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Basic Information
Name
(Required)
First
Middle
Last
Today's Date
MM slash DD slash YYYY
Have a preferred nickname?
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Nickname
Address
Street Address
Address Line 2
City
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Armed Forces Americas
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State
ZIP Code
Phone
Email
Date of Birth
(Required)
MM slash DD slash YYYY
Social Security Number
Reason for visit
Check-up
Irregular cycles
Newly pregnant
Heavy bleeding
Infertility
Pelvic pain
Vaginal discharge/itching
Hormone issue
Painful/frequent urination
Other
Appointment with:
Dr. Cudihy
Claire Barnett, PA-C
Dr. Voltz
Any
Detailed reason for visit
Marital Status
(Required)
Married
Single
Engaged
Divorced
Widowed
Are you Employed?
Yes
No
Employer Info
Employer Name
Employer Phone
Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Length of Employment
Position Held
Insurance Coverage through Employer?
Yes
No
Spouse Information
Spouse's Name
First
Last
Spouse's Date of Birth
MM slash DD slash YYYY
Spouse's Social Security Number
Spouse's Employer
Spouse's Employer Phone
Spouse's Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Spouse's Position
Spouse's Length of Employment
Insurance Coverage through Spouse's Employer?
Yes
No
Emergency Contact Information
Person to contact in case of emergency or if we are unable to contact you at home or work.
Emergency Contact Name
First
Last
Emergency Contact Phone
Relationship to Patient
Insurance Information
Do you have Medical Insurance?
(Required)
Yes
No
Do you have Secondary Medical Insurance?
(Required)
Yes
No
Primary Insurance
Upload Front of Insurance Card
Max. file size: 256 MB.
Upload Back of Insurance Card
Max. file size: 256 MB.
Policyholder's Relationship to You (Self, Spouse, Mother, Father, etc.)
Secondary Insurance
Upload Front of Insurance Card
Max. file size: 256 MB.
Upload Back of Insurance Card
Max. file size: 256 MB.
Policyholder's Relationship to You (Self, Spouse, Mother, Father, etc.)
Gynecological History
Age menstrual periods began
Age menstrual periods stopped (Menopause)
Date of last menstrual period (Start)
MM slash DD slash YYYY
Typical menstrual cycle length
Number of days of menstrual bleeding
Number of tampons/pads per day
Do you have pelvic pain with mentrual period?
Yes
No
Do you have PMS symptoms?
Yes
No
Do you have excessing bleeding at menstrual periods?
Yes
No
Do you have bleeding between menstrual periods?
Yes
No
Are you sexually active?
Yes
No
Do you have pain with intercourse?
Yes
No
Are you using any methods to avoid pregnancy?
Yes
No
Any abnormal paps?
Yes
No
Date of last pap test
MM slash DD slash YYYY
Date of last mammogram
MM slash DD slash YYYY
Last mammogram results
Normal
Abnormal
Medical History
Have you ever been diagnosed with a medical problem?
(Required)
Yes
No, I have never been diagnosed with a medical problem.
Diagnosed conditions
High blood pressure
Diabetes
DVT/PE/blood clots
Asthma
Migraines
Heart disease
Kidney Disease
Seizure/Epilepsy
Cancer
Anxiety/Depression
PTSD
Genetic condition
List any other conditions here:
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List all medications currently taking (include dosage and frequency)
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List all allergies to medications, generic allergies (dust, pollen, etc.) and allergic reaction
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Have you ever had surgery?
(Required)
Yes
No, I have never had surgery.
List all past surgeries including month & year of operation
Surgery Type
Approximate Month/Year
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Preferred Pharmacy
Pharmacy Name
Pharmacy Address
Pharmacy Phone #
Social History
Home Environment (living with)
Spouse
Children
Partner
Other
Any issues with domestic violence?
Yes
No
Religion
Do you smoke cigarettes?
Yes
Former
Never
How many cigarettes a day?
Alcohol Use
Never
1-2 times per year
1-2 times per month
1-2 times per week
Daily
Do any 1st degree relatives (mom, dad, brother, sister, children) have any cancers or genetic conditions?
Have you ever been pregnant?
(Required)
Yes
No, I have never been pregnant.
Obstetrical History
Date of Delivery
Weeks @ Delivery
Live Birth, Stillbirth, Miscarriage, ectopic
Vaginal, CS, D&C, pills
Sex/Name/Weight
Provider
Location
Complications or other info
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List each pregnancy and as many details as possible. Click + to add more
Signature
Privacy Policy Acknowledgement
Release of Information Questionnaire
May we inform family members about your appointments, treatment, general medical condition, diagnosis, healthcare operation and/or your payments?
Yes
No
If you woud like to limit this information to only specific family members, please list them here:
Name
Phone Number
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I acknowledge that I have been informed about and am aware of the Privacy Practices of this office.
Signature
Financial Policy
Please be advised that we do not take Medicaid (any type) as secondary to your Primary Commercial Insurance.
Payment is required for all services at the time they are rendered. Acadiana OB/GYN, LLC accepts payment in the form of cash, checks, and credit card.
If a check is returned to the office due to insufficient funds, the original check amount plus a $25.00 return check fee must be received within 30 days from the date the check was returned to avoid further late fees and/or collection action.
After a balance has reached 45 days past due, a late fee will be assessed. After 90 days past due, your account will be turned over to an outside collection agency for further action. The patient will be responsible for any charges incurred in such action.
Please help us better serve you and our other patients by keeping all scheduled appointments. If you must change an appointment, please do so as soon as possible, at least 24 hours before your scheduled appointment.
PATIENTS WITH PRIVATE INSURANCE
Acadiana OB/GYN, LLC is pleased to participate in a number of different insurance plans. While we are pleased to be able to participate in these plans, it is impossible for our office staff to be aware of each plan’s specific requirements. Your plan may have limitations on the frequency of services performed or where service may be performed. Some plans may require a referral from your primary care physician as well. It is the patient’s responsibility to inform Acadiana OB/GYN, LLC of specific limitations set forth by their insurance plan(s). If Acadiana OB/GYN, LLC is to order services that are considered non-covered by a patient’s insurance carrier, payment for these services becomes the financial responsibility of the patient. Due to the overwhelming number of insurance plans, it is impossible for our office staff to guarantee coverage by any individual plan. It is your responsibility to verify that we are a member of your network before presenting to our office for treatment. It is in your best interest to verify this information directly by calling the customer service number on the back on your insurance card. If we participate with a commercial insurance plan under which you are covered, we will bill the carrier for all charges for services rendered. We will bill both your primary and secondary insurance plans for contracted plans. You will be responsible at the time of service for payment of your annual deductible, co-pays, and any non-covered charges. In the event that we are not aware of a charge that is not covered by your plan, you will be billed for the balance after we obtain a denial from your insurance carrier. For those patients who have chosen a medical insurance plan that we do not have a contractual relationship with, we will require payment in full at the time of service. You will be responsible for the charges for your treatment with your insurance company and we will give you a fee bill that contains all the necessary codes and information that you can file with your insurance company for reimbursement. It is your responsibility to verify that you have insurance coverage for any services rendered to you by Acadiana OB/GYN, LLC.
Please sign below stating that you have been informed of this office policy.
Signature
Date
MM slash DD slash YYYY
Financial Obstetric Policy
Unlike other types of services, prenatal care is billed globally and will be billed at the end of your pregnancy, after delivery. Prenatal care includes your office visit and delivery charges.
During your pregnancy, physicians may order additional studies, such as ultrasound and non-stress testes. These services will be billed to your insurance at the time of the service and are not included in the global prenatal care fee. You will be responsible for co-pays and any additional fees for these services, which will be determined by your contract with your insurance.
In addition, please be aware of the cost of delivery. Some insurance companies require the patient to pay part of the delivery charge as a coinsurance and/or deductible. The coinsurance deductible is considered part of the total reimbursement to the doctor. We will arrange a monthly payment plan to pre-collect your deductible which you will be required to pay prior to delivery.
It is your responsibility to inform our office of any changes in your insurance during your pregnancy. If your insurance coverage changes during your pregnancy, it is imperative that you inform our office as soon as possible. We need to obtain a maternity pre-certification to assure your delivery will be covered by the new insurance. You will be responsible for all unpaid balances if you fail to provide the office with a change in your insurance and you deliver without providing our office with proper notification.
If these financial obligations are not met by the specified date, you will be instructed to reschedule appointments until your payments are made current and up to date.
Your signature below signifies that you understand our financial policy and agree to the terms of your responsibility regarding charges incurred at this office.
Signature
Date
MM slash DD slash YYYY
Assignment of Benefits
I authorize the release of any medical information necessary to process any claim(s) filed with my insurance company(s). I hereby authorize an assignment of benefits directly to Damon T. Cudihy, M.D. or John H Voltz, M.D. of all benefits that are payable under each insurance plan. I agree to pay whatever insurance does not pay as is necessary to pay my bill in full.
Signature
Date
MM slash DD slash YYYY
Patient Authorization and Release
Insurers and managed care companies occasionally review medical charts to insure compliance with company procedures. I understand that my chart may be selected for such review and that the confidentiality of the information in my chart will be preserved and I hereby consent to such review and release this physician and any such insurer or managed care company for liability for any reasonable review of my chart.
Signature
Date
MM slash DD slash YYYY
Private Pay Agreement
I understand that because I agree to pay for my medical care without the benefit of health insurance, I will comply with the arrangements that are made between myself and Dr. Cudihy’s/Dr. Voltz’s financial policy. I understand that these arrangements have been made to best suit my financial situation. In the event that I later find it necessary to apply for financial assistance from the State of Louisiana (Medicaid), I understand that I may not be able to use it to pay for any balance or future charges that I may incur while under the care of Dr. Cudihy/Dr. Voltz.
Signature
Date
MM slash DD slash YYYY
Insurance Changes
In the event that my insurance policy is changed, canceled, or my condition is considered pre-existing, I will comply with the arrangements that are made between myself and Dr. Cudihy’s/Dr. Voltz’s financial policy. I understand that these arrangements will be (have been) made to best suit my financial situation. In the event that I later find it necessary to apply for financial assistance from the State of Louisiana (Medicaid), I understand that I may not be able to use it to pay for any balance or future charges that I may incur while under the care of Dr. Cudihy/Dr. Voltz.
Signature
Date
MM slash DD slash YYYY