Practice Closing Notice

Forms

New OB Patient Forms

Notice of HIPAA Privacy Practices

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Patient Privacy Practices Agreement

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    Mark E. Richey, M.D., P.C. made the following good faith efforts to obtain the above-referenced individual’s written acknowledgement of receipt of the Notice of Privacy Practices: (Please identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained.)

    Patient Registration Form

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      Patient Information

      Spouse/Parent Information

      Emergency Contact Information

      Insurance Information

      I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, PPO plans and other health plans to Dr. Mark E. Richey. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information needed to secure the payment.

      Private insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessary.

        Patient Information

        Spouse/Parent Information

        Emergency Contact Information

        Insurance Information

        I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, PPO plans and other health plans to Dr. Mark E. Richey. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information needed to secure the payment.

        Private insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessary.

        New Patient Agreement

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          Dr. Mark E. Richey, PC offers general medical, gynecological, and obstetrical, services for patients that are seen at our practice. As an obstetrical specialist and surgeon, Dr. Richey may sometimes be called away unexpectedly during a normal day of scheduled office visits to care for a patient with an immediate medical need. Should this happen during your appointment time, we will do our best to notify you in advance.

          PAYMENT FOR SERVICES

          Each patient is responsible for the payment of their medical services. We are happy to bill your healthcare payer as a courtesy to you. We will need you to provide us with your insurance cards so that we may bill the correct insurance. If your insurance does not cover the medical services provided, you will be responsible for the balance.

          ALASKA MEDICAID RECIPIENTS

          New Medicaid patients are not being accepted at this time. Patients seen with Medicaid coverage are required each month to provide a state issued proof of eligibility coupon at the time of service and the $3.00 co pay is due at the time of service. If a patient later obtains retroactive primary or secondary coverage under the Medicaid program, the patient may be liable to pay for all services provided prior to providing proof of Medicaid coverage.

          DISCOUNTS FOR IMMEDIATE PAYMENT

          If you would like to pay for your services in full at the time of your visit or prior to services being rendered, we can offer you a 10% discount. The discount does not apply if the clain is to be submitted to your insurance company. This is due to Dr. Richey's participation in federally funded programs and his contracts with certain insurance companies.

          REFERRALS FOR PERINATOLOGY MEDICAL SERVICES

          When a patient has a need to see a specialist for a service that medically justifies it, Dr. Mark E. Richey will use his best professional opinion and expertise to send you to the most qualified practitioner he is aware of to meet your medical need. Dr. Richey provides specialty care in gynecology & obstetrics. If a patient may benefit from the services of a board certified perinatologist, patients may be referred to Alaska Perinatology Associates for those medical needs associated with pregnancy. All patients have the right to choose their practitioners and patient requests will be observed. Please consult Dr. Richey on your preferences at the time of referral.

          PAYMENT & PAYMENT PLANS

          All patients are responsible for any and all charges not paid for or discounted under contract by healthcare insurance payers (Medicare, Medicaid, Private Health Insurance Carriers, etc.). By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to reimbursing Mark Richey MD, PC, timely for the services we provide to you, our valued patient.

          We accept cash, personal checks, money orders, and credit or debit cards (VISA, Mastercard, American Express, Discover Card). You may set up credit card pre-payment and automatic recurring monthly arragements for patient balances.

          We offer patients the opportunity to make payments on balances over the period of three (3) months following the issuance of the first patient statement. Exceptions can be made to extend the repayment period upon review and approval. Failure to pay on a patient account as agreed is a basis for an account to be assigned to collections for bad debt recovery.

          COLLECTION OF PAST DUE ACCOUNTS

          We communicate with our patients to resolve past due accounts in all cases. If we cannot reach a patient by phone following the return of undeliverable mail or if a patient payment agreement cannot be honored and we are not communicated with to resolve account balances, we may find it necessary to use the services of a professional collection agency. Once an account is placed with a collection agency, we will be unable to retrieve it from the collection agency. Please let us know when or if your patient contact information changes so that we can always reach you to discuss any past due accounts.

          PATIENT STATEMENT OF AGREEMENT

          My signature below signifies that I have read and understand this patient agreement for Mark Richey, MD, PC to provide me medical services. I understand and agree to the terms in this patient agreement and intend on complying with them to the best of my ability. I also understand that if I fail to follow the terms of this agreement, I may be denied future services.

          Assignment of Insurance Benefits

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            This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this received on my account when made out to me.

            I authorize Dr. Mark E. Richey to make a deposit into the account of Dr. Mark E. Richey on my behalf.

            A photocopy of this Assignment shall be considered as effective and valid as the original.

            I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

            I authorize Dr. Mark E. Richey to initiate a complaint to the Insurance Commissioner on my behalf.

            Patient Choice of Laboratory Form

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              Please indicate the laboratory service of your choice. We will default any labs or specimens collected in our office to Quest Diagnostics, unless otherwise specified. We will forward any specimens that require laboratory processing to the laboratory of your choice. Laboratory results will be placed on record for physician reference at the designated hospital lab and will also be retained in your patient file here at Dr. Mark Richey’s office.

              When making your choice, you may want to consider:

              • Your health plan coverage for services at any preferred hospitals
              • Convenience of laboratory location and hours of operation
              • Which hospital you are most likely to receive services at if you need or anticipate hospital care services (as your records will be available at that location as well)

              If after completing this form, if you decide you would like to change your laboratory preference, simply complete a new form at your next visit.

              We can fax your orders or results to the laboratory of your choice, as well as provide you with written orders to take with you for your laboratory services.

              Laboratory services will be billed by the facility or company performing the tests. Dr. Mark Richey is not responsible for submitting claims, or billing you or your healthcare insurance payer for laboratory services. You are financially responsible for all laboratory services. Please bring a copy of your insurance card with you to your initial registration at the laboratory.

              Your signature below is confirmation that you have selected a preferred laboratory and understand the terms of laboratory referral services described above.

              Patient Review of Systems Form

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                Please take a moment to complete the following questions. It will help us keep current on very important health issues affecting you and provide the most efficient use of your time with the doctor.

                Patient Medical Genetics Questions Form

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                  Having a baby is a special event. Once a baby is born, families take certain precautions to ensure the baby’s health and safety. The unborn child deserves similar care. While most babies are born healthy, some babies can be born with a birth defect or develop a significant health problem after birth. Many of these problems occur despite the best prenatal care; however, some birth defects can be prevented, or at least detected, before birth with appropriate screening. This questionnaire is designed to identify certain factors in your family or medical history that may have an impact on your pregnancy outcome. It is important to answer all of the questions as completely as possible. You may need to discuss some of the questions with other family members to obtain additional information.

                  Past Pregnancy History

                  Family History

                  Your Family

                  Baby's Father's Family

                  Testing

                  Current Pregnancy

                  New GYN Patient Forms

                  Notice of HIPAA Privacy Practices

                  Click Here
                  Download

                  Patient Privacy Practices Agreement

                  Sign Online
                  Download

                    Mark E. Richey, M.D., P.C. made the following good faith efforts to obtain the above-referenced individual’s written acknowledgement of receipt of the Notice of Privacy Practices: (Please identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons (if known) why the written acknowledgement was not obtained.)

                    Patient Registration Form

                    Sign Online
                    Download

                      Patient Information

                      Spouse/Parent Information

                      Emergency Contact Information

                      Insurance Information

                      I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, PPO plans and other health plans to Dr. Mark E. Richey. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information needed to secure the payment.

                      Private insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information as necessary.

                      New Patient Agreement

                      Sign Online
                      Download

                        Dr. Mark E. Richey, PC offers general medical, gynecological, and obstetrical, services for patients that are seen at our practice. As an obstetrical specialist and surgeon, Dr. Richey may sometimes be called away unexpectedly during a normal day of scheduled office visits to care for a patient with an immediate medical need. Should this happen during your appointment time, we will do our best to notify you in advance.

                        PAYMENT FOR SERVICES

                        Each patient is responsible for the payment of their medical services. We are happy to bill your healthcare payer as a courtesy to you. We will need you to provide us with your insurance cards so that we may bill the correct insurance. If your insurance does not cover the medical services provided, you will be responsible for the balance.

                        ALASKA MEDICAID RECIPIENTS

                        New Medicaid patients are not being accepted at this time. Patients seen with Medicaid coverage are required each month to provide a state issued proof of eligibility coupon at the time of service and the $3.00 co pay is due at the time of service. If a patient later obtains retroactive primary or secondary coverage under the Medicaid program, the patient may be liable to pay for all services provided prior to providing proof of Medicaid coverage.

                        DISCOUNTS FOR IMMEDIATE PAYMENT

                        If you would like to pay for your services in full at the time of your visit or prior to services being rendered, we can offer you a 10% discount. The discount does not apply if the clain is to be submitted to your insurance company. This is due to Dr. Richey's participation in federally funded programs and his contracts with certain insurance companies.

                        REFERRALS FOR PERINATOLOGY MEDICAL SERVICES

                        When a patient has a need to see a specialist for a service that medically justifies it, Dr. Mark E. Richey will use his best professional opinion and expertise to send you to the most qualified practitioner he is aware of to meet your medical need. Dr. Richey provides specialty care in gynecology & obstetrics. If a patient may benefit from the services of a board certified perinatologist, patients may be referred to Alaska Perinatology Associates for those medical needs associated with pregnancy. All patients have the right to choose their practitioners and patient requests will be observed. Please consult Dr. Richey on your preferences at the time of referral.

                        PAYMENT & PAYMENT PLANS

                        All patients are responsible for any and all charges not paid for or discounted under contract by healthcare insurance payers (Medicare, Medicaid, Private Health Insurance Carriers, etc.). By signing this patient agreement, you are acknowledging that you understand this condition of service and commit to reimbursing Mark Richey MD, PC, timely for the services we provide to you, our valued patient.

                        We accept cash, personal checks, money orders, and credit or debit cards (VISA, Mastercard, American Express, Discover Card). You may set up credit card pre-payment and automatic recurring monthly arragements for patient balances.

                        We offer patients the opportunity to make payments on balances over the period of three (3) months following the issuance of the first patient statement. Exceptions can be made to extend the repayment period upon review and approval. Failure to pay on a patient account as agreed is a basis for an account to be assigned to collections for bad debt recovery.

                        COLLECTION OF PAST DUE ACCOUNTS

                        We communicate with our patients to resolve past due accounts in all cases. If we cannot reach a patient by phone following the return of undeliverable mail or if a patient payment agreement cannot be honored and we are not communicated with to resolve account balances, we may find it necessary to use the services of a professional collection agency. Once an account is placed with a collection agency, we will be unable to retrieve it from the collection agency. Please let us know when or if your patient contact information changes so that we can always reach you to discuss any past due accounts.

                        PATIENT STATEMENT OF AGREEMENT

                        My signature below signifies that I have read and understand this patient agreement for Mark Richey, MD, PC to provide me medical services. I understand and agree to the terms in this patient agreement and intend on complying with them to the best of my ability. I also understand that if I fail to follow the terms of this agreement, I may be denied future services.

                        Assignment of Insurance Benefits

                        Sign Online
                        Download

                          This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this received on my account when made out to me.

                          I authorize Dr. Mark E. Richey to make a deposit into the account of Dr. Mark E. Richey on my behalf.

                          A photocopy of this Assignment shall be considered as effective and valid as the original.

                          I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

                          I authorize Dr. Mark E. Richey to initiate a complaint to the Insurance Commissioner on my behalf.

                          Patient Choice of Laboratory Form

                          Sign Online
                          Download

                            Please indicate the laboratory service of your choice. We will default any labs or specimens collected in our office to Quest Diagnostics, unless otherwise specified. We will forward any specimens that require laboratory processing to the laboratory of your choice. Laboratory results will be placed on record for physician reference at the designated hospital lab and will also be retained in your patient file here at Dr. Mark Richey’s office.

                            When making your choice, you may want to consider:

                            • Your health plan coverage for services at any preferred hospitals
                            • Convenience of laboratory location and hours of operation
                            • Which hospital you are most likely to receive services at if you need or anticipate hospital care services (as your records will be available at that location as well)

                            If after completing this form, if you decide you would like to change your laboratory preference, simply complete a new form at your next visit.

                            We can fax your orders or results to the laboratory of your choice, as well as provide you with written orders to take with you for your laboratory services.

                            Laboratory services will be billed by the facility or company performing the tests. Dr. Mark Richey is not responsible for submitting claims, or billing you or your healthcare insurance payer for laboratory services. You are financially responsible for all laboratory services. Please bring a copy of your insurance card with you to your initial registration at the laboratory.

                            Your signature below is confirmation that you have selected a preferred laboratory and understand the terms of laboratory referral services described above.

                            Patient Review of Systems Form

                            Sign Online
                            Download

                              Please take a moment to complete the following questions. It will help us keep current on very important health issues affecting you and provide the most efficient use of your time with the doctor.

                              Gynecology Patient Questions Form

                              Sign Online
                              Download

                                Past Medical and Family History

                                Surgeries/Hospitalization/Major Injury/Illness

                                Health Maintenance

                                Medications

                                Allergies

                                Obstetrical History

                                Gynecological History

                                Social History

                                1. The purpose of this letter is to explain the reason for and proper method of somethings that your doctors staff will do to help you during this visit. During any typical visit, you may be asked very personal questions and then undergo even more personal physical examinations. Our desire is that you better understand these procedures as you have your examination.
                                2. When you come into our office, you do not have to surrender your rights of privacy and personal security. You may remain in control of what you do and what can be done to you. What does happen is that you and the health care providers enter into a partnership where you work together to assure the best health of the patient. The health care providers are responsible for making sure that you understand as much as possible about every procedure that takes place. Also, it is the policy of this office that during any portion of the physical examination a chaperon will be provided. Finally, if at any time during an examination or treatment you do not understand what is happening you have the right and responsibility to ask for more information. Below are described some of the parts of the physical examination which will be performed during your visit.
                                3. Breast (Both sexes): The breast tissue and the underlying structures are examined visually and by touch for any abnormalities that you may need treatment. Because the tissue in and around the breast can be affected by a variety of medical conditions, it is sometimes necessary to examine the chest and breasts even when your main visit is not the breast. The examination may be very brief or very detailed, depending in the findings and condition that is being investigated. Also, you may be asked mto sit or lie in different positions so that the provider can see subtle changes in the structure. However, as stated above you should be a good understanding of each procedure and its intent during the examination.
                                4. Genitalis (male): The penis, scrotum, and testicles can be viewed or examined to investigate a variety of conditions. The inguinal canal, a passage for several structures in the groin, is usually examined by pressing a gloved finger up from below on either side of the groin. Because each of these structures have many nerve fibers, these examinations may be uncomfortable.
                                5. Genitalia (female): The female genitalia are examined visually, by gloved hands, and usually with medical instruments. As with other organs, it may be necessary to examine the genitalia, even though the primary concern is not directly related to those structures. For example, if the provider is investigating the possibility of appendicitis, he/she may feel the area of the appendix with a finger inserted into the vagina. This is because less muscle is there to interfere with the examination of the abdominal contents the female genitalia is rich with nerve fibers, and these examinations, properly performed, may be uncomfortable.
                                6. Rectal (Both sexes): A gloved finger is inserted into the rectum to see if there are any abnormal structures there or in the pelvis. In the male, a firm rubbery organ called the prostate is felt. During the examination of a woman, internal organs are felt between fingers simultaneously in the vagina and the rectum. After the rectal exam, it is common to test any substance on the glove to see whether there is any abnormal bleeding in the rectum.
                                7. This has been a brief description of some very common medical examinations performed in order to better treat you, our patient. If you have any questions please do not hesitate to ask your health care provider.

                                I have read and understand all of the above. I am aware, that if I have any questions during or after my visit, I can ask the provider or anyone of the staff for further information.

                                Medical Releases

                                Realease of Medical Information to Dr. Richey

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                                  I, (name of patient) , authorize (hospital/doctor name) to use and/or disclose my health information as identified below to: Mark E. Richey, M.D., 1200 Airport Heights Drive Suite 205, Anchorage AK 99508, Fax (907) 272-2262 Phone (907) 272-4443

                                  Except to the extent that action has already been taken in reliance upon this authorization, I understand that I may revoke this authorization at any time by giving written notice to (identify the person/entity to whom written notice of revocation must be given). Unless revoked earlier, this authorization will expire 180 days from the date of signing or upon (insert applicable date or event of expiration).

                                  I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or copy any information to be used or disclosed under this authorization.

                                  I also understand that, if the person or entity receiving this information is not a health care provider orhealth plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my health information under other applicable state or federal laws and regulations.

                                  I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (either directly or indirectly) for doing so.

                                  (A copy of this signed form will be provided to the individual and/or the individual’s legal representative.)

                                  Release of Medical Information to Another Doctor

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                                    I, (name of patient), authorize Mark E. Richey, M.D., P.C. to use and/or disclose my health information as identified below to (name and address of recipient).

                                    Except to the extent that action has already been taken in reliance upon this authorization, I understand that I may revoke this authorization at any time by giving written notice to (identify the person/entity to whom written notice of revocation must be given). Unless revoked earlier, this authorization will expire 180 days from the date of signing or upon (insert applicable date or event of expiration).

                                    I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or copy any information to be used or disclosed under this authorization.

                                    I also understand that, if the person or entity receiving this information is not a health care provider orhealth plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my health information under other applicable state or federal laws and regulations.

                                    I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (either directly or indirectly) for doing so.

                                    (A copy of this signed form will be provided to the individual and/or the individual’s legal representative.)