. Swan's medication prescribing and refill policy:

- Oral contraceptives and hormone replacement therapy will be refilled annually during your visit.

- Antibiotics can be refilled only if you are a post-operative patient and require an office visit or virtual visit.

- All other prescription refills are subject to an in-office or virtual visit, if appropriate.

- Controlled substances require a 3-month visit for narcotic medications and a 6-month follow-up for all other controlled medications. These visits can be in-office or virtual, if appropriate. Virtual visits are only possible if you have had an in-office visit within the last year. Pharmacies will void any controlled prescription after 6 months.

- Dr. Swan participates in the Tennessee Prescription Drug Monitoring Program (PDMP), a state database that monitors controlled substance prescriptions. This database will be checked before refilling any controlled medications.

- If you want to ensure there is no lapse in medication for controlled substances, please call us at least 2 weeks before you run out of medication. All virtual visits require audio and video capability on the patient's part.

PRIOR AUTHORIZATION POLICY

Here are the prior authorization policies that you need to know:

- If you have a Medicare insurance plan, please understand that a prior authorization for a hormone replacement medication will not be completed, as Medicare does not provide coverage for hormone replacement therapy.

- 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 cooperation.
Signature*

Clear
Todays Date*

MonthDayYear
Date
Printed Name*
Date of Birth*

MonthDayYear
Date

SURGERY AND PROCEDURE RESCHEDULE, CANCELLATION, AND NO-SHOW POLICY
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 of 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*

Clear
Printed Name*
Date Signed*

MonthDayYear
Date

PRIOR AUTHORIZATION POLICY
HORMONE REPLACEMENT THERAPY

Due to many insurance companies not providing coverage for hormone replacement therapy, please understand that a prior authorization for hormone replacement therapy will not be completed. You may use GOOD RX or pay cash for your prescription.

ALL OTHER MEDICATIONS

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

Any questions please discuss with our nurses or providers.

We appreciate your understanding of the above stated policy and htnak you for your cooperation.

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

Clear
Print Name*
Date*

MonthDayYear
Date

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
Patient Name*
DOB*
Address*
City ST Zip*
Purpose of Disclosure:
I understand that the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information might be re-disclosed without obtaining my authorization.

I understand I have the right to:
- Receive a copy of this authorization
- Refuse to sign this authorization and that treatment, payment, enrollment in a health plan or eligibility for health care benefits may not be contingent on my signing this authorization
- Revoke this authorization, except to the extent that the person(s) and/or organization(s) listed above have already made in reference to this authorization
This authorization will remain in effect for 12 months from the date signed below.
Signature of Patient or Legal Representative*

Clear
Date*

MonthDayYear
Date
If signed by a Legal Representative (authority to act on patient's behalf): Relationship to Patient:
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty:

SWAN UROGYNECOLOGY, PC

PATIENT DEMOGRAPHICS

RESPONSIBLE PARTY (if different from above)

PRIMARY INSURANCE

SECONDARY INSURANCE

MEDICAL HISTORY

CURRENT MEDICATIONS

MEDICAL CONCERNS

REPRODUCTIVE AND SURGICAL HISTORY

PAST MEDICAL HISTORY

PHARMACY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

HOW I PREFER TO BE CONTACTED

FINANCIAL POLICY

MEDICATION PRESCRIBING AND REFILL POLICY

SURGERY AND PROCEDURE RESCHEDULE, CANCELLATION, AND NO-SHOW POLICY

PRIOR AUTHORIZATION POLICY

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

Purpose of Disclosure: