Initial Client Intake Form

Please take your time to carefully fill out this form with as much detail as possible related to your pelvic health concerns.

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Pain Rating: Indicate your CURRENT level of pain by selecting the appropriate number on the scale below (skip if not applicable)
List the activity/position and the pain rating when doing that activity.
List the activity/position and the pain rating when doing that activity.
I have pain with:
Select all that apply.
The pain is located:
Genitourinary Symptom Profile
Please check all that you have experienced in the past year.
If yes, how often?
If so, include the type and amount used per day.
Gastrointestinal Symptom Profile
Please check all that you have experienced within the past year.
Most common consistency of stool:
Please list all medications, supplements and herbs, including frequency of use and dosage.
Please list all hospitalizations, surgeries, procedures, transplants and injuries, including dates. (Is there anything else that may affect your care, i.e, history of endometriosis, hysterectomy, bladder sling placement, sexual/emotional/physical abuse, etc.)
Have you or are you experiencing emotional/physical/sexual abuse?
Please describe your current level of physical activity.
Please describe your sleep patterns and average sleep per night. Do you wake feeling refreshed?
 

Payment Information & Cancellation Policy

We accept cash, check, and credit card payments. Please make checks payable to: Expecting Pelvic Health. Payment is due at time of service.

**Session rates begin at $200 for 60 minutes and $225 for 90 minutes.

Cancellation Policy

Your appointment time has been reserved exclusively for you; any change in appointments greatly impacts availability for other clients.

  • In event of an appointment cancelled within less than 24 hours notice, you will be charged 50% of the cost of the missed appointment.
  • In the event you do not attend your session and do not notify our office, you will be charged for your full session.

Financial Policy

In the event of a returned check, the fee assessed by your bank will be billed to your account.

 

Acknowledgement of Patient Bill of Rights and Notice of Privacy Practices

Expecting Pelvic Health, LLC’S NOTICE OF PRIVACY PRACTICES

12 October 2017

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

I. UNDERSTANDING YOUR HEALTH RECORDS/INFORMATION: Each time you visit Expecting Pelvic Health, LLC (hereinafter “Expecting”), a record of your visit is made. Typically, this record contains your symptoms, examination, test results, diagnoses, treatment, and a plan for future care. This information, often referred to as your health record or health information, serves as a:

  • Plan for your care and treatment.
  • Communication source between health care professionals.
  • Tools with which we can check result and continually work to improve the care we provide.
  • Means by which Medicare, Medicaid or private insurance payers can verify the services billed. Understanding what is in your health record and how the information is used helps you to: * • Ensure its accuracy.
  • Better understand why others may review your health information.
  • Make an informed decision when authorizing disclosures.

II. Expecting’s RESPONSIBILITY

Expecting is required by law to:

  • Maintain the privacy of your health information.
  • Inform you about our privacy practices regarding health information we collect and maintain about you (hereinafter “Privacy Practices”).
  • Honor terms of this Notice.

Expecting will keep your oral, written, and electronic health information safe using physical, electronic, and procedural means. These safeguards follow federal and state law.

Expecting reserves the right to change its Privacy Practices and to make the new provisions effective for all health information it maintains. We may tell you about any changes to our Notice in a number of ways. We may tell you about the changes in a newsletter or post them on our website. We may also mail you a letter that tells you about any changes. Expecting will also post any revised Notice of Privacy Practices at public places in its physical facility.

Note: The federal privacy law (the Health Insurance Portability and Accountability Act of 1996, hereinafter “HIPPA”) generally does not preempt, or override other laws that give people greater privacy protections. As a result, if any state or federal privacy law required us to provide you with more privacy protections, then we must also follow that law in addition to HIPPA. Expecting will not use or disclose your health information without your permission, except as described in this Notice and as permitted by the HIPPA Privacy Regulations.

III. HOW Expecting MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

The following categories describe how we may use and disclose health information about you.

  • We will use and disclose your health information to provide your treatment.

For example, we may disclose your personal health information to primary care providers or other medical care providers who request it to aid in your treatment.

If Expecting consults with a health care facility, Expecting will exchange your health information with that health care facility for treatment decisions.

  • We will use your health information for health care operations.

For example, we may use your health information to evaluate your care and outcomes.

This information will be used to continually improve the quality and effectiveness of the services we provide.

IV. Expecting MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU WITHOUT YOUR CONSENT OR AUTHORIZATION FOR THE FOLLOWING PURPOSES: Required by Law: We may use or disclose your personal health information, as we are required to do by federal, state, or local law. As required by law, we will disclose your health information to public health, or health oversight authorities or legal authorities charged with preventing or controlling disease, injury, or disability. We will also disclose your health information to legal authorities charged with receiving reports of child abuse or neglect or domestic violence. We may disclose your health information to an individual who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition. We may disclose your health information to the extent necessary to avoid a serious and imminent threat to your health or safety or to the health and safety of others. We may also have to report certain work-related instances and injuries to your employer so your work place can be monitored for safety. We may disclose your health information in response to a court order or upon the request from your military command authorities, if applicable, or for any workers’ compensation or similar program as required by law. It will not be a violation of this Notice if we, or any of our employees, business associated or contractors discloses information pursuant to whistleblowers and disclosures by workforce member crime victims

Communication with your designee: If you have directed that your health information may be disclosed to a family member, relative, friend or any other person you identify. This disclosure of health information is relevant to that person’s involvement in providing care or payment for services.

Appointment Reminders: We may contact you to remind you about an appointment for services. Note: Except for the situations listed above, we must obtain your specific written authorization for any other release of your health information. An authorization is different that consent. One primary difference is that unlike with consents, a provider must treat you even if you do not wish to sign an authorization. If you sign an authorization, you may withdraw your authorization at any time, as long as your withdrawal is in writing. If you wish to withdraw your authorization, please submit your written withdrawal to Expecting directly.

V. YOUR RIGHTS TO YOUR HEALTH INFORMATION

Although your health record is the physical property of Expecting, the information belongs to you. All requests in connection with the following rights must be in writing. You have a right to:

  • Inspect and copy your health information. With a few exceptions, you have the right to inspect and obtain a copy of your health information. Expecting may charge a copying fee of 10 cents per page after the first 10 pages.
  • Request a restriction on certain uses and disclosures of your health information. Pure Balance is not required to agree to any requested restriction.
  • Request an amendment to your health records if you believe your health information is incorrect or incomplete.
  • Request confidential communications about your health information. You may request confidential communications by an alternative means and Expecting will accommodate all reasonable requests.
  • Request an accounting of disclosure of your health information. You have a right to ask for an accounting of disclosures of your health information we have made up to six (6) years prior to when the request is made. The accounting of disclosures must include the date of each disclosure, who received the disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. Expecting may not charge you for the list, unless you request such a list more than once per year. In addition, we will not include in the list disclosures made to you, or for purposes of treatment, payment, health care operations, national security, law enforcement/corrections, and certain health oversight activities.
  • Request a new copy of this Notice at any time. Even if you have agreed to get this Notice by electronic means, you still have the right to a paper copy upon request.

VI. To exercise your rights under this Notice, to ask for more information, or to report a problem, you may contact the Privacy Official below:

Ryan Bailey
Expecting Pelvic Health, LLC
114 Dame Rd
Durham, NH 03824
Telephone (603) 817-2180

If you believe your privacy rights have been violated, you may file a written Complaint with the above individual or the Office of Civil Rights in the U.S. Department of Health and Human Services, Washington, DC . There will be no retaliation for filing a Complaint. You may file a Complaint at either entity.

I have read and understand the Patient Bill of Rights and Notice of Privacy Practices for Protected Health Information, which provides a detailed description of the potential uses and disclosures of my protected health information and my rights as a patient. I understand that I may request a hard copy of this form at anytime during my treatment at Expecting PElvic Health, LLC. My signature on this page is required by HIPPA (Health Insurance Portability and Accountability Act).

Typing your full name below serves as your electronic signature and affirms that you have provided accurate information; understand and agree all Expecting PElvic Heatlh, LLC policies; and consent to treatment provided by providers at Expecting Pelvic Health, LLC.