PATIENT INFORMATION

PATIENT INFORMATION

SPOUSE/GUARDIAN INFORMATION

REFERRING PHYSICIAN INFORMATION

PATIENT RESPONSIBILITY:

I authorize the release of any medical records or other information necessary to process my insurance claims on mybehalf. I authorize V SACHAR MD/COASTAL PERINATAL CENTER to appeal all insurance claims as appropriateon my behalf. I agree to be fully responsible for all lawful debts incurred by me or my minor child for services whetheror not covered by insurance.

OBSTETRIC HISTORY QUESTIONNAIRE

Prior pregnancies

Please fill in the table below for all pregnancies, starting with the first, and include all pregnancies, living ordeceased.

If yes, please list:

Medical history

Do you have, or have you had, any of the following conditions:

GENETIC/FAMILY HISTORY

Does the father of the baby, or any close relative of yours or the father, have any of the following (if yes, pleasenote who):

Authorization for Verbal Release of Protected Health Information

STANDARD DISCLOSURE

I authorize V SACHAR MD dba Coastal Perinatal Center to discuss my medical history, diagnosis, treatmentand prognosis with those listed below. I understand this may include information regarding testing, examination andtreatment for HIV, AIDS related illness, mental health and drug, alcohol or chemical abuse, as well as confirmation ofany appointments for me to be seen in the office, hospital, or at another physician’s office.

NO INFORMATION

I do not authorize release of any information concerning my treatment. I understand that this includesconfirmation of appointment dates, times and locations.

This authorization will expire at the end of my treatment with V SACHAR MD dba Coastal Perinatal Center unless Irevoke the consent prior to that time.

V SACHAR MD/COASTAL PERINATAL CENTERPATIENT ACKNOWLEDGEMENT FORM

Our notice of Privacy Practices (“Notice”) provides information about: 1.) the privacy rights of our patients; and 2.)how we may use and disclose protected health information (“PHI”) about our patients.

Federal regulation requires that we give our patients or their authorized representatives (“You”) the opportunity toreview our Notice before signing this acknowledgement. A on-page summary of our Notice is displayed in our officesand in the hospitals we serve. A copy of our Notice will be made available to you and you may also view our Notice byvisiting our internet web site, https://coastalperinatalcenter.com

By signing this form, you acknowledge only that we have provided you with immediate access to our Notice of PrivacyPractices.

FINANCIAL POLICY

OUR FINANCIAL POLICY: Our physicians and staff are very concerned about the cost of your health care and wantto address some issues related to the cost of medical services in our office. Considerable care has been taken in settingour fees. We want to assure you that the charges accurately reflect the complexity of care rendered and the skill andexpertise required for your care.

HMO and PPO MEMBERS: If you are a member of an HMO or PPO in which we participate, your deductible or co-payment is required at the time of service. Sonograms may have a different co-payment that routine visits. You areresponsible to see that we have a current referral on file if your insurance carrier requires one. If we do not have thisreferral at the time of your visit, your insurance company may hold you responsible for all charges. You may also besent back to see your Primary Care Physician prior to being treated to obtain a current referral.

If you are not sure that our physicians are providers for your PPO, call your insurance carrier for clarification.

NEW INSURANCE/CHANGE OF INSURANCE: Should your insurance change at anytime during your pregnancyit is your responsibility to notify us in writing within 10 working days of this change. We have to have this informationin order to file your claim with the correct carrier before the insurance company’s filing deadline.

FEE FOR SERVICE: Our policy requires payment of your deductible and/or coinsurance at the time of service.

Our agreement is with you, not your insurance company. Although we will assist you in submitting your claim to yourinsurance carrier, you are ultimately responsible for the service you receive. Payment to our office is neither contingentnor dependent upon your insurance carrier.

We are pleased to accept MasterCard, Visa, Discover, American Express, checks, cash, money orders, or traveler’schecks

MEDICARE: We are participating providers for Medicare. Please present your Medicare card at your visit. Patientsare responsible for 20% of the amount that Medicare allows. If you have a supplemental insurance, we will submit aclaim for you.

MEDICAID:We are Medicaid providers. Please present your Medicaid letter of eligibility at each of your visits.

AMNIOCENTESIS, OTHER SPECIALIZED TESTING:Our office will charge you for the services we provide.You will receive a separate bill from the laboratory that processes the test. Our office will be happy to provide you withan approximation of the laboratory charges.

If you have any questions regarding our financial policy or your insurance reimbursement, please feel free to discussthem with our billing office or the practice manager.

I have read and understand my financial responsibilities under this policy of V SACHAR MD/COASTALPERINATAL CENTER.

I,hereby consent to have my physician/physician office Coastal Perinatal Center/Dr. V Sachar, communicate with me or members of his staff, where appropriate or other physicians, nurse practitioners and pharmacists via e-mailing regarding the following aspects of my medical care and treatment: [test results, prescriptions, appointments, billing, etc.]. I understand that e-mail is not a confidential method of communication. I further understand that there is a risk that e-mail communications between my physician and me or members of my physician’s office staff, or between my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any e-mail communications between my physician and me or members of his office staff, or between my physician and other physicians, nurse practitioners or pharmacists regarding my medical care and treatment will be printed out and made a part of my medical record. I understand that in an urgent or emergent situation I should call my primary provider or go to the Emergency Room/Labor & Delivery and not rely on e- mail.