New Patient Form

I hereby assign all medical and/ or surgical benefits, to include major medical benefits to which I am entitled, private insurance and any other health plans to Drs. Sigman, Napier, Heintges, and Harms. This assignment will remain in effective until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure payment.

We are committed to providing you with the best possible care. If you have medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policies.

Payment for services not covered by your insurance plan and any out of pocket expenses are due at the time of service. Our office collection policy supersedes any other contract language or statements in managed care contracts or other insurance policies. We accept checks, cash, debit cards: Master Card, Visa, Discover, and American Express. We will be happy to file your insurance if you are a member of one of our managed care plans. We do not file claims on insurance plans that we do not participate with or on new insurance that we have not had an opportunity to verify in advanced of your appointment.

Returned checks and balances older than 60 days may be subjected to an additional collection fees and interest charges of 1-2% per month. Charges may also be made for appointments cancelled without 24-hour notice. Any surgeries that are canceled within 48 business hours of surgery, or patients that no-show for their pre-op appointment will be subject to a $100 cancellation fee. We will gladly answer questions regarding your insurance. You must realize however that:

• Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.
• We will file your insurance for plans in which we participate, only if we have the necessary information to verify your benefits 48 hours prior to your appointment and you present your actual card upon arrival. We do not verify insurance benefits on the same day as your appointment, so you will be asked to self-pay or reschedule.
• Our fees are generally considered to fall within the acceptable range of usual and customary by most companies and therefore, are covered up to the maximum allowable determined by each carrier.
• Not all services are a covered benefit in your contract. Some insurance companies arbitrarily select certain services they will not cover or may set maximum limits. Such services include laboratory charges, sonograms, injections, and in office procedures, etc. You will receive a separate bill for these services. These amounts are your responsibility.

We must emphasize that as a medical care provider, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. It is understood that temporary financial problems may affect timely payments of your account. If you have any questions regarding the above information, please do not hesitate to ask.

I have read and understand my financial obligations under the above policy and will be fully responsible for the payment of any and all services.

To our patients: This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and accountability Act of 1996 (HIPAA).

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of you health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, buy we must provide you with the following important information.

The following circumstances may require us to use or disclose your health information:

1. To the public health authorities and health oversight agencies that are authorized by law to collect information.
2. Lawsuits and similar proceedings in response to a court or administrative order
3. If required to do so by a law enforcement official
4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat
5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities
6. To federal officials for intelligence and national security activities authorized by law
7. To correctional institutions or law enforcement officials you are an inmate or under the custody of a law enforcement official
8. For Workers Compensation and similar programs

Your rights regarding your health information:

1. Communications. You can request that our practice communication with you about you health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.
2. You can request a restriction in out use or disclosure of your health for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request: however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit a signed and dated request to: Dr. Sigman, Napier, Heintges, & Harms 12201 Merit Dr #350 Dallas, Texas 75251
4. You may ask us to amend your health information if you believe it is incorrect or incomplete and as long as the information is kept by or for our practice. To request an amendment, it must be made in writing and provide us with a reason that supports your request for amendment and submitted to: Dr. Sigman, Napier, Heintges, & Harms 12201 Merit Dr #350 Dallas, Texas 75251
5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Private Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact out front desk receptionist.
6. Right to file compliant. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Maggie Fuller at 214-238-7809. All complaints must also be submitted in writing to the practice address. You will not be penalized for filing a complaint.
7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact our office manager, Maggie Fuller at 214-238-7809. I hereby acknowledge that I have been presented with a copy of the Notice of Privacy Practices for Advanced Women’s Healthcare.

I consent to the use or disclosure of my protected health information by Drs. Sigman, Napier, Heintges, and Harms (hereafter known as the clinic) for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of the clinic. I understand that diagnosis or treatment of me by the clinic may be conditioned upon my consent as evidence by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the clinic. The clinic restriction that I request, the restriction is binding on the clinic.

I have the right to revoke this consent, in writing, at any time, except to the extent that the clinic has taken action in reliance on this consent.

My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review the clinic's Notice of Privacy Practices prior to signing this document. The clinic's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of the clinic. The Notice of Privacy Practices for the clinic is also provided in the reception area. The Notice of Privacy Practices for the clinic is also provided in the reception area. The Notice of Privacy Practices also describes my right and the clinic's duties with respect to my protected health information.

The clinic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the clinic and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

Dear valued patient,

Insurance companies typically limit lab work we are able to offer at the "well woman" visit. Labs typically approved and covered as "preventative" include pap smear, HPV testing (for individuals meeting criteria) complete blood count, metabolic panel, and lipid panel.

Urine analyses, vaginal cultures, thyroid, vitamin and hormone testing would generally go towards your deductible or could possibly not be covered if drawn during a preventative care visit.

Any additional lab testing recommended by the physician or requested by the patient may incur separate charges that will be the responsibility of the patient.

We apologize for any inconvenience this may cause.