Your Name:      Email:

Patient Info

     Last Name:      First Name:      MI:

     Date of Birth:      Social Security Number:

     Address:      City:      State:

     Phone:      Cell:      Work:

     Employer:      May we contact you at work?YesNo

Spouse or Guardian

     Name:      Date of Birth:      SSN:

     Employer:      Work Phone:

Primary Insurance Coverage
     Please complete, even if we've taken a copy of your card

     Insurance Company:      CoPay: $

     Subscriber Name:      Relation to Patient:

     Subscriber SSN:      Date of Birth:

     Policy Number:      Group Number:

Secondary Insurance Coverage

     Insurance Company:      Date of Birth:

     Subscriber Name:      Relation to Patient:

     Policy Number:      Group Number:

Emergency Contact Info
     In case of emergency, whom can we contact? (Someone other than spouse or guardian)

     Name:      Relation:      Phone:

     By whom were you referred?

I authorize this office to release to the named insurance company any information necessary to expedite insurance payment. I understand that I am responsible for all charges, regardless of insurance coverage, and that typing my name below serves as a substitute for my signature.

     Guarantor Signature:      Date:

LIFESTAGES
3908 E Flamingo Ave
Nampa, ID 83687

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that LifeStages has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notices of Privacy Practices.

     Patient Name:

     Relationship to Patient:

     Signature:      Date:

Dear Patient,

It is our policy to keep all matters regarding our patients in strict confidence. Please take a few moments of your time to provide us with the names of your family and/or friends who may call for information regarding your test or any other medical information.

Persons I authorize to obtain information for me:

     Person 1:

     Person 2:

     Person 3:

     Patient or Guardian Signature:      Date:

We would like to take this opportunity to welcome you to LIFESTAGES. Your clear understanding of our policies is important to our relationship. Therefore please read carefully and feel free to ask any questions you may have.

Our office hours are:

     Monday-Thursday 8:30-5:00      Friday 8:30 - 12:00

If you have an emergency after hours that cannot wait until normal business hours, please call (208) 442-8035 and an operator will page the doctor on call. Otherwise please hold non-emergent matters until regular office hours.

Please initial after reading each policy – regardless of applicability.

       Refill Requests - Please give 24 hours notice on all refills.
Contact your pharmacy, and they will contact us with your needs. Refills will be authorized Monday thru Friday only, and only during regular office hours. Narcotics (controlled medications) will not be filled after clinic hours, and can only be filled by your primary physician. Please do not wait until you are completely out before calling.

       Appointments – Please give 24 hours notice if you are unable to make your scheduled appointment with your doctor. We understand that circumstances arise when you are unable to do so, but we ask that you provide us adequate notice to fill your appointment time with patients who may need medical attention.

Financial Policies

       Monthly payments are required and balances need to be paid within 90 days of receiving your first statement. Unpaid balances will be reviewed and sent to Bonneville Management Service for payment arrangements or Bonneville Collections which ever applies.

       We will be happy to file your insurance claims for you. However we do request a copy of your current insurance card to ensure accurate billing. Please keep in mind that we do not accept all insurances. It is your responsibility to confirm directly with your insurance company to find out whether or not we participate with them and if they will cover the medical services being provided to you. If your insurance requires a referral, co-pay or deductible, it is your responsibility to have it with you at the time of service. Failure to do so may result in rescheduling your appointment.

       A Parent or Guardian must accompany minors at the first new patient visit. Afterwards, we will accept a written note by the responsible party.

       All NEW patients are required to pay for deductibles and co-pays at time of service. All Private Pay patients (no insurance) will be required to pay in full at the time of service. For your convenience, our office staff can give an estimate of charges for your appointment ahead of time, but these quotes are not exact.

       Medicare only pays for routine physicals every two years. Please be aware that you may be billed for your exam if denied by Medicare.

       As a courtesy, we will bill your insurance for you. However, it is your responsibility to follow up with your carrier if the claims are not paid. Our billing staff will be happy to assist you, please contact them for any questions. If payment is not received by the insurance with in 60 days, the balance will be transferred to patient responsibility.

       All returned checks will be subject to a $20 charge.

       Birth Control/Fertility – Due to the majority of Insurance carriers not covering contraceptive management, payment is due in full at time of any service relating to Birth Control/Infertility. (IUD, Diaphragm fitting, Depo-Provera Injection etc.).

       Effective Jan 1, 2017 our office will complete ONE set of FMLA/Short Term Disability forms, any set thereafter you will be charged $25 to be paid before completion of forms.

Surgery

       All surgeries will be pre-certified prior to admission and the insurance company will quote benefits. Your Co- insurance percentage is required 5 days prior to admission. The remaining balance will be set up on a monthly payment plan to be paid off no later than 3 months from the surgery date.

       Patients with NO Insurance and needing surgery are required to pay half of the total surgery amount 2 days prior to surgery. The remaining balance will be set up on a payment plan or with Bonneville Management Service.

       If our office does not receive the down payment by the deadline your surgery may be postponed until payment is made.

Obstetrics Financial Policies

       Our OB package does not include labs, ultrasounds, or hospital visits. It does include your visits with your doctor and the delivery of your baby, as well as your postpartum visits. The package cannot be billed to your insurance until after delivery, so charges will be posted to your account, and will be a part of your monthly statements.

       Any complication risk, such as cesarean section or multiple births, will change the amount of the package.

       You will be billed for the services performed by the facility separately. You will need to contact them for admission planning and payment arrangements.

     If you have insurance...
       At your first prenatal visit, your insurance will be notified of your pregnancy, and at the same time we will get an estimate of the out-of-pocket amount for your package (assuming you have a normal delivery). We will require your down payment of $100 to be paid at that first visit. The remainder of your portion will be arranged in monthly payments and be paid in full the month prior to your delivery.

     If you have high deductible or no insurace...
       At your first prenatal visit, you will be expected to bring in $350 as your down payment for your prenatal care. We will set up a monthly payment plan that will have your balance paid one month prior to your delivery.

Medicaid Financial Policies      Please check if not applicable

Please initial after reading each policy – regardless of applicability.

       Medicaid patients on the Healthy Connections Program must be responsible for arranging for referrals ahead of the appointment time.

       Our office will not back-bill any laboratory fees for patients with Medicaid approvals provided after the date of service. You will be responsible for those fees.

       You are required to bring your medical card for every visit. If your card is not available for the visit, we may ask you to reschedule your visit.

       Fertility – due to Medicaid not covering family planning services, payment is due in full at time of any service relating to this.

I request that payment of authorized insurance benefits be made, on my behalf, to LifeStages for any services furnished to me by that provider. I authorize any holder of medical information about me to release to the Council on Medical Service and its agents any information needed to determine benefits or the benefits payable for related services. This authorization is in effect until I choose to revoke it.

I understand that I am responsible for all charges regardless of insurance coverage, and I have read and understand the financial policies of LifeStages.

     Patient or Guardian Signature:      Date:

     Name:      Date of Birth:

     Chief Complaint:

Medical History

SelfFamily      Cardiovascular Disease        Details:

SelfFamily      Hypertension                         Details:

SelfFamily      Headaches                              Details:

SelfFamily      Head/Ear/Neck/Throat         Details:

SelfFamily      Respiratory Problems           Details:

SelfFamily      Breast Disease                        Details:

SelfFamily      Jaundice/Hepatitis                 Details:

SelfFamily      Gall Bladder Disease             Details:

SelfFamily      Bowel Disorders                    Details:

SelfFamily      Kidney Problems                   Details:

SelfFamily      Urinary Tract Infections       Details:

SelfFamily      Anemia/Blood Disorders       Details:

SelfFamily      Blood Transfusions                Details:

SelfFamily      Osteoporosis                           Details:

SelfFamily      Diabetes                                  Details:

SelfFamily      Thyroid Disease                     Details:

SelfFamily      Cancer                                    Details:

SelfFamily      Dementia/Neuro Disorders   Details:

SelfFamily     Alcohol/Drug Problems          Details:

Obstetrical History

     Number of Pregnancies:      Births:

Menstrual History

     Date of Last Period:      Prior Period:

     Current Contraception:      Date of Last Pap:

     Please check any that apply:
Vaginal drynessItchingPainful intercourseBurningOther

Medications

Allergies

Hospitalizations or Surgeries

     Illness/Operation:      Date:

     Illness/Operation:      Date:

     Illness/Operation:      Date:

     Illness/Operation:      Date:

Due to new reporting requirements by the government and for our new electronic medical record, we need these additional questions answered by our patients:

Race
     American Indian or Alaskan Native
     Asian
     Native Hawaiian
     Black or African American
     White
     Hispanic
     Other Pacific Islander
     Other
     Unreported or Refused to Report

Ethnicity
     Hispanic or Latino
     Not Hispanic or Latin
     Refused to Report

Language
     English
     Indian (Includes Hindi & Tamil)
     Russian
     Spanish
     Other

Pharmacy of Choice
     (Please list city and street of pharmacy)
     1.

     2.

Do you have a FAMILY HISTORY of any of the following cancers? Please check any that apply:
     Any prostate, colorectal, uterine or endometrial cancer (under 51 years old)
     Any female breast cancer (under 46 years old)
     Ovarian cancer (any age)
     Pancreatic cancer (any age)
     Male breast cancer (any age)
     Abnormal tumor screening results or Ashkenazi Jewish ancestry
     2 or more cancers in the same family member (any age)
     3 or more cancers on the same side of the family (maternal or paternal)
     Any known BRCA1/BRCA2 or other cancer susceptibility gene pathogenic mutations

To provide the highest quality care, it is necessary for patients to attend their scheduled appointments on time. As a courtesy, an appointment reminder may be sent prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time, regardless of prior notification. If you are unable to keep your appointment, please notify us as soon as possible. We understand that occasional missed appointments can occur for a variety of reasons.

A “No Show/Late Cancellation” is defined as missing an appointment without cancelling at least 24 hours before the scheduled time. There will be a charge for a missed or late -cancelled appointment of $25.00. Insurance will not cover charges for missed or late cancellation fees.

An appointment is considered missed when any of the following occur:

• The appointment is cancelled within 24 hours of the scheduled meeting time.
• The patient does not present to the office for the scheduled appointment.
• The patient arrives more than 10 minutes late.

After each missed appointment, you will receive a phone call from our administrative staff. After the third missed appointment within a one-year time period, we reserve the right to remove you from our schedule at which point your account will be reviewed by your provider.

I have read and understand Lifestages Missed Appointment Policy and understand that it is my responsibility to plan and attend appointments according to the schedule that I have created with my provider. Furthermore, I understand that it is my responsibility to give at least 24-hour advanced notice to Lifestages if I cannot attend my scheduled appointment or I will be charged a fee of $25.00 for a No Show or Late Cancellation.

     Patient Name:      Date of Birth:      Date:

    Patient or Guardian Signature:     Relationship to Patient: