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1692 Chatham Parkway
Savannah, GA 31405
www.themidwifegroup.com
1
OB PATIENT INFORMATION
NAME: LAST FIRST MIDDLE
DATE OF BIRTH MARITAL STATUS SOCIAL SECURITY NUMBER
ADDRESS CITY STATE ZIP
PHONE: HOME CELL WORK
EMAIL ADDRESS (for patient portal access):
EMPLOYER OCCUPATION
RACE:
ETHNICITY:
o
No, not
Spanish/Hispanic/Latino
o
Decline to Answer
o
Unknown
o
Yes/Cuban
o
Yes/Puerto Rican
o
Yes, Mexican, American, Chicano
o
Yes, Other Hispanic
o
(Specify)
PREFERRED LANGUAGE:
o English
o Spanish
o Japanese
o Italian
o Hindi
o
Portuguese
o
Russian
o
French
o
o
Tagalog
o
Arabic
o
Bosnian
o
Vietnamese
o
Laotian
o
o
Gujarati
INSURANCE INFORMATION
**please be sure to provide information for the PRIMARY POLICY HOLDER when completing this section**
NAME: LAST FIRST MIDDLE
DATE OF BIRTH GENDER SOCIAL SECURITY NUMBER
ADDRESS CITY STATE ZIP
PHONE NUMBER PATIENT’S RELATIONSHIP TO POLICY HOLDER
INSURANCE COMPANY
GROUP NUMBER POLICY NUMBER
CLAIMS MAILING ADDRESS:
(usually found on back of card)
SECONDARY INSURANCE INFORMATION (if applicable)
**please be sure to provide information for the PRIMARY POLICY HOLDER when completing this section**
NAME: LAST FIRST MIDDLE
DATE OF BIRTH GENDER SOCIAL SECURITY NUMBER
ADDRESS CITY STATE ZIP
PHONE NUMBER PATIENT’S RELATIONSHIP TO POLICY HOLDER
INSURANCE COMPANY
GROUP NUMBER POLICY NUMBER
CLAIMS MAILING ADDRESS:
(usually found on back of card)
PATIENT NAME (please print) DATE OF BIRTH
o
o
o
o
o Other
o Decline to Report
o
White
Black/African
American
American Indian or
Alaskan Native
Asian
Hispanic or Latino (no race
info available)
o
Native Hawaiian or Pacific
Islander
1692 Chatham Parkway
Savannah, GA 31405
www.themidwifegroup.com
2
SPOUSE/SIGNIFICANT OTHER
NAME: LAST FIRST MIDDLE
DATE OF BIRTH MARITAL STAUS SOCIAL SECURITY NUMBER
PHONE: HOME CELL WORK
EMPLOYER OCCUPATION
PARENT/GUARDIAN (if applicable)
NAME: LAST FIRST MIDDLE
ADDRESS CITY STATE ZIP
PHONE RELATIONSHIP TO PATIENT
ALTERNATIVE CONTACT (other than spouse/significant other – if applicable)
NAME: LAST FIRST MIDDLE
ADDRESS CITY STATE ZIP
PHONE RELATIONSHIP TO PATIENT
PREFERRED PHARMACY
NAME LOCATION
PREFERRED LAB
We send all lab work to LabCorp. Your insurance provider may require the use of a different lab. Please select:
LIVING WILL
Do you have a living will?
o
Yes
o
No
o
I’d like information about
establishing a living will
PATIENT SIGNATURE
DATE
o LabCorp o Other (specify):
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1692 Chatham Parkway
Savannah, GA 31405
www.themidwifegroup.com
3
PRIVACY NOTICE
This privacy notice describes how your medical information may be disclosed and used by this practice. This notice also discusses your rights to
access your medical information.
The HIPAA Privacy Rule allows your health information to be disclosed to carry out treatment, payment, and other healthcare operations. We are
required to abide by the information outlined in this privacy notice. We reserve the right to update this policy as changes occur in the HIPAA
Privacy Rule. HIPAA grants you the right to access and control your health information.
USES AND DISCLOSURES
Treatment: Your health information will be disclosed to provide, coordinate, and manage your healthcare. All of the providers in our practice may
have access to your medical records. Additionally, our medical consultants and ultrasonographer review some records to assist us with your care.
Your health information may be disclosed to any other physician or healthcare provider that may become involved in your care.
Healthcare Operations: Your health information will be used to support the business activities of the practice. Examples include, but are not
limited to: quality assessment, employee reviews, nursing and midwifery student training, licensing, and other business activities. Health
information may be shared in our group prenatal sessions.
Payment: Your health information will be used to obtain payment for services provided by this practice. Disclosures may be given to health plans,
insurance providers, and collection agencies.
Business Associates: Your health information may be shared with third party business associates. Examples include billing and legal services. We
have established written contracts that contain the terms that will protect your health information with all third-party business associates. All
business associates must comply with HIPAA guidelines.
Disclosures Requires by Law and Workers Compensation: We are permitted to disclose your health information to comply with workers
compensation laws and legal proceedings. If required, you will be notified of disclosure. The protected health information of members of the
armed forces may be disclosed to authorized federal officials, under certain circumstances.
Abuse or Neglect: We may disclose your protected health information to the appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, or domestic violence.
Emergencies: If you are incapacitated, we may use our best judgement to disclose information that is only directly relevant to your care.
Research and Health Oversight: We are permitted to disclose your information to researchers with an institutional review board has reviewed a
research proposal and established protocols to ensure your health information will be kept confidential. We are permitted to disclose your health
information to a health oversight agency for activities authorized by law. Examples include: audits, investigations, and inspections.
Written Authorization: Unless not required by law, your written authorization will be required for all disclosures of your protected health
information. You can revoke authorization at any time via written request. It is important to note that we are unable to undo any disclosures
previously made with your authorization.
Voicemail: Employees may only leave detailed voicemail messages if the greeting appropriately identifies the patient or anothe
r person who is
authorized to receive information regarding the patient. If there is not appropriate identification, only the minimum necessary information will be
left. This includes the caller’s name, practice name, and a contact number. Patients have the right to opt out of voicemail messages.
PATIENT RIGHTS
You have the right to inspect and copy your protected health information. You may obtain your medical record that contains medical and billing
information. As permitted by federal or state law, we may charge you a reasonable copy fee to provide a copy of your records. You may request
an amendment of your protected health information. We reserve the right to deny your request. If we deny your request for amendment, you
have the right to file a statement of disagreement. We may provide you with a copy of any rebuttal. Federal law prohibits you from inspecting or
copying psychotherapy notes and information compiled in reasonable anticipation of, or use of, civil or criminal proceedings, or administrative
actions or proceedings.
PRIVACY COMPLAINTS/ CLIENT GRIEVANCES
Should you believe that your privacy rights have been violated, and wish to file a complaint, you may contact us by calling our office at (912)629-
6262 and asking to speak with our privacy officer. The director or her designee will personally respond within 10 business days to any complaint
registered by a client about any aspect of Family Health and Birth Center. You may also contact our accrediting organization, The Commission for
the Accreditation of Birth Centers at 240 Independence Drive, Hamburg, PA 19526, phone number 1-877-241-0262. Unresolved complaints may
be directed to the Georgia Department of Community Health, Health Facilities Regulation Division, Attention: Complaints, 2 Peachtree Street NW,
Atlanta, GA 30303-3142, phone: 1-800-878-6442.
1692 Chatham Parkway
Savannah, GA 31405
www.themidwifegroup.com
4
o
I choose to opt-out of voicemail messages.
o
I choose to have voicemail left with minimally
necessary information. In the event that I am not
available, you may leave a message
DISCLOSURE OF CONFIDENTIAL INFORMATION (select one)
I authorize you to disclose information about my care and allow the following individual/s to schedule, reschedule,
and cancel appointments on my behalf:
Name: Relationship:
Name: Relationship:
Name: Relationship:
Name: Relationship:
PATIENT SIGNATURE DATE
CONFIDENTIALITY AGREEMENT FOR PARTICIPATION IN GROUP PRENATAL CARE (for pregnant patients only)
You have the right to expect what is said in class to remain private and confidential. Along with our commitment to
maintain your privacy, you also have a responsibility to respect and protect each other’s privacy. If you have any
questions about this policy, you may ask our HIPAA compliance officer.
I have read the Privacy Notice and understand these policies.
PATIENT SIGNATURE
DATE
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1692 Chatham Parkway
Savannah, GA 31405
www.themidwifegroup.com
5
OUR FINANCIAL POLICY / RELEASE AND ASSIGNMENT
Full payment is due at the time of service. We accept cash, checks, and credit cards. Our practice is committed to
providing the best treatment for our clients, and our charges are reasonable and customary for our area.
I am responsible for payment regardless of the insurance company’s arbitrary determination of reasonable and
customary rates or decisions regarding non-covered services. I agree to pay collection fees associated with any
outstanding balance on my account.
I hereby authorize The Midwife Group and Birth Center/Family Health and Birth Center, Inc. to release any of my
medical records deemed necessary to process my insurance claim. I authorize payment of medical benefits to The
Midwife Group/Family Health and Birth Center Inc., or its providers for services rendered to me. I fully understand that I
am responsible for all charges incurred as a result of services rendered to me and any balance remaining after my
insurance pays. I, the undersigned, a patient at this facility, hereby authorize the providers (and whomever they may
designate as their assistants) to administer treatment as necessary. I hereby certify that I have read and fully
understand this authorization for medical treatment. I also certify that no guarantee or assurance has been made as to
the results that may be obtained.
PATIENT SIGNATURE
DATE
OR SIGNED FOR PATIENT BY
RELATIONSHIP
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1692 Chatham Parkway
Savannah, GA 31405
www.themidwifegroup.com
6
HIV TESTING IN PREGNANCY (for pregnant patients only)
The HIV test is a routine screening in pregnancy. While I do have the right to refuse HIV testing, I understand that doing so may
eliminate me from being eligible for care at The Midwife Group and Birth Center. I consent to HIV testing and understand that the
result will become a part of my medical record.
PATIENT SIGNATURE DATE
DRUG TESTING IN PREGNANCY (for pregnant patients only)
Because the use of illegal drugs/substances is potentially harmful for me and my fetus, drug screening is a routine screening in
pregnancy. While I do have the right to refuse drug testing, I understand that doing so may eliminate me from being eligible for care
at The Midwife Group and Birth Center. I consent to drug testing and understand that the results will become a part of my medical
record.
PATIENT SIGNATURE DATE
NO SHOW FEE
We understand that there are times when you may miss an appointment due to emergency or unexpected obligations for work or
family, however, when you do not call to cancel your appointment in a timely manner, you may be preventing another patient from
getting an appointment. If an appointment is not cancelled at least 24 hours in advance, you may be charged a $25 fee. This fee will
not be covered by your insurance company.
PATIENT SIGNATURE DATE
PARTICIPATION IN EDUCATION
I hereby give my permission for the participation of students in my care. Students will always be supervised by a Certified Nurse
Midwife, Nurse Practitioner, Medical Doctor, Radiologic Technologist, or Registered Diagnostic Medical Sonographer. I may refuse
student involvement at any time.
PATIENT SIGNATURE DATE
AABC PERINATAL DATA REGISTRY (for pregnant patients only)
The purpose of this data registry is to help improve and maintain quality of care of childbearing families, provide for ongoing and
systematic collection of data on normal birth, and facilitate research on maternity care practices that support optimal birth. By
consenting to participate in this registry I understand that all information about me and my pregnancy will be kept confidential. As
required by HIPAA, no identifying information will be seen by those conducting the project except for my date of birth and zip
code. Statistical data will be kept on file and may be used later by other researchers who are studying specific parts of birth center
or midwifery care. I freely consent to participate, and also give permission for data about my newborn to be used.
PATIENT SIGNATURE
DATE
PRINTED PATIENT NAME
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7
DISPLAY NAME AND DUE DATE ON BULLETIN BOARD CONSENT
Some parents choose to display their first name and due date (as well as baby’s name, date of birth and weight after
delivery) on our bulletin board. The HIPAA privacy law requires that our office have written consent to display this
information at our facility. HIPAA also requires that we allow you to choose an expiration date at which time your
information will be removed from display.
o
I give permission to have my name, due date, baby’s name, date of birth, and weight displayed on the bulletin
board. It will be taken off display and provided to me at my six week postpartum visit (or destroyed)
o
I do not give the birth center permission to display information about me or my baby
SIGNATURE DATE
PHOTO DISPLAY CONSENT
Some parents choose to send us photographs of their babies to display on the bulletin board. The HIPAA privacy law
requires that our office have written consent to display any photographs that you send to our facility. HIPAA also
requires that we allow you to choose an expiration date at which time your photograph will be removed from display
and discarded.
o
I give permission to have any pictures I send to the birth center displayed on the bulletin board
indefinitely
o
I do not give the birth center permission to display any photos I may send
o
I give permission to have any pictures I send to the birth center displayed on the bulletin board
until the following date
:
SIGNATURE DATE
PRINT NAME
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8
OB HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential
and will become part of your medical record. Please complete ENTIRE form.
Name
(Last, First, M.I.):
DOB:
Marital status:
Single Partnered Married Separated
Widowed
Divorced
Significant other’s name:
He/She is present for pregnancy deployed incarcerated
Is this pregnancy planned or unplanned? Do you have supportive family and friends?
Highest level of education: Employment: What is your job?
Who do you live with?
What are your living arrangements? House Apartment Mobile Home Other
PERSONAL MEDICAL AND SURGICAL HISTORY:
Please complete this portion of your health history in the patient portal PRIOR to your appointment. This is a very important part of
your care and we want to make the most of your visit with the midwife by having the most updated and complete information
. If the
patient portal is not completed, we may be required to reschedule or have you return for an additional visit to
complete the appointment.
FAMILY HEALTH HISTORY:
Your family history is very important for certain health screening as well as anticipating your health care needs. Please ensure you
complete this section in the
patient portal PRIOR to your appointment.
OB/GYN HEALTH HISTORY
Last Menstrual Period:
Last pap test: Have you ever had an abnormal Pap test?
Age period began? Length of periods? #days between periods?
Any recent changes in your periods?
Yes
No
Are you sexually active?
Yes
No
Do you use birth control?
Yes
No
Do you do regular self-breast exams?
Yes
No
Since your last period, have you had any illnesses, rash, fever or exposure to x-rays or toxic chemicals?
Yes
No
Were you born premature (<37 weeks)
Yes
No
Are you currently breast feeding another baby?
Yes
No
Have you had a UTI (urinary tract infection) within 6 months of this pregnancy
Yes
No
Have you experienced any of the following (check all that apply): NONE
Sexual or physical abuse or assault Domestic violence
Emotional Abuse Childbirth trauma
Major accident or illness or other traumatic event
9
Name:
Pregnancy History
Total # pregnancy: # Premature births #miscarriages/ abortions: # term
births?
LAST NAME:
DOB:
Baby date of birth
day/month/year
Weight
Sex
Weeks
pregnant
Type of
birth
Length of
labor
Complications/ Comments
NUTRITION & EXERCISE
Exercise
Do you exercise? Yes No What type of exercise do you enjoy? How often?
Diet
Are you on any special diet or have dietary restrictions? If so what?
Do you eat three meals a day?
Do you have a working stove?
Do you have running hot and cold water?
Do you receive WIC?
Are you able to purchase the foods you need?
Would you like to speak to someone about your diet and foods?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
#meals you eat in an average day?
How often do you eat:
Never
2-3 times/month
Fast/restaurant food
Frozen meals
Home-cooked meals
Beef
Chicken/Turkey
Pork
Fish, Type?
Deli meat
Beans
Cookies/Cakes/Muffins
Other refined grains (white
bread, white rice, white pasta)
Whole grains
Vegetables (fresh, frozen)
Fruit (Fresh, frozen)
Canned vegetables/fruit
Dairy (milk yogurt, cheese,
butter)
Fried food
Artificial sweetener
Meal replacement bars or shakes
How much water a day?
Once/week 2-3 times/week
How much caffeine a day?
Once/day
2-3 times/day
10
NAME:
_
Genetic Screening: Comments
Are you older than 35 at the time of birth? Yes No
Family history of thalassemia (Italian Greek, Mediterranean or Asian) Yes No
History of Neural tube defect (meningomyelocele, spina bifida) Yes No
Congenital heart defect
Yes
No
Downs Syndrome
Yes No
Tay-sachs (Ashkenazi Jewish, Cajun, French-Canadian)
Yes No
Canavan Disease (Ashkenazi Jewish)
Yes No
Familial dysautonomia (Ashkenazi Jewish)
Yes No
Sickle cell disease or trait
Yes No
Hemophilia or other blood disorder
Yes No
Muscular dystrophy
Yes No
Huntington Chorea Yes No
Mental retardation or autism
Yes No
Other inherited genetic of chromosomal disorder
Yes No
Maternal metabolic disorder (diabetes type 1 or PKU)
You or baby’s father had a child with birth defects not listed above
Recurrent pregnancy loss or stillbirth
Medications including supplements, vitamins, herbs, illicit drugs, recreational
drugs or alcohol or exposure to toxic chemicals or X-rays since last menstrual
period
Infection history:
Do you live with someone with TB or exposed to TB?
Have you ever had chicken pox or had the vaccine?
Have you had the HPV vaccine?
Do you or your partner have a history or herpes?
Have you had a rash or viral illness since your last period?
Do you have a history of Hepatitis B or C?
Do you have a history of STDs (gonorrhea, chlamydia, HPV, HIV or syphilis)?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
Comments:
No
No
No
No
No
No
No
Reviewed by: Date:
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