MESQUITE WOMENS CLINIC
New Patient Form

Serving the Unique Healthcare Needs of Women. Mesquite Women’s Clinic specializes in helping women manage their health through all stages of their lives.

Mesquite Women's Clinic Powered By MedSwift Mesquite Women's Clinic

Please provide the following information

Please provide the following information

Please provide your date of birth

Please provide your home address

What is your marital status?

What race do you best identify with?

Consent to Treatment

I voluntarily consent to receive medical and health care services provided by Mesquite Womens Clinic (MWC) and Dr. Edward Ofori. I understand that such services may include diagnostic procedures, examinations, and treatment. I understand this consent will be valid and remain in effect as long as I remain a patient at MWC.

Consent to Disclosure of Protected Health Information

A copy of 'Confidentiality and Release of Medical Records' is available for you to read at the front desk or on our website or patient portal at your request. A copy for your records will be made available to you by request. By signing this form, you consent that MWC may use and/or disclose protected health information as stated in the 'Confidentiality and Release of Medical Records' for treatment, payment, healthcare operations, and as otherwise allowed by law.

Release From Liability

I release liability and agree to hold harmless MWC and its agents, representative, and employees from any and all liability associated with the release of confidential patient information in accordance with this authorization. I understand MWC cannot be responsible for use of re-disclosure of information by third parties.

Financial Responsibility and Assignment of Benefits (I)

In consideration for receiving medical or health care services, I hereby assign my right, title, and interest in all insurance, Medicare/Medicaid, or other third party payer benefits for medical or health care services otherwise payable to me to MWC. I also authorize direct payments to be made by Medicare/Medicaid and/or my insurance company or other third party payer, up to the total amount of my medical and health care charges to MWC. I certify that the information I have provided in connection with my application for payment by third party payers, including Medicare/Medicaid is correct.

Financial Responsibility and Assignment of Benefits (II)

I agree to pay all charges for medical and health care services not covered by or which exceed the amount estimated to be paid, or actually paid by Medicare/Medicaid, my insurance company, or other third party payer, and agree to make payment as requested by MWC.

Financial Responsibility and Assignment of Benefits (III)

A past due account is an account not paid within 30 days from our 1"1 date of billing you. In the event that you fail to pay in full or make any kind of satisfactory arrangement for payment or otherwise within 60 days of your first bill, (or we are unable to local/notify you of your account status despite reasonable effort) your balance will be turned over to our outside office Collection Agency. A $25 charge will be assessed to all collections accounts, in addition to any accrued interest. If your account is referred to our Collection Agency, interest will continue to accrue at the rate noted herein. In addition, you will be responsible for all added percentage based Collection fees / costs per prevailing collection company contract, Attorney fees, Court Costs, Service Fees & associated Miscellaneous Fees and Costs.

Insurance Coverage Information

Insurance Coverage Address

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN

I hereby authorize the office of Mesquite Womens Clinic to release any medical information required by insurance during the course of examination and treatment, and remit payment directly to us for any benefits due for services rendered. I recognize and accept responsibility for services rendered, regardless of insurance coverage. This includes, but is not limited to, coinsurance, co-payment, deductible, and non-covered services.

MEDICARE AUTHORIZATION

I request that payment of authorized Medicare benefits be made either to me or on my behalf to Mesquite Womens Clinic for any services furnished to me by that physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

LABORATORY SELECTION

We ask that you are aware of your health insurance benefits with your insurance company; services covered, to which laboratory a specimen (such as blood test or pap test) should be sent, and that you have reviewed the amount of your deductible. If you have questions related to your insurance coverage, please contact your insurance company directly. Please be advised that Mesquite Womens Clinic is staffed by LabCorp and will process all blood and urine samples through LabCorp. We will send all pathology (pap, biopsies, etc.) to LMC Pathology Consultants. If you prefer to use, for personal or insurance reasons, Quest, please indicate so prior to us obtaining your sample and we will write you an order to obtain your lab work at another location. By clicking below, you indicate that you have read and understand the above information.

MISSED APPOINTMENT POLICY

As of December 1, 2015, we will institute a new policy regarding missed appointments. If you miss an appointment without providing 24 hours notice to our office, we will charge a missed appointment fee of $50. This charge will be a cash only payment required prior to scheduling your next appointment with our office. If you can't make your appointment, please let us know as soon as possible so we can offer it to someone else. Your consideration is appreciated because the sooner you call us the greater our chances of providing this time to someone else. Please sign below to indicate that you have read and understand this new policy.