Basin Clinic &

Basin Clinic Urgent Care Center

Patient Name:
Chief Complaint/Reason For Visit:
Date of Birth: S.S.#:
Email Address:
Ethnicity:
Marital Status:
Responsible Party S.S.#:
Address:
City: State:
Zip:
Home Phone: Work Phone:
Guardian (if patient is under 18):
Emergency Contact: Phone:
Primary Insurance:

Do you have a regular physician you would like a copy of this visit sent to?

Dr. Name: Patient Signature:__________________________________

In accordance with the Federal Truth-In-Lending Act, all providers are required to give their patients complete information in connection with the extension of credit.

Basin Clinic Policy: The patient is responsible for all medical bills. We bill your insurance as a courtesy. Payment is expected within 30 days of date of service. Our staff will help with completion of insurance forms. It is the patient's responsibility to know their contract benefits, assure collection of insurance payments to Basin Clinic and negotiate with your insurance company over disputed claims.

If You Do NOT Have Insurance: Our policy requires payment in full at time of service. If you can't make complete payment, we require that you make payment arrangements with the receptionist prior to services and make partial payment including a $50 deposit on the date of service.

If You Have Insurance: It is your responsibility to provide us with the correct insurance information. We will bill your insurance for you as long as we have the correct insurance information. However, we require you as a patient to be responsible for any balance your insurance does not pay. Any balance over 30 days is the patients responsibility. Waiting for the insurance payment is a courtesy and it may be withdrawn under certain circumstances. This office does not warrant or guarantee that your insurance company will pay, nor do we promise that an insurance company will pay the fees charged. Insurance policies are an arrangement between the insurance carrier and the patient/insured. If we are a provider for your insurance, be aware that if the patient needs to be referred to another doctor or hospital, that provider may not be a preferred provider for your insurance and the patient/policy holder will be responsible for any amount not paid by their insurance to that non-preferred provider.

If You Have Medicare: We will bill Medicare for you, but due to the length of time for reimbursement, we do ask that you monitor your statement to see that nothing is missed and to inform us if something needs re-billed.

If You Have Medicaid: We require you to pay the co-payment on the date of service. A statement will not be mailed for unpaid co-payments. A hold will be placed on your account and future appointments will not be scheduled until the unpaid co-payment is paid in full.

Co-payments, Deductibles and Non-covered Benefits: As a patient, it is your responsibility to take care of the co-payments or deductible on the date of service. Any non-covered service shall be paid within 30 days of the date of service.

Missed Appointment Policy: We require that you notify us at least 24 hours in advance as to any appointment changes. There will be a missed appointment fee of $25.00 for the first missed appointment. Missed appointment fees will be increased by $25.00 for each additional missed appointment. Future appointments will not be scheduled until all previous missed appointment fees are paid in full.

Forms Of Payment: We accept payment in cash, check, money order, or credit card. There will be a $20.00 charge on all returned checks.

Delinquent Accounts: Accounts not paid within 60 days will be placed in an in-office collection hold, turned over to a collection agency, or taken to small claims court. This action may negatively impact your credit score. We reserve the right to add charges for delinquent accounts, including the cost of sending notification via priority mail, up to a 33.33% collection fee, attorney and court costs and any additional collection fees obtained by our third party collection agency. I authorize disclosure of portions of the patient's records to the extent necessary to determine liability for payment and to obtain reimbursement should this account be turned over to collections.

Monthly Statements: You will receive an itemized monthly statement until your bill is paid in full, placed in an in-office collection hold, or turned over to a collection agency, whether you have insurance or not.

Assignment of Benefits: I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including, Medicare, private insurance, and other health plans. This assignment is to be considered as valid as the original. I understand that an insured retains ultimate responsibility for paying for health care services received. I understand that I am financially responsible for all charges whether or not paid by said insurance.

I have read and fully understand the financial office policy and agree to abide by these terms.

Signature___________________________________Date___________________

DATE_____________________

NAME____________________________________________________
PATIENT SSN#_____________________________________________



FATHER OF BABY
NEWBORN’S PHYSICIAN
REFERRED BY

BIRTHDATE:          AGE:  
RACE:     MARITAL STATUS:

MAILING ADDRESS:

OCCUPATION: (Homemaker, student, etc..)
EDUCATION: (Last grade completed)

PHONE: (Daytime)                 (Evening)

INSURANCE CARRIER/MEDICADE #

EMERGENCY CONTACT:       RELATIONSHIP:       PHONE:

TOTAL PREG

FULL TERM

PREMATURE

ABORTIONS:
INDUCED       
SPON.

ECTOPICS

MULTIPLE BIRTHS

LIVING

MENSTRUAL HISTORY

LMP:
NORMAL AMOUND/DURATION

MENSES MONTHLY: YES NO       FREQUENCY: DAYS
MENARCHE: (AGE ONSET)
ON BCPS AT CONCEPT. YES NO Hcg +

PAST PREGNANCIES (LAST SIX)

DATE MO/YR

SEX M/F

GA WEEKS

LENGTH OF LABOR

BIRTH WEIGHT

TYPE DELIVERY

ANES.

PLACE OF DELIVERY

PERINATAL MORTALITY YES/NO

TREATMENT PRETERM LABOR YES/NO

COMMENTS / COMPLICATIONS

PAST MEDICAL HISTORY


0 NEG
+ POS

DETAIL POSITIVE REMARKS

INCLUDE DATE & TREATMENT


0 NEG
+ POS

DETAIL POSITIVE REMARKS

INCLUDE DATE & TREATMENT

1. DIABETES


16. Rh SENSITIZED


2. HYPERTENSION

17. TUBERCULOSIS

3. HEART DISEASE

18. ASTHMA

4. RHEUMATIC FEVER

19. ALLERGIES (DRUGS)

5. MITRAL VALVE PROLAPSE

20. GYN SURGERY

6. KIDNEY DISEASE/UTI

7. NEUROLOGIC/EPILEPSY

21. OPERATIONS / HOSPITALIZATIONS (YEAR & REASONS)

8. PHYCHIATRIC


9. HEPATITIS/LIVER DISEASE


10. VARICOSEITIES/PHLEBITIS

22. ANESTHETIC COMPLICATIONS

11. THYROID DISFUNCTION

23. HISTORY OF ABNORMAL PAP

12. MAJOR ACCIDENTS

24. UTERINE ANOMALY

13. HISTORY OF BLOOD TRANSFUS.

25. INFERTILITY


AMT/DAY PREPREG

AMT/DAY PREG

# YRS USE



14. TOBACCO




26. STREET DRUGS

15. ALCOHOL




27. OTHER

COMMENTS:

GENETICS SCREENING

INCLUDES PATIENT, BABY’S FATHER, OR ANYONE IN EITHER FAMILY WITH:


YES / NO


YES / NO

1 PATIENT’S AGE > 35 YEARS

10 HUNTINGTON CHOREA

2 THALASSEMIA

11 MENTAL RETARDATION

3 NEURAL TUBE DEFECT (MENINGOMYELOCELE, OPEN SPINE, OR ANENCEPHALY)

IF YES, WAS PERSON TESTED FOR FRAGILE X?

4 DOWN SYNDROME

12 OTHER INHERITED GENETIC OR CHROMOSOMAL DISORDER

5 TAY-SACHS {EG. JEWISH BACKGROUND}

13. PATIENT OR BABY’S FATHER HAD A CHILD WITH BIRTH DEFECTS NOT LISTED ABOVE

6 SICKLE CELL DISEASE OR TRAIT

14. > FIRST-TRIMESTER SPONTANEOUS ABORTIONS OR A STILLBIRTH

7 HEMOPHILIA

15 MEDICATIONS OR STREET DRUGS SINCE LAST MENSTRUAL PERIOD

8 MUSCULAR DYSTROPHY

IF YES, AGENT(S)

9 CYSTIC FIBROSIS

16 OTHER SIGNIFICANT FAMILY HISTORY (SEE COMMENTS)

COMMENTS:

INFECTION HISTORY

YES / NO

4 PATIENT OR PARTNER HAVE HISTORY OR GENITAL HERPES

1 HIGH RISK AIDS

5 RASH OR VIRAL ILLNESS SINCE LAST MENSTRUAL PERIOD

2 HIGH RISK HEPATITIS B

6 HISTORY OF STD, GC, CHLAMYDIA, HPV, SYPHILIS

3 LIVE WITH SOMEONE WITH TB OR EXPOSED TO TB

7 OTHER (SEE COMMENTS)

COMMENTS:
INTERVIEWER’S SIGNATURE________________________________________

INITIAL PHYSICAL EXAMINATION

DATE     PREPREGNANCY WEIGHT    HEIGHT     BP

1. HEENT                       NORMAL        ABNORMAL

12. VULVA        NORMAL        CONDYLOMA        LESIONS

2. FUNDI                         NORMAL        ABNORMAL

13. VAGINA          NORMAL        INFLAMMATION        DISCHARGE

3. TEETH                       NORMAL        ABNORMAL

14. CERVIX        NORMAL        INFLAMMATION        LESIONS

4. THYROID                   NORMAL        ABNORMAL

15. UTERUS         NORMAL        ABNORMAL        FIBROIDS

5. BREASTS                  NORMAL        ABNORMAL

16. ADNEXA         NORMAL        MASS

6. LUNGS                       NORMAL        ABNORMAL

17. RECTUM        NOMRAL        ABNORMAL

7. HEART           NORMAL        ABNORMAL

18. DIAGONAL CONJUGATE        REACHED        NO        CM

8. ABDOMEN                 NORMAL        ABNORMAL

19. SPINES          AVERAGE        PROMINENT        BLUNT

9. EXTREMITIES           NORMAL        ABNORMAL

20. SACRUM        CONCAVE        STRAIGHT        ANTERIOR

10. SKIN           NORMAL        ABNORMAL

21. ARCH             NORMAL         WIDE        NARROW

11. LYMPH NODES           NORMAL        ABNORMAL

22. GYNECOID PELVIC TYPE            YES        NO

COMMENTS: (Number and explain abnormals):
Exam by________________________________