Online Appointment Scheduling

Are you ready to schedule an appointment?

CONTACT US TODAY

Prepare For Your Appointment

Please read the below information and fill out the forms to bring for your 1st appointment.

Whether you are self-referred to our office or are coming based on the recommendation of your provider, it is important that you bring copies of your medical records pertaining to your previous evaluation and treatments. You should call your doctor’s office prior to your appointment and ask to have your records be sent to us and have a copy of these records for your personal medical file to bring to your appointment. Before your initial evaluation, you will be asked to complete our New Patient Form, which is available to download on this page in english or spanish. Advanced completion our forms will allow us to better serve you.

NEW PATIENT FORMS - ENGLISH

Today’s Date

PCP

Patient Name *

First

Middle

Last

Is this your legal name?

Former name *

First

Last

Birth date

Age

Sex

Complete Address

Address Line 1

City

State

Social Security No.

Home Phone No.

Cell Phone No.

Pharmacy

Pharmacy Major Cross Streets

Pharmacy Phone Number

Email *

INSURANCE INFORMATION

(Please provide your insurance card to the receptionist.)

Person Responsible For Bill

Date Of Birth

Address (if different)

Address Line 1

City

State

Home Phone No.

Is this person a patient here?

Is this patient covered by insurance?

Occupation

Employer

Employer Address

Address Line 1

City

State

Employer Phone No

Please Indicate Primary Insurance

Other: [Other insurance]

Subscriber’s name

Subscriber’s S.S. No.

Birth Date

Group No.

Policy No.

Co-payment

Patient’s Relationship To Subscriber

Other

Name of Secondary Insurance (if applicable)

Subscriber’s name:

First

Last

Group No.

Policy No

Patient’s Relationship To Subscriber

Other

IN CASE OF EMERGENCY

Name of Friend Or Relative *

First

Last

Relationship To Patient

Home Phone No.

Work Phone No.

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Blessings OB/GYN and women’s health or insurance company to release any information required to process my claims.

Patient/Guardian signature

Date

HIPPA AUTHORIZATION FORM

Patient’s Full Name

First

Last

Patient Social Security Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Patient’s Date of Birth

Patient’s Telephone Number

I authorize the following person (s):

To receive the following health information regarding my care (please select):

All medical information
Billing related information
My health information related to the following treatment or condition only:
Other:

DO YOU ALLOW INFORMATION REGARDING ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH BE DISCLOSED:

YES, DISCLOSE THIS INFORMATION *
NO, DO NOT DISCLOSE THIS INFORMATION *

*I understand that the information used or disclosed may be subject to re-disclosure by the person or class of person or facility receiving it, and would then no longer be protected by federal privacy regulations.

I may revoke this authorization anytime by notifying Blessings OB/GYN and Women’s Health in writing. I understand that any revocation request will not be effective for any action taken prior to the request. Those actions cannot be reversed and this request will not affect those actions.

Patient Signature

Date

FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copy of medical records. This facility may apply a printing fee of $25.

Financial Agreement

Insurance- We participate in most major insurance plans; however, please be aware that we may not participate in all of their individual plans. It is your responsibility to know your own insurance benefit, including whether or not we are an in-network provider with your plans network. It is also your responsibility to know your covered benefits and any exclusions in your insurance policy. **If you choose to receive care prior to verifying this you understand you will be responsible for any out of network benefits which may include but are not limited to higher copays, deductibles, and co-insurance.
Non-payment-If your account is over 90 days past due, you will receive a final notice letter stating that you have 10 days to pay your account in full. Partial payment will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid we will refer your account to an outside collection agency. An additional 30% will be added to any outstanding balance. You will be responsible for any collection fees, legal fees, or court costs incurred in the collection process.
All copays and deductibles must be paid in full at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. There may an instance where your insurance makes payment directly to you. You understand it is your responsibility to make payment to our office towards any balance due.
Non-covered services- Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered reasonable or necessary by your insurance. You understand you will be responsible for payment of any denied charges. These must be paid in full at the time of your visit.
Proof of insurance- We must obtain a copy of your driver’s license or passport and valid insurance card prior to your visit. If you fail to provide us with the correct insurance information you will be held responsible for the balance of the claim.
Claim submission- We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information to them directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claims. Your insurance benefit is a contract between you and your insurance company for payment of services.
Coverage changes- If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your claim is not paid within 45 days the balance will be automatically billed to you. It is then your responsibility to work with your insurance company for payment of services.
We have an on-site lab for patient convenience. They are not part of Blessings OB/GYN and Women’s Care. Any bill related questions must be discussed with labs billing department.
Release of Information: I assign benefits of my medical insurance to Blessings OB/GYN and Women’s Health and authorize payment directly to Blessings OB/GYN and Women’s Health. I authorize Blessings OB/GYN and Women’s Health to release medical information to payer as required for payment of claims for medical services.

We are committed to providing you with the best possible care and we are willing to discuss our professional fees at any time. Your clear understanding of our Financial Policy is important to our relationship. Please ask if you have any questions about our fees, Financial Policy, or your financial responsibility.

I have read and understand this Patient Financial Agreement. Any questions have been answered to me.

Patient / Guardian Signature

Date

Medical Treatment agreement

Patient or the patients’ legal representative agree to the following terms of encounter s with Blessings OB/GYN and Women’s Health and its providers.

Medical Treatment: The patient consents to the treatment, services and procedures which may include but are not limited to laboratory procedures (including routine urine drug screens), X- ray examinations, telemedicine services, medical and surgical treatments or procedures or anesthesia.
Release of Information: The patient acknowledges and agrees that medical and/or financial records (including information regarding alcohol or drug abuse, HIV/AIDS related and/or to other communicable disease related information) may be release to the following:
1. Healthcare providers or their agent who are providing or have provided healthcare care to the patient
2. Any individual or entity responsible for payment as specified by patient on HIPPA authorization form
3. Any individual or entity responsible for payment as specified by patient on HIPPA authorization form
4. Blessings OB/GYN and Women’s Health legal representatives and professional liability carriers.
5. Individuals and/or originations engaged in medical education and/or research provided that information may only be released without patient identifying information.
6. Individuals and entities as specified by federal and state law.
7. Patient records of services provided at any facility included outpatient surgery centers, hospitals, etc. may be exchanged among facilities to provide appropriate patient care
Contraband: Drugs, alcohol, weapons and other articles specified as contraband by Blessings OB/GYN and Women’s Health may not be brought onto Blessings OB/GYN premises. Any illegal substance will be confiscated and turned over to law enforcement authorities.
Dismissal from physician services: Patient may be dismissed from Blessings OB/GYN and Women’s Health for:
1. Excessive no-shows
2. Inappropriate or disruptive behavior towards other patients or staff
3. Failure to follow treatment recommendations
4. Providing false or inaccurate medical information in regards to previous medical care or medications
5. Failure to meet financial obligations
6. Failing to authorize the release of record to Blessings OB/GYN and Women’s health.
Photographs /Taped Sessions: I understand and agree that a photograph may be take of me for identification purposes or for other treatment purposes. I further agree that therapy sessions may be taped (audio and or videotaping) and that all photographs and tapes will remain the property of Blessings OB/GYN and women’s health. I will not audiotape, videotape or take pictures of Blessings OB/GYN and women’s care staff without their permission/consent.

This agreement shall remain in effect as long as I am seeking services Blessings OB/GYN and women’s health. I will be asked to sign a new agreement every year. This release shall continue for so long as the medical and /or financial records are needed for payment, treatment or healthcare operations.

Date

Patient / Guardian Signature

Only AHCCCS patients

AHCCCS Non-Covered Services Waiver

Date

AHCCCS ID

Patient / Guardian Signature

Any procedures and/or surgeries ordered by the physician will be verified with AHCCCS in advance and discussed with the patient. Should the procedure not be covered and you decide to follow through, you understand you will be held responsible for all costs. By signing below you are agreeing in advance to accept full responsibility for all costs as

Date

AHCCCS ID

Patient / Guardian Signature

NOTICE!!!

FOR SHORT TERM DISABILITY AND FAMILY LEAVE OF ABSENCE FORMS

Please be aware there is a $25.00 charge per document (due at time of request) for all FMLA or short-term disability requests forms which typically take 5 – 7 business days to process.

You may have documents rushed (within 48 hours) for a $50.00 charge per document.

By signing below, you acknowledge that you have been notified of our price and turnaround time for processing documents.

Signature

Date

GYNECOLOGIC HISTORY QUESTIONNAIRE (please complete front and back)

Name

DOB

Date

Chief reason for today’s visit

First day of last menstrual period

Date of last pap smear

Results

Type of birth control currently using

(Including vasectomy, tubal ligation, condoms, abstinence, or natural family planning methods)

Are you happy with this type of birth control?

OBSTETRICAL HISTORY

Are you currently pregnant

If so, on what date what the first positive pregnancy test

Total number of times pregnant: (including miscarriages and abortions)

Total number of live births (include dates and types of deliveries)

Total number of miscarriages

Total number of abortions

Any complications during pregnancies? If so, please explain

Did you have a Cesarean Section: If so, when

Any family history of inherited disorders (i.e. Tay-Sachs, Spina Bifida, Down Syndrome, other genetic disorder)

GYNECOLOGICAL HISTORY

Age at first period

how many days do your periods last

How often do your periods come:

Every 28-30 days
More frequently
Less frequently

How heavy is your menstrual flow

Light
Moderate
Heavy
Extremely heavy

Do you have bad cramps

Do you have PMS symptoms

Any bleeding between periods

Any bleeding after intercourse

Any problems with urination (loss of urine when coughing, sneezing, etc.):

Check any of the following that you have had either in the past or currently

Check any of the following that you have had either in the past or currently
Vaginal Infections
IUD Related Problems
Abnormal Pap Smears (what abnormality and when)

Sexually transmitted disease

Gonorrhea
Chlamydia
Herpes
other

MEDICAL HISTORY

How is your overall health

Excellent
Good
Fair
Poor

Do you smoke

Are you a past smoker

Do you drink alcohol:

How many alcoholic beverages do you have in a week?

Social drug use

If so, what type of drugs do you use

Have you ever been diagnosed with a MEDICAL or PSYCHOLOGICAL condition: If so, what was the diagnosis and when

Have you ever been hospitalized for a medical illness? If so please explain

What surgeries have you had? (Please provide the year including cosmetic)

Do you have allergies to any medications

Do you have any other allergies

Do you have any history of a bleeding disorder

had a blood transfusion

Do you use medication on a regular basis? Please list the name and dosages

Have you had a mammogram

Date and result of last mammogram

FAMILY HISTORY

SOCIAL HISTORY

Marital Status

Occupation

Name

CONTACT US TODAY

Prepare For Your Appointment

NEW PATIENT FORMS - ENGLISH

INSURANCE INFORMATION

IN CASE OF EMERGENCY

HIPPA AUTHORIZATION FORM

Financial Agreement

Medical Treatment agreement

Only AHCCCS patients

AHCCCS Non-Covered Services Waiver

NOTICE!!!

GYNECOLOGIC HISTORY QUESTIONNAIRE (please complete front and back)

OBSTETRICAL HISTORY

GYNECOLOGICAL HISTORY

MEDICAL HISTORY

FAMILY HISTORY

SOCIAL HISTORY

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