1. health and fitness

Welcome to The Women’s Health Institute office of Dr. Sara J. Bernstein, a solo-practitioner specializing in obstetrics &
gynecology. Here at The Women’s Health Institute, we are dedicated to providing the highest quality of medical care to
women at all stages of life: from adolescence, through the child bearing years, and into menopause. To that end we are
diligent in our efforts to continue our education and stay abreast of current medical practice. Understanding each woman's
unique healthcare needs is important to us. We do our best to answer all your questions and to fully explain the risks and
benefits of all treatments and procedures. Finally we believe medical care should be efficient and convenient and will
continually work to make it easy for our patients to see us.
Dr. Bernstein, Our Medical Director:
Sara J. Bernstein, MD was born in Montreal, Canada and moved to Atlanta, GA at an early age. She
attended medical school at the University of Florida and undertook her residency program at the
University of Florida, Shands Hospital urban campus in Jacksonville, FL. After residency, Dr. Bernstein
moved to Wellington to practice, where she resides today with her husband and two daughters.
Office Hours:
Dr. Bernstein has the following office hours:
Monday
Tuesday
Wednesday
Thursday
9:00 am
9:00 am
2:00 pm
9:00 am
– 5:30 pm
– 12:30 pm
– 5:30 pm
– 5:30 pm
If you would like to make an appointment, please feel free to call the office (option 0). Our office staff is available for
appointments and general questions as follows:
Monday
Tuesday
Wednesday
Thursday
Friday
9:00 am
9:00 am
9:00 am
9:00 am
9:00 am
–
–
–
–
–
5:30 pm
4:30 pm
5:30 pm
5:30 pm
4:30 pm
Please realize that when Dr. Bernstein has office hours, our office staff may be busy helping her see patients. We
endeavour to respond to your requests as fast as possible. In general, patient questions are placed into Dr.
Bernstein’s in-box and are reviewed within 1 business day and responded to within 2 business days. We realize that
your request is very important to you.
What is in this packet:
We are required to provide you with certain information and obtain your signature acknowledging that you have
received and read it. For your convenience, we have included the following information in this packet:
I.
II.
III.
IV.
V.
Notice of Privacy Practices
Release, Guarantee, Assignment and Consent for Treatment
Summary of the Florida Patient’s Bill of Rights and Responsibilities
Annual Wellness Services
Policy Acknowledgement
What you need to do:



Read the pages in this folder.
Sign where indicated.
If you wish to have a copy of any of this information for your personal records, please ask our staff. We can
provide you a paper copy to take with you or email a copy with all the pertinent information for your perusal.
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
© 2004, The Women’s Health Institute, LLC
Patient Demographics
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  (561) 784-1933  fax: (561) 784-5109  TheWHI.com
PATIENT’S INFORMATION
NAME IN FULL
EMAIL ADDRESS
SSN
ADDRESS
CITY
HOME PHONE
CELL PHONE
WORK PHONE
AGE
TODAY’S DATE
DATE OF BIRTH
ETHNICITY
STATE
ZIP CODE
EMPLOYER
REFERRED BY
THIS FORM IS BEING COMPLETED BY
PARENT/GUARDIAN INFORMATION (if patient is a minor)
RELATIONSHIP
MOTHER’S NAME IN FULL
AGE
DATE OF BIRTH
ETHNICITY
FATHER’S NAME IN FULL
AGE
DATE OF BIRTH
ETHNICITY
ADDRESS
HOME PHONE
CITY
MOTHER’S CELL PHONE
MOTHER’S WORK PHONE
MOTHER’S EMPLOYER
EMERGENCY CONTACTS
FATHER’S CELL PHONE
STATE
FATHER’S WORK PHONE
FATHER’S EMPLOYER
ZIP CODE
MOTHER’S SSN
FATHER’S SSN
NAME
RELATIONSHIP TO PATIENT
HOME PHONE
CELL PHONE
WORK PHONE
NAME
RELATIONSHIP TO PATIENT
HOME PHONE
CELL PHONE
WORK PHONE
INSURANCE INFORMATION
PRIMARY INSURANCE COMPANY
POLICYHOLDER’S NAME
DATE OF BIRTH
POLICY NUMBER
GROUP NUMBER
SECONDARY INSURANCE COMPANY
POLICYHOLDER’S NAME
DATE OF BIRTH
POLICY NUMBER
GROUP NUMBER
SPECIALTY
PHONE NUMBER
FAX NUMBER
MEDICAL CONTACTS
PRIMARY CARE PHYSICIAN
Payment is expected at the time of service unless arrangements are made prior to appointment time. We accept Visa, MasterCard, Debit Cards, Checks, and Cash.
I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE THIS INFORMATION TO THE SOCIAL SECURITY ADMINISTRATION, HEALTH CARE
FINANCING ADMINISTRATION, MY INSURANCE COMPANY OR ITS INTERMEDIARIES OR CARRIERS, OR TO THIS PHYSICIAN’S OFFICE OR TO MY ATTORNEY OR OTHER DOCTOR’S
OFFICE.
I AUTHORIZE DIRECT PAYMENT OF MEDICAL BENEFITS AND/OR SURGICAL BENEFITS, TO INCLUDE MAJOR MEDICAL BENEFITS TO WHICH I AM ENTITLED, INCLUDING MEDICARE,
PRIVATE INSURANCE, AND ANY OTHER HEALTH PLAN TO THE ABOVE NAMED PHYSICIAN(S).
I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING.
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY SAID INSURANCE.
Patient /Guardian Signature
Witness Signature
Patient Guardian Name (printed)
Witness Name (printed)
© 2004, The Women’s Health Institute, LLC
Date
New Patient Health History
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Medical and Family History
Self
Yes No
Family
Yes
Self
Yes No
1 WT LOSS-GAIN
16 URINARY INCONTINENCE
2 HEADACHES / MIGRAINE
17 URINARY INFECTIONS
3 HEART DISEASE
18 BLOOD TRANSFUSIONS
4 VALVULAR DISEASE
19 ANEMIA / BLOOD DISORDER
5 RHEUMATIC DISEASE
20 BLEEDS EASILY
6 LUPUS
21 VARICOSE VEINS / PHLEBITIS
7 HIGH BLOOD PRESSURE
22 SKIN DISEASE
8 HIGH CHOLESTEROL
23 DIABETES
9 RESPIRATORY/PULMONARY/LUNG DISEASE
24 THYROID DISEASE
10 BREAST DISEASE
25 CANCER (TYPE)
11 JAUNDICE / HEPATITIS
26 EPILEPSY / NEUROLOGICAL
12 HIATAL HERNIA (REFLUX)
27 ARTHRITIS - JOINT PAIN
13 PEPTIC ULCER (STOMACH)
28 OSTEOPOROSIS (FRAGILE BONES)
14 BOWEL DISEASE
29 ANXIETY / DEPRESSION
15 KIDNEY DISEASE
30 SLEEP PROBLEMS
Did your mother take DES or any hormones when she was pregnant with you?
Yes
No
Don't know
Please provide details for all significant prior medical illnesses and current medical problems for which you are under medical treatment:
Please list all surgical procedures you have had and the year they were performed:
Year
Procedure
SURGICAL HISTORY
Please list all current medications:
Medication
Dosage
MEDICATIONS
Please list all medication allergies:
ALLERGIES
© 2004, The Women's Health Institute, LLC
Frequency
Use
Family
Yes
New Patient Health History
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Gynecological History
Age at first period
When was your last period?
When was the period before that?
How far apart are your cycles?
How many days do they last?
Circle any symptoms associated with your period:
cramps
heavy flow/clots
headaches
breast tenderness
change in mood
pelvic pain
none
natural family planning
tubal ligation
spermicide
diaphram
norplant
depoprovera injections
birth control pills
vasectomy
condoms
heterosexual
lesbian
bisexual
Circle your current forms of birth control:
Sexual preference (circle one):
Have you ever had an abnormal pap smear?
IUD
Yes
No
Do you desire pregnancy at this time?
Yes
No
Do you examine your breasts every month?
Yes
No
Do you have pain with intercourse?
Yes
No
Do you have bleeding after intercourse?
Yes
No
Do you use douches?
Yes
No
Have you stopped having periods?
Yes
No
Have you ever been sexually involved with another person?
Yes
No
Number of sexual partners in the last 12 months:
- if yes, list any treatments
- if yes, age at your first encounter:
Number of lifetime sexual partners:
Are you currently sexually active?
Yes
No
Have you ever had a sexually transmitted disease?
Yes
No
- if yes, which ones:
gonorrhea
herpes
PID
hepatitis B
chlamydia
syphilis
HIV
genital warts
Have you ever had any other vaginal infections?
- if yes, which ones:
bacterial vaginosis
Yes
yeast
trichomonas
No
other: ________________
Obstetrical History
Please list all pregnancies you have had including miscarriages, abortions, and ectopic pregnancies
Vaginal or
Length of
Length of
Maternal
Caesarian
Labor
Pregnancy Anesthesia
Year
Sex
Birth Weight Weight Gain
Complications
Social History
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Do you smoke cigarettes? If so, how many cigarettes per day?
For how many years?
Do you drink alcohol?
If so, how many drinks per week?
For how many years?
Do you use drugs?
If so, which ones?
For how many years?
Yes No Do you exercise?
Do you use seatbelts?
Yes No Are you under a lot of stress?
Have you ever received a blood transfusion?
Place of birth: ___________________
If you were not born in this country, how many years have you lived here? ________
Planning Questionaire
Yes
Yes
No
No
Do you have a durable power of attorney?
Have you made a living will?
© 2004, The Women's Health Institute, LLC
New Patient Health History
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Immunizations
Tetanus Booster
Date: _________________
Influenza Vaccine
Date: _________________
Rubella Vaccine
Date: _________________
Pneumococcal Vaccine
Date: _________________
Hepatitis B Vaccine
Date: _________________
Varicella Vaccine
Date: _________________
Present Symptoms (circle any that apply)
General/Constitutional Weight loss
Weight gain
Fever
Night sweats
Tearing
Blind spots
Eye pain
Dizziness
Lightheadedness
Nose bleeding
Dental difficulties
Bleeding gums
Dentures
Neck pain
Neck tenderness
Neck mass
Chest pain
Irregular heart beat
Shortness of breath with exertion
Fainting
Swelling
Shortness of breath when waking at night
High blood pressure
Heart murmur
Shortness of breath lying down
Varicosities
Phlebitis
Painful extremity with movement
Wheezing
Cough
Coughing blood
Respiratory infections
Poor appetite
Difficulty swallowing
Indigestion
Abdominal pain
Heartburn
Burping
Nausea
Vomiting
Vomiting blood
Yellow skin
Constipation
Diarrhea
Abnormal stools
Flatulence
Hemorrhoids
Recent changes in bowel habits
Urinary urgency
Frequent urination
Lack of urine
Getting up at night to urinate
Urinary infections
Nephritis
Vaginal discharge
Painful urination
Stones
Venereal disease
Limitation of motion
Muscular weakness
Muscle cramps
Itching
Pigmentation
Changes in hair growth or loss
Breast lumps
Breast tenderness
Breast swelling
Paralysis
Difficulties with memory or speech
Incoordination
Sensory or motor disturbances
Eyes Double vision
Headaches
Ears/Nose
Nasal obstruction
Mouth/Throat
Neck stiffness
Cardiovascular
Respiratory
Gastrointestinal
Tuberculosis
Genitourinary Blood in urine
Urinary incontinence
Musculoskeletal Joint pain
Rash
Skin/Breast Nail changes
Nipple discharge
Convulsions
Neurologic Tremor
Problem with muscular coordination
Psychiatric
Nervousness
Emotional problems
Hallucinations
Depression
Hormone therapy
Abnormal growth
Increased water intake
Anemia
Intolerance to heat or cold
Endocrine Bleeding tendency
Anxiety
Previous psychiatric care
Previous transfusions and reactions (eg. Rh incompatibility)
Hematology/Lymphatic Lymph node enlargement or tenderness
Allergic/Immunologic Reactions to drugs
Reaction to food
Reaction to insects
Check here if none of the above symptoms apply
© 2004, The Women's Health Institute, LLC
Bladder Health Questionnaire
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
FULL NAME
DATE OF BIRTH
TODAY’S DATE
1. How many times do you urinate in 1 day?
2. How many times do you get up to urinate at night?
3. Do you ever leak urine when you cough, sneeze, laugh, or during athletic activities?  YES  NO
4. Do you usually have a strong sense of urgency to urinate?
 YES  NO
5. Do you have difficulty starting your urine stream?
 YES  NO
6. Have you been treated for a urinary infection?
 YES  NO
- How many?
- How recent?
7. Have you ever leaked urine because you could not make it to the bathroom in time?  YES  NO
8. Does the loss of urine or overactive bladder affect your quality of life?
 YES  NO
Have your bladder symptoms …
9. Caused you to plan “escape routes” to restrooms in public places?
10. Made you avoid activities away from restrooms (walks, running, biking, etc.)?
© 2004, The Women’s Health Institute, LLC
 YES  NO
 YES  NO
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION
FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
NAME
BIRTHDATE
SOCIAL SECURITY #
I understand that as part of my healthcare, this organization originates and maintains health records
describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans
for future care or treatment.
I understand that this information serves as:
 A basis for planning my care and treatment.
 A means of communication among the many healthcare professionals who contribute to my care.
 A source of information for applying my diagnosis and surgical information to my bill.
 A means by which a third-party payer can verify that services billed were actually performed.
 A tool for routine healthcare operations such as assessing care quality and reviewing the
competence of healthcare professions
I understand that I have the right:
 To object to the use of my health information for directory purposes.
 To request restrictions as to how my health information may be used or disclosed to carry out
treatment, payment or healthcare operations – and that the organization is not required to agree to
the restrictions requested.
 To revoke this consent in writing, except to the extent that the organization has already
Office use only:
 Accepted
 Denied
Signature
Title
Date
 I request the following restrictions to the use or disclosure of my healthcare information:
 No restrictions
Patient Signature
Witness Signature
Patient Name (printed)
Witness Name (printed)
© 2004, The Women’s Health Institute, LLC
Date
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  ph: (561) 784-1933  fax: (561) 784-5109  TheWHI.com
Dear Patient:
Under Florida law, physicians are generally required to carry medical malpractice insurance or
otherwise demonstrate financial responsibility to cover potential claims for medical malpractice.
YOUR DOCTOR HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is
permitted under Florida law subject to certain conditions. Florida law imposes penalties against
noninsured physicians who fail to satisfy adverse judgments arising from claims of medical
malpractice. This notice is provided pursuant to Florida law.
Regretfully, the practice has made the decision of being uninsured because the malpractice
insurance premiums have become too expensive and we simply cannot afford this coverage any
longer.
If the action that this practice has taken makes you uncomfortable in initiating or continuing in your
care, it is suggested that you search for an insured physician within your community.
This document MUST be signed before you initiate or continue under the care of the practice.
Thank you,
Sara J. Bernstein, M.D.
I have read this document and acknowledge and understand its contents.
Patient/Guardian Signature
Patient/Guardian Name (printed)
Date
Witness Signature
Witness Name (printed)
Date
Arbitration Agreement
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical
services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered,
will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process
except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it,
are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the
use of arbitration.
Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including
disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the
intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or
services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all
claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the
time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other
licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or
associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or
office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the
health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including,
without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall
select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators
appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the
arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator,
together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees,
or other expenses incurred by a party for such party’s own benefit.
Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional
party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall
be stayed pending arbitration.
The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount
payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the
right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement.
The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration
conducted pursuant to this Arbitration Agreement.
Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one
proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil
action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in
accordance with the procedures prescribed herein with reasonable diligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of
signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties.
Article 6: Retroactive Effect: This agreement shall be effective as the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and
shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration
Agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF
MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING
UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
PATIENT CERTIFICATION:
By signing below I state that I am 18 years of age or older, or otherwise authorized to consent. I have read or have had explained to me the contents of
this form.
Signature of Patient or Patient Representative (Indicate relationship if signing for patient)
Date
Office Signature
Date
© 2004, The Women’s Health Institute, LLC
Patient's Bill Of Rights And Responsibilities
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Florida law requires that we recognize your rights while you are receiving medical care, and also that you respect our right
to expect certain behavior from you. Should you require it, you may request a copy of the full text of this law from us. A
summary of your rights and responsibilities are as follows:
You, the patient have the right to:
 Be treated with courtesy and respect, with appreciation of your individual dignity, and with protection of your need
for privacy.
 A prompt and reasonable response to questions and requests.
 To know who is providing medical services and who is responsible for your care.
 Know what patient support services are available, including whether an interpreter is available if you do not speak
English.
 Know what rules and regulations apply to your conduct.
 Be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives,
risks, and prognosis.
 Refuse any treatment, except as otherwise provided by law.
 Be given, upon request, full information and necessary counseling on the availability of known financial resources
for your care.
 (if eligible for Medicare) - to know, upon request and in advance of treatment, whether the health care provider or
health care facility accepts the Medicare assignment rate.
 Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
 A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request,
to have the charges explained.
 Impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap,
or source of payment.
 Treatment for any emergency medical condition that will deteriorate from failure to provide treatment
 Know if medical treatment is for purposes of experimental research and to give your consent or refusal to
participate in such experimental research.
 Express grievances regarding any violation of your rights, as stated in Florida law, through the grievance
procedure of the health care provider or health care facility which served you and to the appropriate state licensing
agency.
Furthermore, you are responsible for:
 Providing to the health care provider, to the best of your knowledge, accurate and complete information about
present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health.
 Reporting unexpected changes in your condition to the health care provider.
 Reporting to the health care provider whether you comprehend a contemplated course of action and what is
expected of you.
 Following the treatment plan recommended by the health care provider.
 Keeping appointments and, when you are unable to do so for any reason, for notifying the health care provider or
health care facility.
 Your actions if you refuse treatment or do not follow the health care provider's instructions.
 Assuring that the financial obligations of your health care are fulfilled as promptly as possible.
 Following health care facility rules and regulations affecting patient care and conduct.
© 2004, The Women’s Health Institute, LLC
Financial Policies
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Here at The Women’s Health Institute, we understand how important your time is. We work hard to minimize our patient
wait times and to keep our office running on schedule. Please be aware of the following polices and fees:
Any co-pays, out of pocket expenses or current balances must be paid at check-in, prior to your appointment. If you arrive
without any means to pay, we will cancel your appointment and ask you to reschedule (a $25 cancellation fee will be
applied to your account).
Office Fees:
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$25 cancellation fee will be applied to your account if you cancel your appointment with less than 1 business day of
your appointment time.
$50 missed appointment fee will be applied to your account if you do not show up for your appointment.
$25 late fee will also be applied to your account if you arrive more than 10 minutes late but can still be seen.
$50 late fee will also be applied to your account if you arrive more than 10 minutes and have to reschedule your
appointment.
$25* minimum NSF fee + bank charges will be applied to your account for checks received that do not clear at
your bank. *(depending on face value can be up to 5%)
$25 late fee for overdue balances on your account.
$150 cancellation fee will be applied to your account if you have a surgery scheduled and notify our office of your
intent to cancel less than 2 weeks before your planned surgery.
$300 cancellation fee will be applied to your account if you have a surgery scheduled and notify our office of your
intent to cancel with less than 1 week before your planned surgery.
$500 missed surgery fee will be applied to your account if you have a surgery scheduled and do not show up for
your surgery or if you cancel with less than one business day’s notice or if the surgery must be cancelled due to
your not following pre-surgery preparation protocols.
$25 per form to prepare (FMLA, Short Term Disability paperwork, etc.), payable in advance.
$1 per sheet ($0.25 per sheet after first 25) to supply copies of your medical records
If you are having lab work undertaken by The Women’s Health Institute, please ensure that we have your correct and upto-date personal and insurance information. Should any of the information we provide the lab be incorrect, we cannot be
held responsible for any charges you receive from the third party laboratories we use.
Depending on the type of insurance you have and the particular plan you participate in, we find widely varying co-pay, coinsurance, and other out-of-pocket expenses exist from patient to patient. As a courtesy to all our patients we routinely
process charges to your insurance carriers on your behalf but there are no guarantees we will always be paid for the
services provided.
Any patient balances will be processed and invoices mailed out to the address we have on file for you within one (1)
calendar month. Payment of these balances is expected upon receipt of this statement. Your balance can be paid by
check, credit or debit card in the mail or using your credit or debit card by telephoning our offices at (561) 784-1933 (option
2). If you are unable to settle your balance, please call our office for assistance in remedying the matter.
If we do not hear from you within one month of your first invoice, we will apply the late fee to your account and send you a
reminder statement. During this time period, we will make reasonable attempts to contact you. If we do not receive any
payment within these two billing cycles, your last invoice will arrive with a notice explaining our intent to send your account
to collections. Typically, you will receive a 10 day grace period at this time and an explanation that we will apply any fees
associated with the collection agency to your account. This amount will vary but will often be 33-50% of the account total.
Patients who are sent to collections will be discharged from the practice.
Please read and sign below:
I have read and understand the information provided by this form. I understand my responsibilities and the fees that may
be inccured if I am unable to meet them.
Patient / Legal Guardian Signature
Print Name and Relation to Patient
© 2004, The Women’s Health Institute, LLC
Date
Credit Card On File Authorization
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Credit card authorization for charges incurred by the following patients:
Patient Name
Date of Birth:
/
/
Patient Name
Date of Birth:
/
/
Patient Name
Date of Birth:
/
/
I am authorizing The Women’s Health Institute, LLC to charge my credit card for any and all charges
due for the above listed patients. I am authorizing The Women’s Health Institute, LLC to charge my
credit card for the full amount due. I will not dispute charges for sessions that have been performed
or for any appropriate fee billed based upon the current The Women’s Health Institute fee policy.
Fees will be charged for patient sessions, no-shows, cancellations without appropriate notice, and
other appropriate services. I further authorize The Women’s Health Institute, LLC to disclose
information pertinent to the above listed patients’ activities which have been charged, if necessary.
Card Type: Visa MasterCard Discover American Express Care Credit
Card #:
Expiration Date:
/
/
Name as printed on card:
Billing Address:
I affirm to be an authorized user of the above listed credit card understanding that it is my
responsibility to notify The Women’s Health Institute, LLC of any circumstances that could affect this
agreement (lost or stolen card, new expiration date, new billing address, credit limit reached, card
cancelled, etc.)
Cardholder’s Signature:
Date:
/
/
This form will be securely stored and may be updated upon request at any time.
Please note, your credit card will not be charged unless one of above-listed patients incurs a charge
without payment being rendered at that time.
© 2004, The Women’s Health Institute, LLC
Notice of Privacy Practices
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it
carefully.
We are required by law to provide you with this notice that explains our privacy practices with regard to your medical information and how we may use
and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purposes that are permitted or
required by law. You have certain rights regarding the privacy of your protected health information and we also describe them in this notice.
Ways in Which We May Use and Disclose Your Protected Health Information:
The following paragraphs describe different ways that we use and disclose your protected health information. We have provided an example for each
category, but these examples are not meant to be exhaustive. We assure you that all of the ways we are permitted to use and disclose your health
information fall within one of these categories.
Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.
We will also disclose your health information to other physicians who may be treating you. Additionally we may from time to time disclose your health
information to another physician whom we have requested to be involved in your care. For example – we would disclose your health information to a
specialist to whom we have referred you for a diagnosis to help in your treatment.
Payment. We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example – we
may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the
service.
Health Care Operations. We will use and disclose your protected health information to support the business activities of our practice. For example –
we may use medical information about you to review and evaluate our staff’s performance while caring for you. In addition, we may disclose your health
information to third-party business associates who perform billing, consulting, or transcriptions services for our practice.
Other Ways We May Use and Disclose Your Protected Health Information:
Appointment Reminders. We will use and disclose your protected health information to contact you as a reminder about scheduled appointments or
treatments.
Treatment Alternatives. We will use and disclose your protected health information to tell you about or to recommend possible alternative treatments
or options that may be of interest to you.
Others Involved in Your Care. We will use and disclose your protected health information to a family member, a relative, a close friend, or any other
person you identify that is involved in your medical care or payment for care.
Research. We will use and disclose your protected health information to researchers provided the research has been approved by an institutional
review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
As Required by Law. We will use and disclose your protected health information when required to by federal, state, or local law. You will be notified of
any such disclosures. We will disclose medical information about you when required by federal, state, or local law. We may release medical information
about you to authorized federal officials for national security and intelligence activities.
To Avert a Serious Threat to Public Health or Safety. We will use and disclose your protected health information to a public health authority that is
permitted to collect or receive the information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also
disclose your health information to a foreign government agency that is collaborating with the public health authority.
Worker’s Compensation. We will use and disclose your protected health information for worker’s compensation or similar programs that provide
benefits for work-related injuries or illnesses.
Inmates. We will use and disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that
correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with
health care; to protect the health and safety of others; or for the safety and security of the correctional institution.
Future Communications. We may communicate to you via newsletters, mail outs, email, or other means regarding treatment options, health related
information, disease-management programs, wellness programs, quality assurance, specials, other community based initiatives or activities our facility is
participating in, or other information our practice feels would be beneficial to you.
Organ Donor. We may disclose your medical information to organizations engaged in the procurement, banking, or transplantation of organs for the
purpose of organ or tissue donation and transplant.
Military. If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may
also release medical information about foreign military personnel to the appropriate foreign military authority.
Medical Oversight and Licesure. We may disclose your medical information to health oversight agencies as required by agencies who enforce
compliance with licensure or accreditation requirements. Such activities include, for example, audits, investigations, inspections, and licensure.
Court Order. We may disclose your medical information in response to a court or administrative order. We may also disclose medical information about
you in response to a subpoena, discovery request, or other lawful process. We may disclose your medical information for law enforcement purposes as
required by law. For example, we may disclose medical information about you to comply with laws that require the reporting of certain types of wounds
or other physical injuries.
We may disclose your medical information to coroners, medical examiners or funeral directors consistent with applicable law to carry out their duties.
© 2004, The Women’s Health Institute, LLC
Notice of Privacy Practices
10131 Forest Hill Blvd, Suite 130  Wellington, FL 33414  561.784.1933  fax: 561.784.5109  TheWHI.com
Although your health record is the physical property of the health care practitioner or facility that compiled it, the information belongs to you. You have
the right to:
Paper Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist
at your next visit or by calling and asking us to mail you a copy.
Request a Copy. You have the right to request copy the protected health information that we maintain about you in our designated record set for as
long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for
making decisions about you. Any psycho-therapy notes that may have been included in records we received about you are not available for your
inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.
If you wish to inspect or copy your medical information, you must submit your request in writing to our practice manager. You may mail in your request
or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored
off-site, we are allowed up to 60 days to respond but must inform you of this delay.
Request Amendment. You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must
make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and the reasoning that supports your
request.
We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if:

the information was not created by us, or the person who created it is no longer available to make the amendment;

the information is not part of the record which you are permitted to inspect and copy;

the information is not part of the designated record set kept by this practice;

or if it is the opinion of the healthcare provider that the information is accurate and complete
Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your medical information for treatment,
payment, or health care operations. For example – you could request that we not disclose information about a prior treatment to a family member or
friend who may be involved in your care or payment for care. Your request must be made in writing to our practice manager.
We are not required to agree to your request if we feel it is in your best interest to use or disclose that information. However, if we do agree, we will
comply with your request unless that information is needed for emergency treatment.
Accounting of Disclosures. You have the right to request a list of the disclosures of your health information we have made outside of our practice that
were not for treatment, payment, or health care operations. Your request must be made in writing and must state the time period for the requested
information. You may not request information for any dates prior to April 14, 2003 (the compliance date for the federal regulation) nor for a period of time
greater than six years (our legal obligation to retain information).
Your first request for a list of disclosures within a 12-month period will be free. If you request an additional list within 12-months of the first
request, we may charge you a fee for the costs of providing the subsequent list. We will notify you of such costs and afford you the opportunity to
withdraw your request before any costs are incurred.
Request Confidential Communications. You have the right to request how we communicate with you to preserve your privacy. For example – you
may request that we call you only at your work number, or by mail at a special address or postal box. Your request must be made in writing and must
specify how or where we are to contact you. We will accommodate all reasonable requests.
File a Complaint. I you believe we have violated your medical information privacy rights, you have the right to file a complaint with our practice
manager or directly to the Secretary of Health and Human Services.
To file a complaint with our practice manager, you must make it in writing within 180 days of the suspected violation. Provide as much detail as you can
about the suspected violation and send it to our practice manager. You should know that there would be no retaliation for your filing a complaint.
Uses or Disclosures Not Covered. Uses or disclosures of your health information not covered by the notice or the laws that apply to us may only be
made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose health information about
you for the reasons stated in your written authorization. Disclosures made in reliance on the authorization prior to revocation are not affected by the
revocation.
More Information. If you have questions or would like additional information, you may contact our practice manager at 561-798-8818.
Effective Date: 2009-07-01
PATIENT CERTIFICATION:
By signing below I state that I am 18 years of age or older, or otherwise authorized to consent. I have read or have had explained to me the contents of this
form.
Signature of Patient or Patient Representative (Indicate relationship if signing for patient)
© 2004, The Women’s Health Institute, LLC
Date