New Patient Form | McDowell Mountain Gynecology in Scottsdale, AZ

First Name

Last Name

Mobile Phone Number

Date of Birth

Email Address

Emergency Contact Name / Number / Relationship

Marital Status

Referring Physician / PCP

Phone / Fax

Pharmacy # / Location

Disclaimer

I UNDERSTAND that it is the policy of McDowell Mountain Gynecology to Deliver all test results via the patient portal system. I also understand that it is my responsibility to check the portal for any and all test results. I further understand that if I do not receive my test results via the portal and have not been notified of the results in any other manner it is ultimately my responsibility to contact McDowell Mountain to inquire of the results.

INSURANCE DISCLAIMER As a courtesy, we will submit your claim for all services to your insurance company. Please remember your individual health insurance policy is a contract between you and your insurance company, we are not part of that contract. Be aware that some of our services may not be covered by your insurance policy. By presenting for care, you agree that you are responsible for all services and charges, regardless of your insurance; we will not alter your claim, change diagnosis or report a different eservice than what was performed in order to have your insurance cover the charges. It is your responsibility to know your insurance policy. You will be held responsible for all charges.

CONSENT FOR TREATMENT/INSURANCE AUTHROIZATION AND ASSIGNMENT I or my representative, recognizing the need for care, consent to call and any services deemed necessary and ordered by my physician, including bit not limited to, laboratory testing, medical and or surgical treatment examination and other services rendered under the specific instructions of my physician. I authorize and request that payments under my medical insurance programs be made directly to Rachel L Spieldoch, M.D. PLLC, for any services provided for me, understanding there is clear legal documentation of the treatment/visit. I also authorize the provider to release any information needed for payment of claims and further permit copies of this authorization to be used in the place of the original.

Responsible Party

Date

Print Name

HIPAA CONSENT FOR PAYMENTS

INITIAL - This is a patient consent for records release for disclosure of protected health information with credit card, debit card and financial disclosure disputes. All services rendered by McDowell Mountain Gynecology are billable and due upon service unless contractually agreed upon otherwise. Once treatment is received this is NON-REFUNDABLE. Services performed that are paid with a credit card, debit card, check or financing third party is not eligible for challenges after the service has been provided. There is Document, legal proof of every service provided. By signing this form, I am irrevocably consenting to allow McDowell Mountain Gynecology and all of its affiliates to use and disclose my protected health information to any financial entity (credit card, debit card, bank of financing) if they request such proof to assist in the processing of the payment.

I agree to the statement above and I WILL NOT challenge, credit, debit or financing payments once services are provided. I understand that by consensually receiving I am bound to this payment.

I DO NOT AGREE and will pay for services rendered each time with a cashiers check, money order or cash. I understand that the amount due for such services will be required to be paid in full before each service is rendered.

Name

Signature

Date

NOTICE OF PRIVACY PRACTICES AND PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I UNDERSTAND that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.

I UNDERSTAND that McDowell Mountain Gynecology may use or disclose my protected health information for treatment, payment or health care operations – which means for providing health care to me, the patient; and taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information.

INITIAL - McDowell Mountain Gynecology has a detailed document called the “Notice of Privacy Practices”. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information. I UNDERSTAND that I have the right to read the “Notice” before signing this agreement. If I ask, McDowell Mountain Gynecology will provide me with the most current Notice of Privacy Practices. My signature below indicates that I have been given that chance to review the Notice of Privacy Practices. My signature means that I agree to allow McDowell Mountain Gynecology to use and disclose my protected health information to carry out treatment, payment and heath care operations. I have the right revoke this consent in writing at any time; accept to the extent that McDowell Mountain has taken action relying on this consent.

Date

Relationship if signed by another party:

INFORMED CONSENT FOR TELEMEDICINE SERVICES

Signature

Date

PATIENT NOTICE OF FINANCIAL POLICY

Fees and Charges

I acknowledge a credit card reversal (chargeback) will be subject to a $35.00 fee

I acknowledge a returned check fee will be a minimum of $35.00.

I acknowledge that there is a $35.00 fee for completing all FMLA paperwork.

I acknowledge there is a $50 administrative and copy fee for obtaining your medical records for your personal use. If your medical records are in storage there will be an additional $25.00 fee.

I acknowledge there is a 24 hour notice required for cancellation of appointments. Missed appointments and appointments not cancelled within 24 hours will be subject to a $70 fee to be paid prior to your next visit.

I acknowledge there is a 48 hour notice required if you are unable to keep ULTRASOUND, PROCEDURAL or URODYNAMIC appointments. These will be subject to a $100.00 fee.

I acknowledge that there are products and services provided by McDowell Mountain Gynecology that are not covered by insurance and are on a cash pay basis. I am fully responsible when I agree to these services.

I have read the financial policy for the office and understand that I am ultimately responsible for all charges on my account. It is my financial responsibility to remit payment for any charges not covered by my insurance plan including but not limited to co-insurance, co-payments and deductibles. I understand that co-payments for the office are due at the time of service. I understand that refunds are only given if no account balance is due on my account and when my claims have been completely adjudicated. Furthermore, I understand once it has been determined a refund is due; it may take a minimum of 6 weeks. I understand that obtaining services immediately prior to bankruptcy is considered fraud. I understand that once my account is put into collections I will be responsible for any additional charges to collect any and all unpaid balances, including but not limited to collection agency and attorney fees. I understand that if I refuse to pay my bill, a collection fee of 30% of the amount due will be charged to my account.

Patient Initials

Date

Home | Patient Information | Medical Form

Please complete the following form and submit it when done

PHONE NUMBER & Fax

480-483-9011

480-483-2803

EMAIL ADDRESS

mmgynecology@gmail.com

OUR LOCATION