28 Feb patient_profile Posted at 20:18h in by prescriptionpr 0 Comments 0 Likes My Patient Profile Patient InformationPatient First Name*Patient Last Name*Date of Birth*Address*Apartment #City, State, Zip*Phone: xxx-xxx-xxxx*Cell: xxx-xxx-xxxxEmail address*Marital Status:Please selectMarriedSingleDivorcedWidowedSeparated OtherEthnicity:Please selectNoneHispanic Or LatinoNon Hispanic Or LatinoOther Or UndeterminedRace:Please selectAmerican Indian Or Alaska NativeAsian/OrientalBlack Or African AmericanNative American Or Pacific IslanderWhite/CaucasianUndeterminedPatient EmploymentEmployment Status:Please selectEmployeedRetiredUnemployedOtherEmployerPhone: xxx-xxx-xxxxSpouse/PartnerSpouse's NameCell: xxx-xxx-xxxxWho Referred You to Our PracticeReferrer NameRelationshipEmergency ContactSame as SpouseNameRelationshipPhone: xxx-xxx-xxxxVisit InformationDoctor's Name:Please selectMarci Ostroff, MDMarni Sanders, MDChristine J. Duncan, MDNicole A. Bell, MDNicole R. Smizer, MDEsther Hirschhorn, MDAmy Newman, NPReason for Visit:*Please selectPreventativeProblemDateTimePrimary InsuranceSame as PatientPolicy Holder*Insurance Co.*Relationship to Patient:*Please selectSelfSpouseChildOtherIns. Card ID#*DOB of insured*Secondary InsurancePolicy HolderPolicy Holder PhoneInsurance Co.Relationship to PatientIns. Card ID#DOB of insuredPharmacyPharmacy Name*Address*Phone: xxx-xxx-xxxxFax: xxx-xxx-xxxxPerson Responsible for BillingSame as PatientNameAddressCity, State, ZipYOU MUST PRESENT A VALID CURRENT INSURANCE CARD & VALID PHOTO ID AT TIME OF APPOINTMENT. YOUR COPAY IS DUE AT CHECK IN.Assignment of BenefitsMedicare Patients - I request that payment of authorized Medicare benefits be made to WOMEN FOR WOMEN OBSTETRICS AND GYNECOLOGY for any services furnished to me by Marci Ostroff, M.D., Christine Duncan, M.D., Marni Sanders, M.D., Nicole A. Bell, M.D., Nicole R. Smizer M.D., Esther Hirshhorn, M.D., Amy B. Newman, CNM, WHNP. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any and all information needed to determine benefits or benefits payable for related services. I certify that the information given by me to WOMEN FOR WOMEN OBSTETRICS AND GYNECOLOGY, in applying for payment under the Medicare program, is correct and complete. I authorize the release of all records required to act on this release. This assignment will remain in effect until revoked by me or amended on the HIPAA form provided to me. I understand that I may be held responsible for any balance due for services that Medicare may consider not covered. For services that require specific guidelines from Medicare, an ABN must be provided to me to sign. I understand that interest and collection fees may apply if the account becomes delinquent.Non-Medicare Patients - I hereby assign to WOMEN FOR WOMEN OBSTETRICS AND GYNECOLOGY any and all benefits from my insurance plan or any other protection maintained by the patient and/or on the Patient's behalf or benefit, and authorize and direct such benefits to be paid directly to WOMEN FOR WOMEN OBSTETRICS AND GYNECOLOGY or Marci Ostroff, M.D., Christine Duncan, M.D., Marni Sanders, M.D., Nicole A. Bell M.D., Nicole R. Smizer M.D., Esther Hirshhorn, M.D., Amy B. Newman, CNM, WHNP. for services provided to the patient by the listed providers. I certify that the information given by me to these providers for payment under any Insurance plan, Managed Care or any other payment protection is correct and complete. I authorize the release of all records required to act on this release. This assignment will remain in effect until revoked by me or amended on the HIPAA form provided to me. I understand that I may be held responsible for any balance due for services that my insurance plan may consider not covered. I understand that interest and collection fees may apply if the account becomes delinquent.: By checking this box you attest that the information above is correct and accurate.SubmitThis field should be left blank
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