It is very I M P O R T A N T prior to your visit:
Please print the 3 forms below:
1. Receipt of HIPAA Policy Form
2. Patient Registration Form
3. Patient Intake History Form
Please take your time completing them in detail. We would like to review these forms as far ahead of your visit as possible to provide you the best service possible during your visit with us.
•You may bring them or mail them to us: Ruth Haskins MD, 1611 Creekside Drive, Suite 103, Folsom, CA 95630
•You may fax them to us: 916.817.6943
•You may bring them with you to your visit.
Please arrive early enough to your visit that we have plenty of time to review your history with you.
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Receipt of HIPAA Policy Form |
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Patient Registration Form |
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Patient Intake History Please review our HIPAA Form: |
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If you have not had a chance to complete the 3 forms as directed above, you must arrive at least 20 minutes prior to your appointment time so we may assist you at collecting this valuable information here in our office.
IF AT ANY TIME YOUR INSURANCE CARRIER OR COVERAGE CHANGES OR YOUR CONTACT INFORMATION CHANGES, IT IS VERY IMPORTANT TO NOTIFY US IMMEDIATELY.
Your Visit:
We appreciate the busy lives our patients have competing with maintenance of their health care. We try to accommodate our patients' needs for appointment times and days. Every effort is made to see our patients at their scheduled time, but occasional medical emergencies or obstetrical deliveries may cause delays. We do our best to keep patients from being inconvenienced.
Please remember to bring your cell phone, so we may alert you if we are running late, and to entertain you if your appointment is delayed. We want you to be connected to your world on the day of your office visit, so do feel free to keep your electronic device handy.
We would prefer for you to keep sick youngsters away from susceptible healthy pregnant women in our reception area, so please contact our office to reschedule your appointment to the end of the morning or end of the afternoon if you must bring your child who is not well. Children under three years old need to have a partner to hold them, or be in a stroller or car seat to keep them from meandering about the room during your office visit.
We appreciate the busy lives our patients have competing with maintenance of their health care. We try to accommodate our patients' needs for appointment times and days. Every effort is made to see our patients at their scheduled time, but occasional medical emergencies or obstetrical deliveries may cause delays. We do our best to keep patients from being inconvenienced.
Please remember to bring your cell phone, so we may alert you if we are running late, and to entertain you if your appointment is delayed. We want you to be connected to your world on the day of your office visit, so do feel free to keep your electronic device handy.
We would prefer for you to keep sick youngsters away from susceptible healthy pregnant women in our reception area, so please contact our office to reschedule your appointment to the end of the morning or end of the afternoon if you must bring your child who is not well. Children under three years old need to have a partner to hold them, or be in a stroller or car seat to keep them from meandering about the room during your office visit.
We are delighted to see you. In order to allow us to maximize the benefit of your visit it is important the we have the right information.
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On every visit, please be sure to bring both your insurance card and your copay with you. We cannot continue with your scheduled visit without both of these items.
Please take time to talk to your insurance benefits advisor (call the 1-800- number on the back of your insurance card) to find out which lab and which imaging facility best suits your insurance plan. We must rely on you to know this! Payment is required at the time of service for any charges not covered by your insurance. We rely on you to know the limitations of your particular policy. We try to make such payments as convenient as possible by accepting personal checks, Mastercard or Visa. Checks returned for insufficient funds will result in a $25 assessment fee to the patient directly. There will be a $25.00 administrative fee assessed at the time of receipt for each complicated medical form that requires a physician signature (such as disability requests, FMLA requests and school or occupation physical exam forms). |
It is very important for all patients to have their previous Ob/Gyn Medical Records sent to our new practice prior to your first visit with Dr. Haskins. Please do this as soon as possible, even if your office evaluation is not due for quite some time. Having your prior medical records will allow us to care for you in the interim. Without your records we cannot refill prescriptions or answer minor questions by telephone.
Please download and complete the relevant release form. In order to optimize your care, pertinent ob/gyn records from your primary care doctor or a previous Gynecologist should be sent to the Haskins practice prior to your first visit here.
You may use the following form to facilitate release of such records:
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On the release form, complete all bolded items, initial the two lines that require initials, sign where indicated, then mail or hand carry the release request to your prior or other doctor. You must allow at least 14 days to elapse before we can expect to have the pertinent medical records that you have requested.
Please take a moment to review your rights and responsibilities:
Consistent, quality, compassionate and informative care for women of all ages.
