Patient Documents
For your convenience we have provided some of the forms you may need to fill out for your appointment. We have also provided some of the handouts that you can get in our offices.
Please click on the appropriate link below to obtain the forms for your visit. We ask that you do not fax these to us in advance, instead simply bring them along with you to your appointment. Please remember to bring your insurance card and photo identification to every visit.
New Patient Gynecological Visit
Registration Form
Notice of Privacy Practices
New Patient History Form
First Obstetric Appointment
Registration Form
Notice of Privacy Practices
OB Fee Information Sheet (for patient to sign)
OB Payment Collection and Charge Posting Procedures (for patients to keep in personal records)
Handouts
3 Hour Glucose Tolerance Test
Guidelines for 3 Hour GTT (English)
Guidelines for 3 Hour GTT (Espanol)
Bone Density Test
Instructions for the Scan
Patient Questionnaire for the Scan
To find out more about bottle feeding, please print out “Tips for Bottle Feeding Moms”
To find out more about billing, please print out “Your Financial Responsibility”
For more information about ultrasounds during pregnancy, please print out “What to Expect During Your Ultrasound.”
To learn more about what to expect during pregnancy, please print out “Frequently Asked Questions of Pregnancy.”
Records
If you would like to request your medical records from our practice, please fill out the Authorization for Release of Records Form and mail or fax it to us, attention to Kathy.
FEES FOR COPIES:
§ 90-411. Record copy fee.
A health care provider may charge a reasonable fee to cover the costs incurred in searching, handling, copying, and mailing medical records to the patient or the patient's designated representative. The maximum fee for each request shall be seventy-five cents (75¢) per page for the first 25 pages, fifty cents (50¢) per page for pages 26 through 100, and twenty-five cents (25¢) for each page in excess of 100 pages, provided that the health care provider may impose a minimum fee of up to ten dollars ($10.00), inclusive of copying costs. If requested by the patient or the patient's designated representative, nothing herein shall limit a reasonable professional fee charged by a physician for the review and preparation of a narrative summary of the patient's medical record. This section shall only apply with respect to liability claims for personal injury, and claims for social security disability, except that charges for medical records and reports related to claims under Article 1 of Chapter 97 of the General Statutes shall be governed by the fees established by the North Carolina Industrial Commission pursuant to G.S. 97-26.1. This section shall not apply to Department of Health and Human Services Disability Determination Services requests for copies of medical records made on behalf of an applicant for Social Security or Supplemental Security Income disability. (1993, c. 529, s. 4.3; 1993 (Reg. Sess., 1994), c. 679, s. 5.5; 1995 (Reg. Sess., 1996), c. 742, s. 36; 1997-443, ss. 11.3, 11A.118(b).)
