Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 4**Consent to transmit patient information and my signature electronically. *I agreeI do not agree (Please close form and contact office)All data submitted through this form electronically will be treated in accordance with our privacy policy and will be encrypted and stored securely. Patient Contact Information Name *FirstLastAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Home Phone *Alternate Phone (ie. work, cell)May we leave a messageHome PhoneAlt. PhoneEmergency Contact Emergency Contact Name *FirstLastRelationship to patient *Emergency Contact Phone (Home/Cell/Work) *About Patient Date of Birth *SSNRace (Optional)American Indian / Alaska NativeHawaiian / Pacific IslanderAfrican AmericanAsianWhiteEthnicity (Optional)Hispanic / LatinoNot Hispanic / LatinoPrimary Care PhysicianPreferred Pharmacy & LocationPharmacy PhoneDo you have medical insurance? *YesNoInsurance CompanyMember IDGroup IDClaims Address, City, State, ZipCustomer Service PhoneResponsibile for Patient Is someone else responsible for this patient? *YesNoResponsible Party Name *FirstLastRelationship to patient *Date of Birth *SSNAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (Home/Work/Cell) *Patient Authorizations Patient Authorizations-Check all that apply *Authorization to Consult with Four Corners OB-GYN: I hereby authorize Southwest Midwives to release my medical information to four Corners OB-GYN on the event my care requires a physician consultation.Third Party Payor Authorization/ Release: I hereby authorize direct payment to Southwest Midwives of any third party payor benefits (insurance company, government agency, ect.) I hereby authorize Southwest Midwives to release medical records to any third party payor.**Authorization for PBM (Prescription Benefit Manager): I hereby authorize Southwest Midwives to have access to all PBM information. Definition below.**Prescription Benefit Management (PBM) consent is an agreement that allows a pharmacy benefit manager (PBM) to request and use a patient’s prescription history for treatment purposes. By signing below, I agree to the patient authorizations that I selected in the previous section. * Clear Signature NextPatient Informed ConsenT NOTICE TO OUR PATIENTS REGARDING PAYMENT: If you are SELF PAY—FULL payment of services rendered is required at the time of service. **CURRENT INSURANCE CARDS MUST BE PRESENTED AT THE TIME OF SERVICE** If we ARE contracted with your insurance—FULL payment of co-pay’s, co-insurance, or deductibles are required at the time of service. We will bill your insurance—as a courtesy to you. Please understand if we are not contacted by your insurance within 60 days the balance will be your responsibility. If we ARE NOT contracted with your insurance—FULL payment of services is required at the time of your visit. We will bill your insurance—as a courtesy to you, but full payment is required at the time of service, if a refund is due to you we will issue it when insurance pays us. Please understand if we are not contacted by your insurance within 60 days, the balance will be your responsibility. Or we would be happy to give you the necessary paperwork so you can bill your insurance yourself. OB patients: We will bill your insurance, whether we are contracted or not, for your global package— as a courtesy to you. The above information does apply to services not covered in your OB contract. Please be familiar with what this includes. Non-global problem visits are billed separately. Check each box below upon reading to acknowledge that you have read and agree to the following: OB Patients with Blue Cross Blue Shield *For the most part this insurance ONLY pays for ONE ultrasound /pregnancy. If you chose to have a pregnancy confirmation ultrasound as well as the routine 20-week ultrasound, be aware that you may be responsible for full payment of the 20-week ultrasound.Pre-authorization Requirements *Southwest Midwives will obtain ALL referrals from other physicians, or pre-authorizations from insurance to be in compliance with your insurance or medical coverage. However, it is very helpful to us if you are also aware of your insurance requirements and double-check with us that we are meeting those requirements. If SWMW fails to obtain a required preauthorization, we will do our best to correct the mistake, but ultimately, you will be responsible for payment.Annual Exams *Some insurance companies do not cover preventive care visits. Due to insurance fraud issues, we cannot change the reason for your visit AFTER you have left the office. We contract with many insurance carriers to offer you discounted services and specialty care, but we do not know what your specific plan covers. Please let us know whether you are being seen for a problem or a routine physical exam, so that we may provide you with appropriate care and avoid insurance disappointments.Record Release *We do charge a fee to release records, unless one of our doctors has referred you elsewhere. We only release records for visits and tests done here at this office.Medicaid Patients *All Medicaid patients are responsible for ensuring they are eligible for Medicaid benefits at the time of service. Proof of this eligibility is required in the form of a Medicaid card, an eligibility letter from Medicaid, or an eligibility letter from your case worker. If Medicaid denies a claim due to ineligibility 100% payment is the patient’s responsibility.Account Balances *All past due balances, or collection accounts must be paid in full at the time you come in for your appointment. You may call to set up payment arrangements, but these must be reasonable and paid in a timely manner. All arrangements MUST be made in advance!Cancellations *In order to provide the best possible service and availability to ALL our patients, should you need to cancel your appointment, we ask that you please do so at least 24-hours in advance. If your appointment is not cancelled in advance a fee of $40 will be assessed to your account.Emergency Contact *I give my consent to both SW Midwives and Aspen Billing to discuss finances and medical information with my listed Emergency Contact.Download a copy of this form for your records. By signing below, I agree to all of the items listed on the Patient Informed Consent form and I have been provided a digital copy of this form for my records. * Clear Signature NextCONTRACT OF FINANCIAL RESPONSIBILITY In agreeing to be responsible for your medical care, Southwest Midwives requires that you be responsible for your financial obligations to us. Check each box below upon reading to acknowledge that you have read and agree to the following: (If you are a minor, under 18 years of age, your parent or legal guardian must accept financial responsibility on your behalf) Payment for Services *I agree that I will pay in full for all services provided to me by Southwest Midwives at the time of service, unless my services are covered by a contracted insurance.Co-pay, Co-insurance, Deductibles *I understand that my insurance company or health plan may require me to pay co-payments, coinsurance or deductibles. I agree to pay these in full at the time of service, or within 30 days if billed separately. Authorizations-Check of have Contact Insurance *I understand that if my contracted insurance has not paid within 60 days of billing them, I will be required to contact them to find out why the claim has not been paid. I understand payment is my responsibility at that time as well.Fail to Pay *I understand that if, 60 days after billing, I fail to pay any balance due on my account, further action may be taken on my account, unless other previous arrangements have been made and approved by Southwest Midwives.Account Collections *If my account is sent to collections, or I am taken to small claims court, I am responsible for all amounts due plus all collection and court costs including: 1) A handling charge – up to 50% of my account balance, or an interest fee of 33% from the date of service – will be added to my account; 2) If I am taken to small claims court an extra handling charge of $210.00 will also be added to my account; 3) All collection expenses charged by the collection agency, or court costs incurred; 4) All reasonable attorney’s fees; 5) Any discounts I may have received on my account will be reversed.Small Claims Court *I also understand that at the discretion of Southwest Midwives, I may be taken to small claims court for full reimbursement of all fees and balances.Alternative Care *If further action must be taken on my account, Southwest Midwives may require me to permanently seek further care elsewhere, in accordance with guidelines set forth by the Colorado State Board of Medical Examiners.We appreciate your understanding of this financial agreement and look forward to working with you as a client! Download a copy of this form for your records. By signing below, I agree to all of the items listed on the Contract of Financial Responsibility form and I have been provided a digital copy of this form for my records. * Clear Signature Nextprovider notice of privacy practice THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Use and Disclosures of Health Information: We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, to evaluate the quality of care that you receive, and in consultation with the physicians at Four Corner’s OB/GYN when protocols require a chart review. Continuity of care is part of treatment and your records may be shared with other providers to whom you are referred. Information may be shared by paper mail, electronic mail, fax or other methods. We may use or disclose identifiable health information about you without your authorization for several reasons. Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask you for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop further uses and disclosures. We may change our policy at any time. Before we make a significant change in our policy, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person(s) listed in the “Our Legal Duty” section below. Individual Rights: In most cases, you have the right to look at or get a copy of health information about you that we use to make decisions about you. If you request copies, we will charge you only normal photocopy fees. You also have the right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment or related administrative purposes and other than when you explicitly authorized it. If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add missing information. Complaints: If you are concerned that we violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person(s) listed in the “Our Legal Duty” section below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person(s) listed in the “Our Legal Duty” section below can provide you with the appropriate address upon request. Our Legal Duty: We are required by law to protect the privacy of your information, provide this notice about our information practices that are described in the notice, and obtain your acknowledgment of receipt of this notice. If you have any questions or complaints, please contact Megan Cleveland, owner of Southwest Midwives Inc., by email (megan@swmidwives.com). Acknowledgement of Receipt of Notice of Privacy Practices: Please sign your name and print your name and date on this acknowledgement form and return to the receptionist or to the address above. (Upon request, we will gladly provide you with a copy of this privacy notice for your records.) Download a copy of this form for your records. By signing below, I the terms of the Provider Notice of Privacy Practice and I have been provided a digital copy of this form for my records. * Clear Signature Submit
