New Patient Forms

New Patient Forms

Click on each section below to fill out our new patient forms digitally. Please submit all three before your scheduled appointment. Call Houston OB/GYN today at 478.923.6216 with any questions or to make an appointment!

PATIENT INFORMATION


INSURANCE INFORMATION




HIPPA PRIVACY NOTICE AND AUTHORIZATION TO RELEASE INFORMATION

I give my authorization for Dr. Carlo Lee to provide treatment and disclose all or part of my patient records to any insurance company or association, the Federal or State Government such information as may be necessary for the completion of all clinical claims. This is not a blank authorization and will not be used for any other purpose, to protect your privacy. Our policy is to protect your private medical records. By doing so, we have requested you to sign this authorization to share information as needed, to render proper medical care. Any other form of release of information will be required in writing by you. Our office will contact you by phone, and/or leave a message, for appointments, results, and/or to schedule procedures. We may need to send a card or letter to contact our office. The bills we send out will contain visit information for billing purposes only. We have signed agreements to contractors, and other outside agency, to protect you medical information. If you have a complain or require copies of your medical record, we must have your request in writing and give this to our (PHI) * Compliance Officer. Any complaints or request will be reviewed and responded in writing. By law we have 30 days to provide copies of medical records, unless it is a medical emergency. Our HIPPA information and a summary of our policies are posted in the waiting room. If you have any questions or concerns, please address this with our compliance office at your appointment or provide this in writing and if you disagree with our policy you must inform us in writing. Our office reserves the right to accept or reject your dispute. * Our HIPPA Compliance Officer – will handle all records.

ASSIGNMENT OF BENEFITS

I hereby authorize payment to Houston Ob/Gyn LLC for benefits herein specified and otherwise payable to me for any services rendered by the practice subsequent to this date. The undersign has been Advanced Notice that “Routine Care” and “Preventative Care,” may not be payable by insurance. The responsible party and/or patient agree to pay for All UNPAID Medical Expenses upon billing sent to undersigned. The undersign understands that a monthly interest of 1 1/2 % or a minimum of $4 a month charge will be added to the unpaid balance. If your bill is turned over to a collection agency, the undersign agrees to pay any court cost or excessive fees to collect unpaid balances. Authorization of benefits is to be paid on my behalf to Houston Ob/Gyn LL copy shall be as valid as the original.


If you provide us with your email address we can send you health information via your email.

I, the undersigned, the patient or authorized by the patient, certify that I have read the foregoing and agree to execute the above and accept the terms. Authorizing consent to treat the patient and taking financial responsibility for any charges incurred as stated about.

Current Medications (please include vitamins, herbal supplements and over-the-counter medications)


Menstrual History


Obstetrical History

(including miscarriages and terminations)




Surgical History

(not including c-sections listed above)


Hospitalizations

(not including surguries listed above)


Family History

Mother

Father

Brother/Sister

Brother/Sister

Brother/Sister


Personal/Family History

Have you or any close members of your family (not listed above) including grandparents, aunts, and/or uncles had any of the following medical conditions?

Breast Cancer

Ovarian Cancer

Endometrial Cancer

Colon Cancer

Colon Polyps

Other Cancers (list type)

High Blood Pressure

Heart Disease/Angina

Elevated Cholesterol

Osteoporosis

Diabetes

Mental Illness

Substance Abuse

Blood Clots/Thrombosis

Problems with Anesthesia


Social History


Pap Smear


Mammogram