Patient Information
Last Name: ____________________ First Name: _________________ Birth Date: _____________ Sex: __________
Social Security Number: ______________ Emergency Contact Name: ____________________ Phone #: __________
Race: __________ Marital Status: ____________ Primary Language: ______________ Ethnicity: ________________
Address: _________________________________________ City/State/Zip: __________________________________
(Please circle best contact number below)
Home #: _____________________ Cell Phone #: _____________________ Work Phone #: _____________________
Employer: _____________________________________ Email Address: ______________________________________
Pharmacy Name/Location (this is where we will call in your medications): __________________________________
Insurance Information
Primary Insurance Company: ____________________ Contract #: __________________ Group #: ________________
Policy Holder: ______________________ Policy Holder DOB: _____________ Relationship to Patient: ____________
Co-pay Amount: __________________
Secondary Insurance Company: __________________ Contract #: __________________ Group #: ________________
Policy Holder: ______________________ Policy Holder DOB: _____________ Relationship to Patient: ____________
Person Responsible for Payment
Name: ___________________________________________ Relationship to Patient: ______________________
Address: ___________________________________ City/State/Zip: __________________________________
Employer: _____________________________________ Work #: ____________________________________
I authorize Eastside Women’s Specialists, its physicians and employees to leave detailed messages specific to my
medical care including test results on the phone number(s) listed below. I understand that once a voicemail message
exists, it is no longer covered under HIPAA and therefore is not protected from unauthorized access.
 I agree to allow VOICEMAIL
 I DO wish to have test results or other information released to the following person(s):
Name: _______________________________________________ Relationship: ___________________
Name: _______________________________________________ Relationship: ___________________
 I DO NOT wish to have test results or other information released to any other person other than myself.
Patient Signature: ___________________________________________________ Date: ___________
Consent to Treatment I, the undersigned, do hereby agree and give my consent for Eastside Women’s Specialists to provide any medical care
and treatment they consider necessary and proper in diagnosing or treating my physical and mental condition.
Release of Medical Information I hereby authorize the release of medical records to the referring and family physician(s), as well as any/all
records necessary to process insurance claims.
Assignment of Insurance and Medicare Benefits I hereby assign any and all insurance benefits providing coverage for medical and/or surgical
treatment to which I am entitled, to Eastside Women’s Specialists.
Medicare Assignment: Statement to permit of Medicare Benefits to Provider, Physician, and Patient. I request that payment of authorized
Medicare benefits be made either to me or on my behalf for any services furnished me by Eastside Women’s Specialists including physician
services, radiological services, and consulting services. I authorize any holder of medical or other information about me to release to the Health
Care Financing Administration and its agents any information needed to determine these benefits or the benefits for related services.
We are willing to assist you by supplying information to your insurance carrier and/or managed care organization to help in getting your claim
for medical payments processed. You may not rely upon our doing so in every instance and the responsibility remains yours to make certain that
we are paid for our services to you. Providers, insurance carriers, or managed care organizations have various procedures and regulations and
varying opinions as to who is primarily responsible for payment for treatment. A photocopy of this authorization shall be considered as effective
and valid as the original.
Financial Agreement This information is given for the purpose of establishing or updating records with Eastside Women’s Specialist. It is my
understanding that any and all records here concerning my personal and medical history are the confidential property of Eastside Women’s
Specialists. I understand that I am responsible for any and all charges incurred by me or us, and that I agree to pay any costs of collection
incurred, including reasonable attorney’s fees, payment is due at the time of medical services rendered. I hereby waive to the extent allowed by
law, all personal property rights of exemption under the constitution and laws of the State of Alabama, in connection with or related to the
collection of any amounts due for services rendered. I am aware that some services related to my treatment may be referred to other providers and
that I may be billed separately by those providers for services not otherwise covered by insurance, including deductible and co-payments. Itemized
charge tickets are provided for each visit for reimbursement by your insurance carrier. Patients requiring special arrangements will be considered
on an individual basis. Patients covered by insurance should remember that they are responsible for all charges incurred, regardless of their plan
coverage.
Notice of Privacy Practices Attached, please find the Eastside Women’s Specialists’ Notice of Privacy Practices. Your name and signature on
this cover sheet indicates that you have received a copy of our notice of Privacy Practices on the date indicated. If you have any questions
regarding the information set forth in this notice, please do not hesitate to contact us or the HIPPA hotline at 1-866-742-4922.
Patient Signature: __________________________________________________Date: _________________________
The following Consents apply ONLY to our Pregnant Patients
Consent for Obstetrical Treatment I understand that the care of my physical condition, as well as that of my unborn child may require that I
have certain diagnostic tests and/or medical treatments. These may include, but are not limited to, laboratory testing such as blood typing, HIV,
ultrasonography and tests of fetal well-being. I understand that the testing and the results of the testing will be kept confidential unless otherwise
required by law. I therefore, knowingly and voluntarily consent to such procedures as are deemed necessary during my pregnancy by the medical
staff of Eastside Women’s Specialists. I acknowledge that no guarantee has been made as to the outcome of my pregnancy as a result of the tests
and treatments to which I am consenting.
Obstetrical Consent of Payment I have provided Eastside Women’s Specialists with my current insurance card and give my permission to
verify coverage for prenatal care, delivery and any charges incurred for my obstetrical care. I understand that if any change occurs in my current
insurance status, I am responsible for providing that information to Eastside Women’s Specialists and will be responsible for all charges incurred
for my care.
The normal global obstetric fee includes routine prenatal visits, delivery and a 6-week postpartum visit. Any non-routine visits are the patient’s
responsibility and if not covered by insurance payment, will be expected at the time of visit.
Medicaid patients – if you are applying for Medicaid presently, Eastside Women’s Specialists will allow 3 months for Medicaid approval. After
3 months, if Medicaid is not active for Maternity coverage, we will begin collecting on a private pay basis. When Medicaid becomes active,
payments will be refunded.
Patient Signature: __________________________________________________ Date: _______________________
Office Policies
Scheduling Appointments
Please call for an appointment during our normal business hours and have ready all health insurance information.
Please understand that you must bring your current health insurance card, your driver’s license or picture ID and your
co-pay in order to be seen by your doctor. If you do not have these with you, your appointment will be rescheduled.
Also, if a referral from your primary care provider is necessary, please arrange to have that sent prior to your visit. We
recommend you call a few days ahead of your appointment to make sure we have received it. If not received, your visit
will either be rescheduled or you can pay for visit in full.
Initial _________________
Canceling Appointments
If you need to cancel or reschedule your appointment, please call us as soon as possible. This will avoid a possible noshow fee of $40.00
Initial __________________
Late Appointments
Please make every effort to be on time for your appointment. We respect the time of our patients and our providers
strive to stay on schedule so that you don’t have to wait long. If you arrive late for your appointment, if possible, we
will try to fit you in after the other scheduled patients have been seen. However, you may be asked to reschedule if you
are 30 minutes past your scheduled time.
Initial __________________
Prescriptions








It is your responsibility to notify the office in a timely manner when refills are necessary
Approval may take up to 3 business days, so please be courteous and do not wait to call
Medication refills will only be addressed during regular office hours
We will not refill medications prescribed by other providers
It is important to keep your scheduled appointments. Repeated no-shows or cancellations will result in a denial
of refills
If you have questions regarding medications, please discuss these during your appointment.
New symptoms or events not addressed during previous appointment OR if it has been longer than 6 months
since you have been seen, you will need a new clinic appointment. Your provider will not diagnose or treat over
the phone
Narcotic pain medications cannot be called in. If approved, you will need to pick up a written prescription
Initial ___________________
Financial
Copayments are due at time of service. If you have a residual balance from a previous visit, it must be paid in full prior
to being seen by the doctor. We will make every effort to confirm eligibility and charges associated with your care, but
ultimately, it is your responsibility to know your policy.
Initial __________________
Obstetrical Services
If your insurance does not fully cover the fees related to your care and delivery, we will work with you on a payment
plan. Please note, your balance owed must be paid in full by your 28th week of pregnancy.
Initial _________________
Surgical Services
Our staff will contact your insurance company to determine what amount will be paid towards your surgical procedure.
You are responsible for any deductibles, co-payments or any remaining balance. Payment in full is required three days
prior to your scheduled surgery date or your case will be canceled.
Initial _________________
Courtesy
Please, do not use your cell phone while your doctor is in the exam room with you. He/she will need your full attention
to give you the best care possible. We do not allow more than 1 visitor in your exam room, so plan accordingly.
During your ultrasounds, only 2 people are allowed in the room with you.
Initial _________________
Forms/Excuses



FMLA/Disability Forms will require 3 business days to complete. There is a $10 completion fee. Also, there is
a $10 fee for each additional family member’s forms.
WIC forms should only be done at time of visit. Outside of the patient visit, there is a $5 completion fee.
Work/School Excuses, Limitations of Pregnancy, Dental Permissions need to be completed at time of visit.
Please ask your MA during intake if you need them. Be aware that we are unable to give excuses unless you
were seen or treated by one of our physicians.
Please note that we cannot fax medical forms to non-medical fax machines. You will have to pick up this paperwork at
our office.
Initial __________________
Patient Signature: __________________________________________________ Date: _________________________