New Patient Packet

 

Do you have Healthcare Insurance?  
Yes     No

May we give out any medical/financial information to anyone other than yourself, your treating physician or insurance company?  
Yes     No

ePrescribing allows physicians to electronically send an accurate, error free and understandable prescription directly to a pharmacy. Benefits are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBM’s are third party administrators of prescription drug programs who provide medication history and maintain formularies, or lists of drugs covered by a particular drug benefit plan. Having this information allows your provider to help you find the most beneficial and cost-effective treatments while improving your overall care.

By signing this consent form at the bottom of the page, you are agreeing that Mid-Kansas Woman’s Health can request and use your prescription medication history from other health care providers and/or third party benefit payers for treatment purposes.

I hereby acknowledge that I have received a copy of this clinic’s Notice of Privacy Practices. I understand my signature requests that payment be made to the provider and authorizes release of medical information necessary to pay the claim. A photocopy of the authorization and assignment shall be considered as valid as the original. If item 12 of CMS-1500 claim form is completed, my signature authorizes release of the information to the insurer or agency shown above in Medicare/Other Insurance Company assigned cases. Co-pay must be paid at time of service. Please let us know if you need more information.

Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

Patient History Form

 

Please check any that may apply  

Age or Year
  Adenoids
  Appendectomy/Appendix
  Breast Augmentation
  Breast Reduction
  Cataracts
  Cardiac Surgery

  Cesarean Section
  Colonoscopy
  Cervical Cone Biopsy
  Cervical Cryo
  Cervical Laser
  Cervical LEEP
  Cytoscopy
  D&C
  Endometrial Ablation

Age or Year
  Gallbladder Removal
  Hip Replacement   R   L  
  Hysteroscopy
  Hysterectomy
Abdominal
Vaginal
Laparoscopic
Robotic
  Knee Replacement   R   L  
  Laparoscopy
  Laparotomy
  Mastectomy   R   L  
  Ovaries Removed   R   L  
  Tonsillectomy
  Tubal Ligation
  Wisdom Tooth Extraction

Other  

Please fill out for each pregnancy even if it was a miscarriage or abortion.

If you have had a tubal ligation, hysterectomy, or are over the age of 50, only date and type of delivery are necessary.
 

Type  
Abortion    
C-Section    
Miscarriage    
Vaginal Delivery  

Gestational Age    

Baby Weight    

Sex  
M     F     

   Add another pregnancy?

---

Please check if anyone in your immediate family has been diagnosed or treated for the following:
 

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

Mother   Father   Sister   Brother   Mat. GM   Mat. GF   Pat. GM   Pat. GF  

How often per week do you exercise?    
Daily    
Times per Week  
Occasionally    
Rarely    
Never

Tobacco Use (current or previous)  
Yes     No

Alcohol Use (current or previous)  
Yes     No

Illicit Drug Use (current or previous)  
Yes     No

Sexual Preference  
Heterosexual (Straight)    
Homosexual (Gay)    
Bisexual

Current Gender Identity  
Male    
Female    
Transgendered Male    
Transgendered Female    
Non-Binary

History of  
Physical Abuse
Sexual Abuse

Do you have
monthly periods?    
Yes    
No

Bleeding
between periods?    
Yes    
No

Do you use more
than 2 pads per hour?     
Yes    
No

Do you have     
cramping?  
Yes    
No

Bleeding after
intercourse?     
Yes    
No

Results  
Normal    
Abnormal     

Results  
Normal    
Abnormal

Breast Biopsy?  
Yes    
No

Results  
Normal    
Abnormal     

Results  
Normal    
Abnormal

Hepatitis A    
Yes    
No

Hepatitis B    
Yes    
No

Zostovax    
Yes    
No

Gardisil (HPV)    
Yes    
No

Tetanus (within last 5 years)    
Yes    
No

Varicella (Chicken Pox)    
Yes    
No

Pneumovax:    
Yes    
No

Influenza (Flu)    
Yes    
No

Add another?

Add another?

Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

Informed Consent

 

Mid-Kansas Women’s Center is committed to providing you with the best possible care and your understanding of our policies and procedures is important to our professional relationship. Please feel free to ask if you have any questions about our fees, our policies or your responsibilities. We request that you carefully review the following information and return this form to us with your signature and today’s date.

Insurance
We will file your insurance claims; however, we will not become involved in disputes between you and your insurance carrier. You are responsible for the timely payment of your account. Your responsibility may include but is not necessarily limited to, deductibles, co-payments, co-insurance, and non-covered charges. Co-payments are due at the time you check in at the front desk and PRIOR to being seen. This requirement is part of the contract you have with your insurance carrier.

Please bring your current insurance card to each appointment. We reserve the right to reschedule appointments if proof of insurance cannot be furnished at the time of the appointment. Medicaid, and KanCare patients must notify us of their coverage within the month they first become eligible. We are permitted by those programs to charge you directly for services if your card is presented late.

Payment Options
We accept cash, checks or any of the following credit cards for payment: Visa, Master Card and Discover. If your insurance company does not pay the full balance, you will be sent a statement notifying you of any amount due from you. If you cannot pay the balance in full, please contact our billing department to make payment arrangement. Special financing is also offered through CareCredit for those patients who qualify. While we are willing to work with you regarding outstanding balances, it is necessary that you remain in contact with us. Delinquent accounts may be turned to a collection agency.

Payment Requirements for Surgery
When setting up your surgery, we will contact your insurance company to evaluate your estimated out-of-pocket expenses. We require a 50% payment prior to surgery. The remaining balance is due at the time you receive a statement.

Payment Requirements for Obstetrical Care
During your first appointment with our office, you will be scheduled to meet with one of our billing staff. We will contact your insurance company to evaluate your estimated out-of-pocket expenses. Various payment arrangements are available and will be discussed with you in detail. However, please know that our policy is that payments should be made regularly during the course of the pregnancy and payment in full is required prior to your delivery.

Returned checks
The charge for a returned check is $30.00 payable in cash or money order. This amount will be applied to your account in addition to the insufficient fund amount. You may be placed on a “Cash Only” basis following any returned check.

Appointment times
Although we endeavor at all times to maintain on time appointments, our doctors are often called to the hospital during the day for deliveries. This may require a delay in your appointment time or you may be given the option of seeing one of our other providers. We appreciate your understanding and patience during these times and request that you allow time in your schedule for possible delays in your appointment time.

Cancellations
A specified amount of time is reserved for each patient and certain costs are incurred by the practice in preparation for the appointment. If you are unable to keep your appointment, please call our office so your appointment time can be released to someone on our waiting list. Although we appreciate a twentyfour (24) hour notice, we will accept a cancellation up to two hours prior to the appointment. We reserve the right to impose a charge of $35.00 for patients who miss appointments without calling to cancel.

Laboratory
Mid-Kansas Women’s Center utilizes LabCorp for all laboratory testing.

Referrals
If a referral form is required, it is the patient’s responsibility to obtain this form from the primary care physician PRIOR to any appointment. Failure to obtain a referral form may result in a reduction of benefits or may require that your appointment be rescheduled.

Minors
The parent(s) or guardian(s) of a minor is responsible for full payment of all services provided to the minor and will receive a billing statement for any balances not covered by insurance. A signed release to treat may be required for unaccompanied minors.

Personal Items
Personal items are the responsibility of the patient and we encourage you to keep your personal items with you during your office visit(s). Food and beverages are not permitted in the waiting room or patient treatment areas.

To insure that proper attention can be focused on our patients, we encourage you to bring no more than one child between the ages of two and six to your appointment. Infants and well behaved older children are welcome.

Financial Responsibility
I agree to pay Mid-Kansas Women’s Center any and all charges for services rendered. I understand that regardless of any assigned insurance benefits, I am responsible for paying the total charges for all services rendered.

Signature of Patient – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

Signature of Responsible Party (if different from patient) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

Cancer Family History Questionnaire

 

Instructions: Your personal family history of cancer is important to provide you with the best care possible. Please complete the chart below based upon your personal and family history of cancer. Leave blank what you do not know. The following relatives should be considered: Parents, siblings, half-siblings, children, grandparents, grandchildren, aunts, uncles, nieces and nephews on both sides of the family.

Breast, ovarian, or pancreatic cancer at any age     
Yes     No

Colorectal or uterine cancer at 64 or younger     
Yes     No

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No    

Yes     No