Basin Clinic & Basin Clinic Urgent Care Center
Patient Name: Chief Complaint/Reason For Visit: Date of Birth: S.S.#: Responsible Party S.S.#: Address: City: State: Zip: Home Phone: Work Phone: Guardian (if patient is under 18): Emergency Contact: Phone: Primary Insurance:
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Dr. Name: Patient Signature:__________________________________
In accordance with the Federal Truth-In-Lending Act, all doctors are required to give their patients complete information in connection with the extension of credit.
Basin Clinic Policy: The patient is responsible for all medical bills. Our staff will help with completion of insurance forms. It is the patient’s responsibility to know their contract benefits, assure collection of insurance payments to us and negotiate with your insurance company over disputed claims.
If You Don’t Have Insurance: Our policy requires payment in full at the time of service. We offer a 25% cash discount when paid in full at the time of service. If you cannot make complete payment we require that you make payment arrangements with the receptionist prior to service and make a $100 partial payment on the day service is rendered.
If You Have Insurance: We will be glad to bill your insurance for you as long as we have correct insurance information. We require a one time $50 deposit for new patients with insurance in case the visit is applied to your yearly deductible. We require you as a patient to be responsible for any balance your insurance does not pay. Any balance over 30 days is your responsibility. If we are a provider for your insurance, be aware that if the patient needs to be referred to another doctor or hospital, that provider may not be a preferred provider for your insurance and the patient/policy holder will be responsible for any amount not paid by their insurance to that non-preferred provider.
Forms of Payment: We accept payment in cash, check, money order, Visa, MasterCard, American Express or Discover. There will be a $30.00 charge on all returned checks.
Delinquent Accounts: Those accounts not paid within 90 days will be turned over to collections or taken to small claims court. We reserve the right to add late charges for delinquent accounts. Should collection be necessary, the responsible party agrees to pay and additional 33% collection fee charged by the collection service and all legal fees of collection, with or without suit, including attorney fees and court costs. We will no longer provide medical care once an account has gone to collection.
Monthly Statements: You will receive an itemized monthly statement until your bill is paid in full whether you have insurance or not. Interest of 1.5% per month will be applied to any amount over 30 days if a payment has been received.
To the extent necessary to determine liability for payment and to obtain reimbursement for this account, I authorize disclosure of portions of the patients record. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, and other health plans to Rodney S. Anderson, M.D.; Karl L. Breitenbach, M.D.; Laura B. Arnold, M.D.; Kirk J. Woodward, M.D.; Mike Olsen, M.D.; Amy Olsen, FNP; Aaron Fausett, PA-C; Scott Frisby, PA-C; Michael Wilson, PA-C and Carolyn Henry, LCSW. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as the original. I understand that I am financially responsible for all charges incurred.
I certify that the above information is accurate to the best of my knowledge. I have read and agree to the Financial Policy of this office.
Signature___________________________________Date___________________
DATE_____________________
NAME____________________________________________________ PATIENT SSN#_____________________________________________
FATHER OF BABY NEWBORN’S PHYSICIAN REFERRED BY
BIRTHDATE: AGE: RACE: MARITAL STATUS: S M D W SEP
MAILING ADDRESS:
OCCUPATION: (Homemaker, student, etc..) EDUCATION: (Last grade completed)
PHONE: (Daytime) (Evening)
INSURANCE CARRIER/MEDICADE #
EMERGENCY CONTACT: RELATIONSHIP: PHONE:
TOTAL PREG
FULL TERM
PREMATURE
ABORTIONS: INDUCED SPON.
ECTOPICS
MULTIPLE BIRTHS
LIVING
MENSTRUAL HISTORY
LMP: Definite Approx. Unknown NORMAL AMOUND/DURATION
MENSES MONTHLY: YES NO FREQUENCY: DAYS MENARCHE: (AGE ONSET) ON BCPS AT CONCEPT. YES NO Hcg +
PAST PREGNANCIES (LAST SIX)
DATE MO/YR
SEX M/F
GA WEEKS
LENGTH OF LABOR
BIRTH WEIGHT
TYPE DELIVERY
ANES.
PLACE OF DELIVERY
PERINATAL MORTALITY YES/NO
TREATMENT PRETERM LABOR YES/NO
COMMENTS / COMPLICATIONS
M F
Yes No
PAST MEDICAL HISTORY
0 NEG + POS
DETAIL POSITIVE REMARKS
INCLUDE DATE & TREATMENT
1. DIABETES
0 +
16. Rh SENSITIZED
2. HYPERTENSION
17. TUBERCULOSIS
3. HEART DISEASE
18. ASTHMA
4. RHEUMATIC FEVER
19. ALLERGIES (DRUGS)
5. MITRAL VALVE PROLAPSE
20. GYN SURGERY
6. KIDNEY DISEASE/UTI
7. NEUROLOGIC/EPILEPSY
21. OPERATIONS / HOSPITALIZATIONS (YEAR & REASONS)
8. PHYCHIATRIC
9. HEPATITIS/LIVER DISEASE
10. VARICOSEITIES/PHLEBITIS
22. ANESTHETIC COMPLICATIONS
11. THYROID DISFUNCTION
23. HISTORY OF ABNORMAL PAP
12. MAJOR ACCIDENTS
24. UTERINE ANOMALY
13. HISTORY OF BLOOD TRANSFUS.
25. INFERTILITY
AMT/DAY PREPREG
AMT/DAY PREG
# YRS USE
14. TOBACCO
26. STREET DRUGS
15. ALCOHOL
27. OTHER
COMMENTS:
GENETICS SCREENING
INCLUDES PATIENT, BABY’S FATHER, OR ANYONE IN EITHER FAMILY WITH:
YES / NO
1 PATIENT’S AGE > 35 YEARS
10 HUNTINGTON CHOREA
2 THALASSEMIA
11 MENTAL RETARDATION
3 NEURAL TUBE DEFECT (MENINGOMYELOCELE, OPEN SPINE, OR ANENCEPHALY)
IF YES, WAS PERSON TESTED FOR FRAGILE X?
4 DOWN SYNDROME
12 OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER
5 TAY-SACHS {EG. JEWISH BACKGROUND}
13. PATIENT OR BABY’S FATHER HAD A CHILD WITH BIRTH DEFECTS NOT LISTED ABOVE
6 SICKLE CELL DISEASE OR TRAIT
14. > FIRST-TRIMESTER SPONTANEOUS ABORTIONS OR A STILLBIRTH
7 HEMOPHILIA
15 MEDICATIONS OR STREET DRUGS SINCE LAST MENSTRUAL PERIOD
8 MUSCULAR DYSTROPHY
IF YES, AGENT(S)
9 CYSTIC FIBROSIS
16 OTHER SIGNIFICANT FAMILY HISTORY (SEE COMMENTS)
INFECTION HISTORY
4 PATIENT OR PARTNER HAVE HISTORY OR GENITAL HERPES
1 HIGH RISK AIDS
5 RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD
2 HIGH RISK HEPATITIS B
6 HISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILIS
3 LIVE WITH SOMEONE WITH TB OR EXPOSED TO TB
7 OTHER (SEE COMMENTS)
COMMENTS: INTERVIEWER’S SIGNATURE________________________________________
INITIAL PHYSICAL EXAMINATION
DATE PREPREGNANCY WEIGHT HEIGHT BP
1. HEENT NORMAL ABNORMAL
12. VULVA NORMAL CONDYLOMA LESIONS
2. FUNDI NORMAL ABNORMAL
13. VAGINA NORMAL INFLAMMATION DISCHARGE
3. TEETH NORMAL ABNORMAL
14. CERVIX NORMAL INFLAMMATION LESIONS
4. THYROID NORMAL ABNORMAL
15. UTERUS NORMAL ABNORMAL FIBROIDS
5. BREASTS NORMAL ABNORMAL
16. ADNEXA NORMAL MASS
6. LUNGS NORMAL ABNORMAL
17. RECTUM NOMRAL ABNORMAL
7. HEART NORMAL ABNORMAL
18. DIAGONAL CONJUGATE REACHED NO CM
8. ABDOMEN NORMAL ABNORMAL
19. SPINES AVERAGE PROMINENT BLUNT
9. EXTREMITIES NORMAL ABNORMAL
20. SACRUM CONCAVE STRAIGHT ANTERIOR
10. SKIN NORMAL ABNORMAL
21. ARCH NORMAL WIDE NARROW
11. LYMPH NODES NORMAL ABNORMAL
22. GYNECOID PELVIC TYPE YES NO
COMMENTS: (Number and explain abnormals): Exam by________________________________
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