Greeting from Dr. Bader and staff,
It is our pleasure to welcome you to the office. In order to provide quality services in a timely manner for our customers, we have enclosed several forms that must be completed prior to your appointment time.
Please bring updated insurance information when you visit. Any co-payments that are predetermined by your insurance plan should be paid on the date of your visit. It is the responsibility of the individual to understand their insurance benefits and check into relevant stipulations specific to their plan. If you are enrolled in Hoosier Health/Medicaid please check with your primary care physician’s office to have the referral (or prior authorization) faxed to the office.
If you do not have insurance, payment arrangements can be made. However, we require seventy-five dollars ($75.00) on the first visit. We do accept Visa, MasterCard, and Discover credit cards for your convenience.
Any cancellation should be made 24 hours before your appointment. Cancellations made less than 24 hours prior to an appointment or not showing for your appointment significantly decrease the opportunity to schedule a future visit and possibly may result in you being charged a fee.
It is our office policy to confirm appointments 24 to 48 hours in advance. If for any reason, you do not receive a call to confirm your appointment, please contact us to verify the scheduled time of your appointment. We would greatly appreciate updates on any changes of names, phone numbers, addresses or other relevant information.
Please arrive 15 minutes before your appointment time with the following pages completed. If you or a family member (whomever is the patient) is currently taking any medications please bring those medications in a bag. A detailed list of current medications, strength, and dosage is also sufficient. We hope this information is informative and helpful. We look forward to meeting you!
Sincerely,
Dr. Patricia Bader and all of the Genetics Team
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NORTHEAST INDIANA GENETIC COUNSELING CENTER, PATRICIA I. BADER, MD
PATIENT INFORMATION (PLEASE PRINT)
Referred by: ___________________________________________ Family Physician: ________________________________________
Patient’s Name: ______________________________________________
Patient’s Address: ____________________________________________ City:___________________ State: _________ County:________________________________ Zip:________________________
DOB: _____/______/_____ Social Security #: ________________________________
Patient's Race: [ ]Asian [ ]White [ ]Black [ ]Hispanic [ ]American Indian [ ]Other________________________________________
Gender: [ ]Male [ ]Female Biological mother’s name ________________________________(and DOB) __________________________
Marital Status: [ ]Single [ ]Married [ ]Divorced [ ]Widowed
Home Phone #: _______________________________________________ Emergency Phone #1: ________________________________
Mobile Phone #: _______________________________________________ Emergency Phone #2: ________________________________
Employer’s Name: _________________________________________________________________________________________________
Employer’s Address: _______________________________________________________________________________________________
Employer’s Phone #: _______________________________________________________________________________________________
Patient’s current medications (strength & dosage):_______________________________________________________________________
_______________________________________________________________________________________________________________
Information ON RESPONSIBLE PARTY OR SPOUSE
Responsible Party’s Name: _________________________________________________
Responsible Party’s Address: _______________________________________________
City: _____________________________________________State: _________ County: _______________ Zip: __________________ Social Security #: ________________________________ DOB:___/___/___ Relationship: ___________________________________
Employer’s Name: ________________________________________________
Employer’s Address: _____________________________________________________________________________________________
Employer’s Phone #: _____________________________________________________________________________________________
Insurance Name (other than Medicaid):____________________________ Identification #:_____________________________________
InsuranceAddress:_______________________________________________________________________________________________
Effective Date:_______________ Group#:___________________________________________________________________________
I understand and agree that I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information on this sheet and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes.
_______________________________________________ _____________________
Signature (Patient/Parent/Guardian) Date
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND NFORMATION Page 3
Parkview Memorial Hospital Patricia I. Bader, MD
Medical Geneticist
Northeast Indiana Genetic Counseling Center, Inc.
11143 Parkview Plaza Dr
Fort Wayne, IN 46825
(260) 482-3886 Fax: (260) 482-1910
NAME OF PLACE RELEASING INFORMATION: Northeast Indiana Genetic Counseling Center, Inc.
DR. ________________________________________________
OTHER: _____________________________________________
PURPOSE OF DISCLOSURE: Medical information & Coordination of services/treatment
PATIENT'S NAME: ______________________________ DOB: ___________________
TELEPHONE #: _________________________________ SSN#:___________________
DATES OF SERVICE/ADMISSION DATE: ________________________________________
I authorize you to release/exchange the following information (written or verbal) from my medical records: Emergency room records, Laboratory reports, History and physical a Nursing notes, Discharge summary a Medication documentation, Consultation a Physician orders, Surgery and pathology a Rehab assessments, X-ray reports a Other: ____________________________________________________
This release of information will allow Patricia I. Bader, MD, to obtain medical records from other physicians who have participated in your care, or the care of your child(ren), in order to accurately diagnose you and/or your child(ren) or make referrals of same.
This release of information will enable you to have access to your amniocentesis or other test results, when
applicable, in a confidential and legal manner.
If you wish any other party to have access to your amniocentesis or other test results, please list their names here:
(1) ____________________________________________ (2) _________________________________________________
(3) ____________________________________________ (4)_________________________________________________
This signed authorization is valid for 90 days or may be revoked at any time.
Patient's Signature: ____________________________________________________ Date:___________________________
Witness: _____________________________________________________________ Date:____________________________