Download Patient`s Name: S - dr

S. M. Stemmer, M.D.
Obstetrics & Gynecology
807 N. Haddon Ave. Suite 207
Haddonfield NJ 08033
Patient’s Name:__________________________ S.S.#__________________
D.O.B.:____________
Age: _____yrs.
Marital Status:
S
M
D
W
Address______________________________ City________________
State___ Zip______
Home Phone: (
Preferred Way to be contacted: ___Home
DO NOT CALL HOME___
)___________Cell ___________
___Work
DO NOT CALL WORK___
___Cell
___Email
DO NOT LEAVE MESSAGE ON ANSWING MACHINE___
We may share you medical information with? First name_______________ Last name _______________
Email ______________________________ Race: ______________ Ethnicity:_________
Do you speak English? ____ Yes ____No, Language? _________________________
Emergency Contact _________________ Phone _______________ Relationship ___________
Employer____________________________ Work Phone ____________________
Pharmacy_________________ (
)_____________ Referred By:______________
Primary Physician:______________________ Phone (
)___________
PRIMARY INSURANCE INFORMATION: (if the patient is not the subscriber, please fill out all of the information below)
Ins. Comp.________________________
Subscriber’s Name _______________________
ID#__________________ Group #_________
Relationship to patient _______________
Subscriber’s D.O.B.___________________
Subscriber’s S.S.# ________________________
SECONDARY INSURANCE: (if the patient is not the subscriber, please fill out all of the information below)
Ins. Comp.__________________________
Subscriber’s Name _____________________
ID#__________________ Group #_________
Relationship to patient _______________
Subscriber’s D.O.B.___________________
Subscriber’s S.S.# ________________________
I hereby authorize and request Dr. Stemmer to release minimal medical information including only date of service, procedure, and
diagnosis codes from my examination necessary to process the claim. I also request that the payment go directly to Dr. Stemmer. I
hereby acknowledge that payment for services is due in full when service is rendered. I understand that if there is an outstanding
balance more than 30 days past due, I will be responsible for a service charge of 1.5% per month of the outstanding balance. Accounts
that go to collections will be subject to a 30% charge and you will be responsible for all collection costs including attorney fee and court
cost.
Patient’s Signature: _____________________________
Date:_________________
S. M. Stemmer, M.D.
Obstetrics & Gynecology
807 N. Haddon Ave. Suite 207
Haddonfield NJ 08033
Date: ____________________________
Name____________________________ Date Of Birth ______/_____/______ Age_____ Height _______
Social Security #______-_____-________ Previous Dr.___________________ Marital Status S
M D
W
Chief Complaint: ______________________________________________________________________
Major illness: ________________________________________________________________________
Present Medications: ___________________________________________________________________
Allergies: _____________________________________ Blood Transfusions: YES______ NO______
Smoker?____ How much?______ How long?______ Stopped Smoking ____ Alcohol?______ How much?_____ Drugs? ____
Jehovah witness Yes______ No_____ *in case of emergency would you accept blood transfusions? Yes_____ No______
History: (if you check one, please give a brief description)
STD’s
Chlamydia_____
Gonorrhea ______
Trichomonas _____
Bladder infection_____
Back pain _____
Bone disease _____
Chest pain _____
Constipation _____
Blood in stool _____
HPV ___
Herpes _____
Kidney Infection _____
Kidney stone_____
Appetite: poor ___ normal_____
Hemorrhoids _____
Headaches_____
Indigestion_____
Get up at night to urinate ___________ Loss of urine when: laughing______
Menstrual History: Age started ________
Every_______ days
coughing____
sneezing______
for_______ days
Menstrual Flow: _____ scant ____moderate ____profuse Menstrual Pain ___ mild ____ Moderate _____severe
Discharge ______ Itchy _______
Burning ______
Odor ______
Difficulty getting pregnant ________
Bleeding between periods: ____ After intercourse:____ Last Period ___/____/___ Last Pap ____/_____/_____
Colonscopy Y___ N___ _____/_____/_____
Last Mammogram
OPERATIONS:
_____/_____/_____
YEAR
Bone Density: ___/___/___
___ abnormal
HOSPITAL
___ normal
COMPLICATIONS
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
FAMILY HISTORY:
CANCER ___________ DIABETES ______________ HEART DISEASE _____________
MENTAL DISORDER _______ HIGH BLOOD PRESSURE ________ TWINS _______ ABNORMAL BABIES
________
HISTORY OF BIRTHS:
# of Pregnancies _______
# of Deliveries _______
# of live children _______
Spontaneous Abortions _____ How long into pregnancy? ________ wk Cause?________ Elective Abortions _______
LABORS
DATE
SEX
WT.
LABOR DURATION
Patient’s Signature: _____________________________
HOSPITAL COMPLICATIONS
Date:_________________
S. M. Stemmer, M.D.
Obstetrics & Gynecology
807 N. Haddon Ave. Suite 207
Haddonfield NJ 08033
Financial Policy
We welcome you to our practice. The following is a statement of our financial policy. All patients must complete
our Patient Information Sheets before seeing the doctor.
Unless previous arrangements have been made, all payments are due at the time of the appointment. Payment may
be made by cash, check, Master Card, Visa or Discover. We will only bill insurance carriers with whom we
participate (have signed and agreement with).
Regarding Managed Care Insurance with which we participate: You are responsible to supply our staff with
your primary and secondary insurance identification card(s) at the time of your appointment. If your insurance
company requires a referral from your primary doctor, you must also present this to our receptionist prior to being
seen, as we cannot bill your insurance without it. If you do not obtain a referral when your insurance company
requires one, you will be required to pay for the visit in full. If your insurance company requires a copay, it must
be paid at the time of the appointment.
Regarding Non- participating Insurances: If we do not participate with your insurance, the bill is your
responsibility and is due at the time of service. We accept cash, check, Master Card, Visa or Discover. Your
insurance policy is a contract between you and your insurance company. Our office is not part of the contract.
Our practice is committed to providing the highest quality of treatment to our patients, and we charge what is usual
and customary for our area. We know how confusing insurance plans can be. If you have any questions, feel free
to ask us. We may be able to help you.
We do participate with Medicare. This means that we will submit your claim to Medicare. The 20% difference
between what Medicare “allows” and what Medicare “pays” will be sent to your secondary insurance if you have
one, or to you. You will also be responsible for payment of your yearly deductible.
Returned Check Fee- $25.00 will be added to your bill if this occurs, since our bank charges us a fee for any
checks that are returned.
Any outstanding balance for which the patient is responsible is due within 30 day of billing and will be responsibe
for a service charge of 1.5% per month of the outstanding balance. Any account that has gone 90 days without
payment is subject to immediate collection process. Accounts that go to collections will be subject to a 30%
charge and you will be responsible for all collection costs including attorney fee and court cost.
Thank you for your cooperation. If you have any questions or concerns, please feel free to ask. If you cannot pay
in full at the time of service, please let us know before you see the doctor that you would like to discuss a payment
plan.
I have read the above Stemmer OB/GYN Financial Policy. I understand and agree to abide by its terms.
_________________________________________
____________________
Signature of Patient/Parent/Guardian
Date
Patient’s Signature: _____________________________
Date:_________________
S. M. Stemmer, M.D.
Obstetrics & Gynecology
807 N. Haddon Ave. Suite 207
Haddonfield NJ 08033
_____ Do not phone at home
_____ Do not phone at work
_____ Send all mail to alternate address: _______________________________________________
_____________________________________________________________________________
_____ Restrict information to individuals: _______________________________________________
_____ Do not leave messages on answering machine
_____ Do not mail reminder cards
_____ Other privacy request
Chart was sent to:
initials and date:_______________________
Initials and date
Patient’s Signature: _____________________________
Pt.’s initials or
verbal date
Date:_________________
S. M. Stemmer, M.D.
Obstetrics & Gynecology
807 N. Haddon Ave. Suite 207
Haddonfield NJ 08033
ACKOWLEDGMENT OF RECEIPT
OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy
Practices for Dr. Stemmer.
Patient Name: _________________ Signature: ____________________
If person signing is not the patient, please print your name and relationship to
patient:
Name:_______________________ Relationship:_________________
__________________________________ requested a copy of Notice of
Privacy Practices for Dr. Stemmer.
_____YES
_____NO
--------------------------------------------------------------------------------------------Office Use
__ Patient/ representative requested copy of Notice of Privacy Practices for Dr. Stemmer.
______ If no acknowledgment could be obtained, state the reasons why and the efforts
taken to try to obtain the acknowledgment. ________________
_______________________________________________________
_______________________________________________________
Patient’s Signature: _____________________________
Date:_________________