New Patient Form

Please enter "N/A" if a certain field is applicable.
All fields are required.


Basic Information

Your Name
Date of Birth
Age
Address
Email
Cell Phone
Home Phone
Work Phone
SSN
Employer
Choose one:


Emergency Contact

Emergency Contact Name
Relationship
Address
Phone Number


Guarantor

Whose Insurance is it Under?

Same as Patient

OR

Name
Date of Birth
SSN
Phone
Address
Employer
Work Phone


Policies

There are a few policies that you must be aware of regarding making and keeping appointments. These policies have been developed to respect the time of you, the patient, as well as the provider. These policies are industry standard, and merely reflect appropriate behavior and etiquette on the patient’s part. Failure to apply these policies causes either inefficiency of the office, which causes long wait times for patients, or non-productivity for the provider, which is economically not acceptable for a small practice.

  1. If you call and make an appointment and do not show up for that appointment without 24 hours notice, you will be billed for the appointment. You will be financially responsible for the bill. Please initial that you have read and understand the policy:
  2. If you have a scheduled appointment, and show up 15 minutes or more after your scheduled time, you may not be able to be seen at your appointment time. You may be asked to wait until you can be worked in, or you will be asked to come back on a different day. Please initial that you have read and understand the policy:


Current Medicine and Symptons

List the medication you currently take:
List any other doctors you are seeing and why:
List any drug allergies:
Do you smoke cigarettes?
For how long?
How many packs a day?
Check anything that you, yourself, have had in the past or are having currently:

How often do you get your period?
Have you ever used:
How many pregnancies have you ever had?
How many full term babies?
How many preterm babies?
How many miscarriages or abortions?
Have you ever had an abnormal Pap Smear?
If yes, when and what was done?
When was your last Pap Smear?
Do you take any of the following? Vitamins Calcium Iron


Medical History Synopsis

List any surgeries that you have had and when they were done.
Do you still have a:
Uterus? Ovaries? Appendix? Tonsils?
Have you had your tubes tied?
C-Section:
Vaginal Birth:
Are you:
Highest Education Level:
Do you work?
Where and what do you do there?
How much and how often do you drink alcohol?
Do you exercise?
How often?
Do you want to lose weight?
Do you take any street drugs or other people’s pain medications?
What do you do for fun?
Has anyone ever hurt you physically or sexually?
When was that?
Did you recieve conseling for that?

Would you like to?
Select who has any of the following health problems.
Please select all that apply.
Mom Dad Sibling Mom's Mom Mom's Dad Dad's Mom Dad's Dad Other
Heart Attack
Cancer
Stroke
High Blood Pressure
Diabetes
Depression
Alcohol or Drug Problems


Consent to treat/ authorization to realease information/ assignment of benefits

I, on this day , duly consent to the following conditions below while under the care of Darien Women’s Clinic, in an effort to facilitate proper coordination of care, assessment, diagnosis, collaboration and referral for medical services.

CONSENT FOR MEDICAL TREATMENT

I/we voluntarily consent to medical treatment and diagnostic procedures provided by Darien Women’s Health and associated physicians, clinicians and other personnel. I/we consent to the testing for infectious diseases, such as, but not limited to syphilis, AIDS, hepatitis and testing for drugs if deemed advisable by the provider.
Date
Signature

AUTHORIZATION FOR RELEASE OF INFORMATION

The practice providers and physicians are authorized to release any medical information required in the processing of applications or submission of information for financial coverage or further medical treatment. This includes information referring to psychiatric care, sexual assault or tests for infectious diseases including AIDS/HIV and for services provided during this visit. I/we also agree to the release of medical or other information about me to government federal or state regulatory agencies as required by law.
Date
Signature

ASSIGNMENT OF INSURANCE BENEFITS

I/we guarantee payment of all charges made for or on account of the patient and I/we assign our rights in any insurance benefits or other funding to the providers of Darien Women’s Health.. I/we understand that I/we am/are responsible for any charges not covered by insurance or other forms of benefits. For Medicare beneficiaries: I/we have provided all necessary information for proper assignment of Medicare benefits.
Date
Signature

WORKER’S COMPENSATION Patient record release and authorization:

Worker’s Compensation law provides that written information which pertains directly to a workers’ compensation claim must be provided by a healthcare facility/physician to the insurance carrier, the employer, the employee, their attorneys, or the applicable State Workers’ Compensation Commission . I authorize Darien Women’s Health to provide copies of my medical records or to speak to duly authorized representatives of any of the above regarding my medical records, medical treatment, or condition.
Date
Signature

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I/we have received a copy of the Notice of Privacy Practices.
Date and Time
Signature of Patient/ Legal Guardian



HIPAA Statement of Information and Privacy Practices

How We Collect Information About You:
Daren Women’s Health and Darien Primary Care Inc and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of applications that is either required by law, or necessary to process applications or other requests for assistance through our organization.

What We Do Not Do With Your Information:
Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached to applications, or directly or indirectly given to us, is held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered patient confidential, is restricted by law, or has been specifically restricted by a patient/client in a signed HIPAA consent form.

How We Do Use Your Information:
Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between Darien Women’s Health / Darien Primary Care Inc, and other health care providers, including but not limited to other physicians, nurses, medical product or service providers, pharmacies, and insurance companies. If you apply or attempt to apply to receive assistance through us and provide information with the intent or purpose of fraud or that results in either an actual crime of fraud for any reason including willful or un-willful acts of negligence whether intended or not, or in any way demonstrates or indicates attempted fraud, your non-medical information can be given to legal authorities including police, investigators, courts, and/or attorneys or other legal professionals, as well as any other information as permitted by law.

Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources:
Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of Darien Women’s Health or Darien Primary Care Inc. We reserve the right to use non-identifying information about our clients (those who receive services or goods from or through us) for fundraising and promotional purposes that are directly related to our mission. Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client’s express advance permission. You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy.

I have received this information and have also signed an acknowledgement of having received and agreed to such policy.

Signature of PatientDate