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Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Address*

Apartment #

City, State, Zip*

Phone: xxx-xxx-xxxx*

Cell: xxx-xxx-xxxx

Email address*

Marital Status:

Ethnicity:

Race:

Patient Employment

Employment Status:

Employer

Phone: xxx-xxx-xxxx

Spouse/Partner

Spouse's Name

Cell: xxx-xxx-xxxx

Who Referred You to Our Practice

Referrer Name

Relationship

Emergency Contact

Same as Spouse

Name

Relationship

Phone: xxx-xxx-xxxx

Visit Information

Doctor's Name:

Reason for Visit:*

Date

Time

Primary Insurance

Same as Patient

Policy Holder*

Insurance Co.*

Relationship to Patient:*

Ins. Card ID#*

DOB of insured*

Secondary Insurance

Policy Holder

Policy Holder Phone

Insurance Co.

Relationship to Patient

Ins. Card ID#

DOB of insured

Pharmacy

Pharmacy Name*

Address*

Phone: xxx-xxx-xxxx

Fax: xxx-xxx-xxxx

Person Responsible for Billing

Same as Patient

Name

Address

City, State, Zip

YOU MUST PRESENT A VALID CURRENT INSURANCE CARD & VALID PHOTO ID AT TIME OF APPOINTMENT. YOUR COPAY IS DUE AT CHECK IN.

Assignment of Benefits

Medicare 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.

My Patient Profile

Patient Information

Patient Employment

Spouse/Partner

Who Referred You to Our Practice

Emergency Contact

Visit Information

Primary Insurance

Secondary Insurance

Pharmacy

Person Responsible for Billing

Assignment of Benefits