New Patient Form

New Patient Intake

Please complete ALL sections to the best of your knowledge.
Patient Contact Information
PATIENT NAME*

First NameLast Name
Age*
PATIENT DOB*

MonthDayYear
SOCIAL SECURITY NUMBER*
ADDRESS*

Street Address

Street Address Line 2

CityState

Zip Code
PHONE*
MARITAL STATUS*

SingleMarriedOther
EMAIL*
example@example.com
PATIENT DRIVERS LICENSE

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PATIENTS' OCCUPATION
NAME OF EMPLOYER
EMPLOYER PHONE
EMPLOYER ADDRESS

Street Address

Street Address Line 2

CityState

Zip CodeCountry
WHO MAY WE THANK FOR REFERRING YOU?
Spouse/Partner Or Guardian Information
NAME

First NameLast Name
DOB

MonthDayYear
OCCUPATION
EMPLOYED BY
Emergency Contact Information
NAME*

First NameLast Name
PHONE *
RELATIONSHIP TO PATIENT *
Primary Insurance Information
WHAT TYPE OF INSURANCE COVERAGE DO YOU HAVE?*

Insurance (Employer, Marketplace, and Medicaid)Self PayMedicare
INSURANCE COMPANY NAME*
MEMBER/CARD ID NUMBER*
PLEASE TAKE A PHOTO OF THE FRONT AND BACK OF YOUR INSURANCE CARD. BE SURE TO ZOOM IN SO THAT THE INFORMATION CAN BE CLEARLY READ. THANK YOU.
INSURANCE CARD FRONT

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INSURANCE CARD BACK

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PERSON RESPONSIBLE FOR COVERAGE*

First NameLast Name
RELATIONSHIP TO PATIENT*
DOB*

MonthDayYear
Social Security #*
MEDICARE ID NUMBER
Please read and accept the following terms*

I, the undersigned (or my dependent), agree and assign the insurance to CELEBRATION OBSTETRICS AND GYNECOLOGY. ALL insurance benefits, if any, are otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance. If action is instituted to collect this note or any portion thereof, the below named patient promises to pay all collection costs and additional sums as may be deemed responsible in said action; I, at this moment, authorize the doctor to release all information necessary to secure the payment of benefits.
SIGNATURE*

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Date

MonthDayYear
Date
Authorization for Release of Information

For Use or Treatment, Payment, or Health Care Operations
PATIENT NAME

First NameLast Name
PATIENT DOB

MonthDayYear
Date
I authorize the release or use of my individually identifiable health information (PHI "Protected Health Information") and medical record information by Celebration Obstetrics and Gynecology to carry out treatment, payment, or health care operations. I have reviewed the Celebration Obstetrics and Gynecology Notice of Privacy Practices to fully describe the potential release and use of such information. I understand that I have the right to review such notice before signing this consent form.

Celebration Obstetrics and Gynecology reserve the right to change the terms of the Notice of Privacy Practices at any time. If Celebration Obstetrics and Gynecology change the terms, you may obtain a copy of the revised notice.

You retain the right to request that we further restrict how your PHI is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we decide to your requested restriction(s), such conditions are binding on the practice.
I acknowledge and agree that the Practice may disclose my PHI and medical record information, confirm or change appointment times and speak to the office on my behalf with the following individuals who are my family members, legal representatives, guardians, healthcare surrogates, or have power of attorney to the individuals listed below:
DO YOU WANT TO NAME OR GIVE AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION TO ANY PERSON(S) ?*

YESNO
NAME

First NameLast Name
DOB

MonthDayYear
RELATIONSHIP TO PATIENT
NAME

First NameLast Name
DOB

MonthDayYear
RELATIONSHIP TO PATIENT
Florida State Law 384.25

I agree and have been given notice that the practice may also disclose the following types of information in my medical record to the appropriate authorities as Celebration Obstetrics and Gynecology is required by Florida State Law 384.25. (Please initial ALL categories below.)
HIV/AIDS INFORMATION*

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PLEASE INITIAL
MENTAL HEALTH INFORMATION*

Clear
PLEASE INITIAL
SUBSTANCE ABUSE INFORMATION*

Clear
PLEASE INITIAL
STI INFORMATION*

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PLEASE INITIAL
IF PATIENT IS UNDER THE AGE OF 18, PREGNANCY INFORMATION

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PLEASE INITIAL
Authorization To Contact
I understand that if the practice needs to contact me, it will be via the primary phone number listed in my file. I agree to keep this number updated at all times and understand that my demographics are my responsibility. I acknowledge that I can update my demographics through several sources. I can update them in the office directly, through a call to the phone center, or through my patient portal Should the Practice need to communicate with me and my phone is unavailable, after 3 attempts a certified letter will be sent through the mail. I elect for correspondence to be directed to me in the optional form of:
Email or Fax*

EmailFax
Email
example@example.com
Fax
At all times, you retain the right to revoke this consent. Such revocation must be submitted to the Practice in writing. The revocation shall be effective except to the extent that the Practice has already taken action based on the prior consent. The Practice may refuse to treat you if you (or an authorized representative) do not sign this consent form. If you (or an authorized representative) sign this consent and then revoke it, the Practice has the right to refuse to provide further treatment to you as of the time of revocation (except to the extent that the Practice is required by law to treat individuals I have read and understand the information in this consent. I have received a copy of this consent and I am the patient or the authorized party to act on the behalf of the Patient to sign this document verifying consent to the above terms.
SIGNATURE OF PATIENT OR AUTHORIZED REPRESENTATIVE*

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RELATIONSHIP TO PATIENT
BILLING AND FINANCIAL POLICY
If you have insurance, we will provide insurance claim filing for your primary insurance plan with which we participate; however, if we do not accept your insurance plan or if a claim is denied or a balance is due, you are responsible for payment of the balance owed. We expect payment within 30 days from the date we notify you of such determination. It is our policy that we do not take secondary insurance and do not file claims to secondary insurance. You are responsible for paying any co-pay, deductible, co-insurance, or any other balance not paid for by the insurance or third-party payer within 30 days. Please note all claims must be finalized before any refunds will be submitted for processing. Refund processing can take up to 30 days to issue. For Obstetrical patients, all claims, including delivery, must be finalized.

It is the responsibility of the patient/guardian to provide us with current insurance plan information before services are rendered for accurate billing of services to be filed. You are also responsible for contacting your insurance company to ensure we are in-network with your particular plan. It is your responsibility to know all the guidelines of your plan requirements regarding authorizations, deductibles, co-payments, and other vital requirements for all services.

It is the responsibility of the patient/guardian to obtain any referrals that the insurance company may require before the scheduled visit. Failure to do so will result in the need to reschedule your appointment, and a potential $50.00 late notice rescheduling fee may apply.

In consideration of services rendered, you agree to transfer and assign to Celebration Obstetrics and Gynecology all rights, title, and interest in any payment due to you or otherwise payable to you for services rendered.

Please initial in the space provided and sign your name acknowledging your consent and agreement.
INSURANCE*

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Initial
SELF PAY: In consideration of the services rendered, you agree to pay Celebration Obstetrics and Gynecology by the regular rates and terms of service/costs for Celebration Obstetrics and Gynecology. Unless prior arrangements have been made, payment is due in full when services are rendered. You affirm that you are duly authorized as the patient or a patient’s guardian/agent to execute this document and accept its terms.
SELF PAY*

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Initial
MEDICARE/MEDICAID: Patient’s certification authorization to release information and payment request. You certify the information given to Celebration Obstetrics & Gynecology in applying for payment under Title XVIII/XIX of the Social security act is correct. You authorize any holder of medical or other information about you to release to the Social Security Administration/Division of Family Services or its intermediaries or carriers any information needed for this or a related Medicare/Medicaid claim. You further certify all insurance proceeds pertaining to treatment or services provided shall be assigned to Celebration Obstetrics & Gynecology.
MEDICARE/MEDICAID*

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Initial
LABORATORY CHARGES: We collect and send specimens to a laboratory for processing. We are NOT responsible for laboratory charges. If you have any questions regarding the laboratory charges, you must call the laboratory listed on the bill.
LABORATORY CHARGES*

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Initial
OFFICE CHARGES AND POLICY

OB Contract: Any OB contract signed by the patient must be paid by the 28th week of pregnancy. Non-payment of the contracted amount may result in discharge from the practice for non-compliance with our financial policy.

Credit Cards: For your convenience, we will keep your credit card information on file to be used for balances on your account that are your responsibility (co-insurances, co-pays, deductibles), not to exceed $150.00. Your signature on this financial policy will be noted as a signature on file for all credit card transactions.

FMLA: There is a $25.00 fee for FMLA paperwork. This fee is due PRIOR to any paperwork being faxed or picked up. There is a $50.00 fee for expedited FMLA paperwork.

Returned Check Fee: A $25.00 fee will be assessed to your account for any returned checks

Cancellation/No Show Policy/Late: A $50.00 fee will be assessed to your account for “NO SHOW” if you fail to cancel or reschedule an appointment with at least 24-hour notice. A $200.00 fee will be charged for surgeries canceled less than 7 days prior to the surgery date. Patients who arrive late for their appointment will be rescheduled.
OFFICE CHARGES/POLICY*

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Initial
COLLECTION POLICY: You understand and agree that all accounts must be brought current within 30 days of the rendered service. After 30 days, a late fee charge of $25.00 per month will be assessed. After 60 days, the account will be turned over to collection agencies or an attorney for collection. Should this account be referred to an attorney for collection, you will be responsible for reasonable attorney’s fees, court costs, recording fees, and collection expenses.

You further agree that the exclusive venue for any collection action shall be in Osceola County, Florida. You authorize Celebration Obstetrics & Gynecology and, at this moment, give all of its affiliated entities, employees, agents, and Independent Contractors permission to call you through the use of dialing equipment, artificial voice, or similar technology even if you are charged for the call. You expressly agree that Celebration Obstetrics & Gynecology may make such automated calls and all of its affiliates, contractors, and agents. With such consent, you expressly waive any claim against Celebration Obstetrics & Gynecology, its affiliates, contractors, and agents for making such calls, including any claim under the Telephone Consumer Protection Act.

You also expressly agree that this provision applies to text messaging. You authorize Celebration Obstetrics & Gynecology, its affiliates, contractors, and agents to use any cell phone or other telephone number to contact you for any purpose, including a collection of an outstanding invoice at the number set forth below. If you have a change in address or telephone number, it is your responsibility to provide Celebration Obstetrics & Gynecology with your updated contact information.
COLLECTION*

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Initial
PATIENT/GUARDIAN PRINTED NAME*
SIGNATURE*

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Date

MonthDayYear
Date
PATIENT NAME

First NameLast Name
HIPAA

Health Insurance Privacy and Portability Act
PATIENT NAME*

First NameLast Name
PATIENT DOB*

MonthDayYear
Date
The privacy of your medical information is important to us. We understand that your medical information is personal, and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and comply with specific legal requirements. This notice will tell you about how we may use and share medical information about you. We also describe your rights and particular duties we have regarding the use and disclosure of medical information.
OUR LEGAL DUTY

We Have the Right To:
1. Keep your medical information private.
2. Give you this notice describing your legal duties, privacy practices, and your rights regarding your medical information.
3. Follow the terms of the notice that is now in effect.
We Have the Right To:
1. Change our privacy practices and the terms of this notice at any time, providing that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.
SIGNATURE*

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Acknowledgment Form
Our notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy from our front desk staff.

You have the right to request that we restrict how protected health information about you is used or released for treatment, payment, or health care operations. We are not required to agree to this restriction, but our agreement binds us if we do.

By signing this form, you consent to our use and release of protected health information about you for treatment, payment, and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made releases in reliance on your prior consent.
PATIENT/GUARDIAN SIGNATURE*

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PATIENT NAME

First NameLast Name
Should be Empty:

New Patient Intake

Patient Contact Information

Spouse/Partner Or Guardian Information

Emergency Contact Information

Primary Insurance Information

Authorization for Release of Information

Florida State Law 384.25

Authorization To Contact

BILLING AND FINANCIAL POLICY

HIPAA

Acknowledgment Form