BOARD CERTIFIED IN OBSTETRICS AND GYNECOLOGY
Thank you for choosing OBGYN – Total HealthCare for Women and Dr. McQuillin as your women’s
healthcare provider.
To help your first visit go more smoothly, please print and completely fill out the provided forms, sign, and bring
them with you on your first visit. Also please bring your Insurance Card and Picture Identification (i.e. Drivers
License) with you. Please request any needed records from other health care providers that need to be
transferred to us at least 2 weeks in advance. Please review your insurance coverage regarding annual exams and
other coverage. These have been changing a lot lately due to insurance plan changes with Obama Care, and we
don’t want you to be surprised about your insurance coverage.
Please use the checklist below to make sure you have completed all needed forms. In addition, depending on
your insurance provider, there may be some extra forms to fill out once you get to the office.
We never know exactly when new babies are going to arrive or when emergencies will develop at the hospital.
Because of this, you may find that the office is running behind schedule every now and then. We will try to call
you if we are running very behind to allow you the opportunity to re-schedule your appointment. We have an
automated notification system that works with your e-mail and text messages.
Thank you again for choosing us as your Total HealthCare for Women provider.
Registration Form
Health History Questionnaire
Financial Policy
Acknowledgment of Receipt of Notice of Privacy Practices
PAMELA A. M
C
QUILLIN, M.D., P.A.
FAX (949) 862-7691 • http://www.dr-pam.com
1330 EAST 8
TH
STREET, SUITE 420 • ODESSA, TX 79761-4733 • PHONE (432) 580-9191
PAMELA A. MCQUILLIN, M.D., P.A.
REGISTRATION FORM
(PLEASE PRINT CLEARLY)
LAST NAME:_________________________ FIRST NAME:_____________________ MI:_______
MAILING ADDRESS:_____________________________ CITY:_______________ STATE:_______
ZIPCODE:___________ SOCIAL SERCURITY#:_________________DATE OF BIRTH: ___/___/____
HOME # :(____) ____-____ CELL #: (____) _____-_______ WORK #: (____) _______-_______
MARITAL STAUS: (CHECK ONE) SINGLE____ MARRIED_____DIVORCED_____WIDOWED_____
E-MAIL (PRINT CLEARLY) _________________________________________________________
PATIENTS EMPLOYER NAME & ADDRESS: ____________________________________________
INSURANCE INFORMATION
NAME OF INSURANCE:____________________ SUBSCRIBERS NAME:___________________________
SUBSCRIBERS EMPLOYER NAME & ADDRESS: _______________________________________________
SUBSCRIBERS DOB: _____________________ SOCIAL SECURITY #:________________________
RELANTIONSHIP TO PATIENT: (CHECK ONE) SELF____SPOUSE___CHILD_____OTHER____
PHARMACY NAME & ADDRESS: __________________________________________________________
IN CASE OF EMERGENCY – (NOT IN THE SAME HOUSEHOLD)
NAME:__________________ RELANTIONSHIP:______________PHONE#:__________________
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Pamela A McQuillin, M.D., P.A. I understand that I am financially responsible for any balance on my
account. I also authorize Pamela A McQuillin M.D., P.A. or my insurance company to release any information required to process my claim. I hereby acknowledge that I/my child/may need medical care and treatment.
I voluntarily consent to the performance of medical services and the use of all means of diagnostic and laboratory work of any kind (including but not limited to the taking of blood, tissue, fluids and other body
samples and videotapes, photographs and other radiographic or ultrasound procedures,) upon myself/ my child/ my ward which are deemed necessary or prudent by the attending physician or any other medical staff
person. I am aware that the practice of medicine is not an exact science. I acknowledge that no guarantees have been me as to the results of the care I hereby authorize.
DISCLOSURE: Please carefully review the information contained in this notice. ORMC meets the definition of a “physician owned hospital” under 42 CFR 489-3. The hospital is owned in part by physicians. Pamela A.
McQuillin M.D is a shareholder at this facility. A list of physician ownership is available from each hospital. You have the right to choose the provider of your health care services. Although we believe that ORMC will
be able to meet your needs, you have the option to use a facility other than ORMC, specifically in Odessa, Texas you may choose to use the County Hospital (Medical Center Hospital). You will not be treated differently
by your physician if you choose to use a different facility. Your physician may have an on-call physician covering at another hospital. If desired your physician or any staff member can provide information about
alternative healthcare providers. If you have any questions concerning this notice please feel free to ask your physician or any representative of ORMC. We welcome you as a patient and value our relationship with
you.
X___________________________________________________________________________________
PATIENT/GUARDIANS SIGNATURE DATE
Original Date:
_____/_____/_____
Dates Revised:
_____/_____/_____
_____/_____/_____
_____/_____/_____
_____/_____/_____
HEALTH HISTORY QUESTIONNAIRE
All questions contained in this questionnaire are strictly confidential and
will become part of your medical record.
Name:
(Last, First, M.I.)
DOB _____/_____/_____
Marital
Status:
Single
Partnered
Married
Separated
Divorced
Widowed
Previous or Referring Doctor:
Date of Last Annual
Physical Exam: ____/_____/_____
PERSONAL HEALTH HISTORY
Childhood Illness:
Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever Polio
Tetanus _____________________
Pneumonia ______________________
Hepatitis _____________________
Chickenpox ____________________
Immunizations
and Dates:
Influenza _____________________
MMR ____________________
Other ______________________
(Measles, Mumps, Rubella)
List Any Medical Problems That Other Doctors Have Diagnosed:
Surgeries:
Year Reason Hospital
Other Hospitalizations:
Year Reason Hospital
Have you ever had a blood transfusion? ............................................................................
Yes
No
Please turn to next page
List Your Prescribed Drugs and Over-the-Counter Drugs, Such as Vitamins and Inhalers:
Name the Drug Strength Frequency Taken
Allergies to Medications:
Name the Drug Reaction You Had
HEALTH HABITS AND PERSONAL SAFETY
Exercise:
Sedentary (No exercise)
Mild Exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional Vigorous Exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular Vigorous Exercise (i.e., work or recreation 4x/week for 30 minutes)
Diet:
Are you dieting?..........................................................................................
Yes
No
If yes, are you on a physician prescribed medical diet? .............................
Yes
No
# of meals you eat in an average day?______________
Rank Salt Intake
Hi
Med
Low Rank Fat Intake
Hi
Med
Low
Caffeine:
None
Coffee
Tea
Cola # of Cups/Cans Per Day? ______
All questions contained in this questionnaire are optional and will be kept strictly confidential.
Alcohol:
Do you drink alcohol? ................................................................................
Yes
No
If yes, what kind?_____________________ How many drinks per week? _____
Are you concerned about the amount you drink? ......................................
Yes
No
Have you considered stopping? .................................................................
Yes
No
Have you ever experienced blackouts? ......................................................
Yes
No
Are you prone to “binge” drinking? ...........................................................
Yes
No
Do you drive after drinking? ......................................................................
Yes
No
Tobacco:
Do you use tobacco?
..........................................................................
Yes
No
Cigarettes - Pks/day_____
Chew - #/day _____
Pipe - #/day _____
Cigars - #/day _____
# of Years _____
or Year Quit _____
All questions contained in this questionnaire are optional and will be kept strictly confidential.
Drugs:
Do you currently use recreational or street drugs? .....................................
Yes
No
Have you ever given yourself street drugs with a needle? .........................
Yes
No
All questions contained in this questionnaire are optional and will be kept strictly confidential.
Sex:
Are you sexually active? ...........................................................................
Yes
No
If yes, are you trying for a pregnancy? ......................................................
Yes
No
If not trying for a pregnancy list contraceptive or barrier method used? __________
Any discomfort with intercourse? .............................................................
Yes
No
Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a
major public health problem. Risk factors for this illness include intravenous drug use and
unprotected sexual intercourse. Would you like to speak with your provider about your
risk of this illness?......................................................................................
Yes
No
Personal Safety:
Do you live alone?......................................................................................
Yes
No
Do you have frequent falls? .......................................................................
Yes
No
Do you have vision or hearing loss? ..........................................................
Yes
No
Do you have an Advance Directive and/or Living Will? ..........................
Yes
No
Would you like information on the preparation of these? .........................
Yes
No
Physical and/or mental abuse have also become major public health issues in this country.
This often takes the form of verbally threatening behavior or actual physical or sexual
abuse. Would you like to discuss this issue with your provider? ..............
Yes
No
Please remember that the following recommendations are very
important to maintaining your health.
When in a car, wear your safety belt at all times. Keep children in protective seats.
While riding a motorcycle or bicycle, wear a helmet.
Always have functional smoke detectors and fire extinguishers in your home.
If you own a firearm, make sure that it is accessible only to you. Take every
precaution to ensure that children do not have access to a loaded firearm.
Keep the firearm and ammunition in separate locations.
FAMILY HEALTH HISTORY
Age
Age at
Death
Significant Health Problems
or Cause of Death
Age
Age at
Death
Significant Health Problems
or Cause of Death
Father
M
F
Mother
M
F
M
F
M
F
Brothers
and
Sisters
M
F
Children
M
F
M
F
Grandparents (Mother’s Side)
M
F
Male
M
F
Female
M
F
Grandparents (Father’s Side)
M
F
Male
M
F
Female
Continued on Back Side
MENTAL HEALTH
Is stress a major problem for you? ..............................................................................................
Yes
No
Do you feel depressed? ................................................................................................................
Yes
No
Do you panic when stressed? ......................................................................................................
Yes
No
Do you have problems with eating or your appetite? ..................................................................
Yes
No
Do you cry frequently? ................................................................................................................
Yes
No
Have you ever attempted suicide? ...............................................................................................
Yes
No
Have you ever seriously thought about hurting yourself? ...........................................................
Yes
No
Do you have trouble sleeping? ....................................................................................................
Yes
No
Have you ever been to a counselor? ............................................................................................
Yes
No
WOMEN
Age at onset of menstruation: _____ Date of last menstruation: _____/_____/_____
Period every _____ days. Heavy periods, irregularity, spotting, pain or discharge? ...................
Yes
No
Number of pregnancies _____ Number of live births _____
Are you pregnant or breastfeeding? ............................................................................................
Yes
No
Have you had a D&C, hysterectomy or cesarean section?...........................................................
Yes
No
Any urinary tract, bladder or kidney infections within the last year? .........................................
Yes
No
Any blood in your urine? .............................................................................................................
Yes
No
Any problems with control of urination? ....................................................................................
Yes
No
Any hot flashes or sweating at night? ..........................................................................................
Yes
No
Do you have menstrual tension, pain, bloating,
irritability or other symptoms at or around time of period? ................................................
Yes
No
Experienced any recent breast tenderness, lumps or nipple discharge? ......................................
Yes
No
Date of last pap and rectal exam? ____/_____/_____
OTHER PROBLEMS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly
explain.
Skin_____________________
Head/Neck _______________
Ears _____________________
Nose ____________________
Throat ___________________
Lungs ___________________
Chest/Heart _______________
Back ____________________
Intestinal _________________
Bladder __________________
Bowel ___________________
Thyroid __________________
Circulation _______________
Recent Changes In:
Weight __________________
Energy Level _____________
Ability to Sleep____________
Other Pain/Discomfort:
__________________________
_______________________
_______________________
_______________________
_______________________
DISCLOSURE: Please carefully review the information contained in this notice. Odessa Regional Medical Center and Basin Healthcare Center both meet the definition of a “physician-owned hospital” under 42 CFR
489.3. The hospitals are owned in part by physicians. Pamela McQuillin, M.D., is a shareholder at both of these facilities. A list of physician ownership is available from each hospital. You have the right to choose the
provider of your health care services. Although we believe that both Odessa Regional Medical Center and Basin Healthcare Center will be able to meet your needs, you have the option to use a facility other than
Odessa Regional Medical Center or Basin Healthcare Center , specifically, in Odessa, Texas, you may choose to use the County Hospital, (Medical Center Hospital). You will not be treated differently by your
physician if you choose to use a different facility. Your physician may have an on-call physician covering at another hospital. If desired, your physician or any staff member can provide information about alternative
health care providers. If you have any questions concerning this notice, please feel free to ask your physician or any representative of either Odessa Regional Medical Center or Basin Healthcare Center. We welcome
you as a patient and value our relationship with you.
_______________________________________________ _________________________
Patient Signature Date
BOARD CERTIFIED IN OBSTETRICS AND GYNECOLOGY
DISCLOSURE:
Please carefully review the information contained in this notice. Odessa Regional Medical Center meets the definition
of a “physician-owned hospital” under 42 CFR 489.3. The hospital is owned in part by physicians. Pamela A.
McQuillin, M.D., is a shareholder at Odessa Regional Medical Center. A list of physician ownership is available from
the hospital. You have the right to choose the provider and hospital for your health care services. Although we believe
that Odessa Regional Medical Center will be able to meet your needs, you have the option to use a facility other than
Odessa Regional Medical Center, specifically, in Odessa, Texas, you may choose to use the County Hospital (ie.
Medical Center Hospital). You will not be treated differently by your physician if you choose to use a different facility.
Your physician may have an on-call physician covering at another hospital. If desired, your physician or any staff
member can provide information about alternative health care providers. If you have any questions concerning this
notice, please feel free to ask Dr. McQuillin, any of her staff, or any representative of Odessa Regional Medical Center.
We welcome you as a patient and value our relationship with you.
Patients Signature: _________________________________________ Date: ________________
Witness Signature: _________________________________________ Date: ________________
PAMELA A. M
C
QUILLIN, M.D., P.A.
FAX (949) 862-7691 • http://www.dr-pam.com
1330 EAST 8
TH
STREET, SUITE 420 • ODESSA, TX 79761-4733 • PHONE (432) 580-9191
Pamela A. McQuillin, M.D., P.A.
1330 E 8TH ST STE 420
ODESSA TX 79761
CONSENT FOR MEDICAL SERVICES AND FINANCIAL AGREEMENT
PATIENT NAME ________________________________________________ DATE OF BIRTH______________________
Medical Consent: The undersigned consent authorizes any medical treatment, surgery, examination, laboratory procedure, x-ray examination, and/or physical therapy treatment that may be considered advisable or necessary
for the patient in the judgment of the attending physician.
BASIC POLICY: Payment for service is due in full at the time service is provided in our office. We accept Insurance, Checks, Credit Cards, Care Credit, and Cash. No "Post Dated" Checks will be accepted. If at any point
during or after my treatment in the clinic I should desire a copy of my medical records, there will be a minimum fee of $12.00. After the first 20 pages there will be a fee of $0.50/page. Payment must be received in advance
along with a HIPPA compliant release form and an original signature. Should I desire to have them mailed, I must that Pamela A. McQuillin, M.D., P.A. with a self-addressed stamped envelope. The preparation may take
up to four weeks. For any form that Pamela A. McQuillin, M.D., P.A. is asked and agrees to fill out, there will be a minimum fee of $25.00 payable prior to completion of the form. This fee will be billed directly to me and
will not be filed with an insurance company or other third party.
FOR PATIENTS WITH INSURANCE: You must present you insurance card at the time of your visit. Failure to notify us of any changes in your insurance may cause the entire charged amount to become your
responsibility. We bill most insurance providers for you if proper paperwork is provided to us. We will also bill some secondary insurance providers for you as a courtesy. If your secondary provider does not pay the amount
the primary insurance provider states you owe us, you will owe the difference between what the secondary provider pays and the amount the primary states you owe. Co-payments and deductibles are due at the time of
service. Our failure to collect these amounts may be a violation of our contract with your insurance company and may result in civil and criminal penalties and/or expulsion from your insurance plan. In addition, your failure
to pay the required co-amounts is a violation of your financial responsibility for coverage and we my report your refusal to pay these amounts to your employer and/or insurance company representative. Since your agreement
with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated for care. Certain tests may be ordered by Dr. McQuillin. I agree to be
financially responsible for these services should they be considered “non-covered” or not medically indicated by my insurance company. If an insurance carrier has not paid us within 60 days of billing, professional fees are
due and payable in full from you. Payment plans for obstetrical care and surgeries are handled through Care Credit.
MEDICARE PATIENTS: We will bill Medicare for you. We will also bill secondary insurance carriers for you. All co-payments or deductibles are due and payable at the time of service is provided.
MEDICAID PATIENTS: You must present your current Medicaid Card prior to each visit.
Release of Medical Records: The undersigned authorizes the release of information in the patient’s medical records to his/her private physician and to any physician, hospital, or agency to which Pamela A. McQuillin, M.D.,
P.A., refers the patient. The undersigned also authorizes any physician, hospital or agency to which the patient is referred the release of information to Pamela A. McQuillin, M.D., P.A. regarding treatment by said physician,
hospital or agency.
SURGERY FEES: All co-pays, deductibles, and payments for surgical procedures are due prior to your surgery. Your carrier may require prior authorization. Unless it is an emergency surgery, surgeries will be
rescheduled if payments have not been received by you prior to the surgery.
NON-COVERED SERVICES: Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or upon notice of insurance claim denial.
PERSONAL INJURY CASES: This office does not bill for auto accident or other liability or lawsuit-related cases. You are responsible for payment at the time of service. We do not accept liens.
MISSED APPOINTMENTS In fairness to other patients and the doctor, we require at least 24 hours' notice to cancel appointments. You may be charged for missed appointments or dismissed from the practice for
repeated missed appointments.
FAILURE TO FOLLOW MEDICAL ADVICE: You may be dismissed from the practice for failure to follow Dr. McQuillin's medical advice.
FINANCE CHARGES : Past due accounts over 90 days may be assessed a finance charge of 18% APR.
COLLECTIONS: Patient responsibility is due upon receipt of insurance explanation of benefits (EOB). Because it is extremely impractical or difficult to ascertain all items of damage or amounts thereof which would be
sustained by us as a result of an account becoming delinquent, Patient and Financial Responsible Person agree that any charges which are not paid in FULL when due shall be subject to a late fee. If balance remains unpaid 90
days after the date of the EOB, a $35.00 late fee may be charged and account may be transferred to IC Systems for collections. Should Patient’s account be referred to an attorney for collection, Patient and Financial
Responsible Person agree to pay, in addition to all sums due, all reasonable attorney’s fees, court costs, and all reasonable costs of collection. All statements returned to us without a forwarding address may be charged
$30.00 and turned over to a collection agency.
DISCLOSURE: Please carefully review the information contained in this notice. Odessa Regional Medical Center and Basin Healthcare Center both meet the definition of a “physician-owned hospital” under 42 CFR
489.3. The hospitals are owned in part by physicians. Pamela McQuillin, M.D., is a shareholder at both of these facilities. A list of physician ownership is available from each hospital. You have the right to choose the
provider of your health care services. Although we believe that both Odessa Regional Medical Center and Basin Healthcare Center will be able to meet your needs, you have the option to use a facility other than Odessa
Regional Medical Center or Basin Healthcare Center , specifically, in Odessa, Texas, you may choose to use the County Hospital, (Medical Center Hospital). You will not be treated differently by your physician if you
choose to use a different facility. Your physician may have an on-call physician covering at another hospital. If desired, your physician or any staff member can provide information about alternative health care providers. If
you have any questions concerning this notice, please feel free to ask your physician or any representative of either Odessa Regional Medical Center or Basin Healthcare Center. We welcome you as a patient and value our
relationship with you.
I have read, understood, and agreed to all the provisions in this agreement. I understand that my insurance is an agreement between my insurance company and me. I also understand that I am responsible for
my balance regardless of my insurance. I am ultimately responsible for all professional fees due to Pamela A McQuillin, M.D.. I understand that I may incur a 18% finance charge if my balance goes beyond
90 days. I consent to and authorize any medical treatment and I give permission for my physician and her clinical team to take any necessary diagnostic films, lab studies, photos or study models, to properly
enable complete diagnosis and treatment. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance, and any other health plans, to Pamela
A. McQuillin, M.D.. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand I am financially responsible
for all charges whether or not paid by said insurance. l hereby authorizes said assignee to release all information necessary to secure the payment. Appointment times are given as estimated times that patients
will be seen by the doctor. I understand the length of the office visits are based on the needs of each individual patient in the clinic and unforeseen delays at the hospital including the delivery of babies.
Because of this, there may be minimal or extended delays.
Patient's Signature: X____________________________________________________ Date: ___________________________________
MEDICARE PATIENTS SIGNATURE ON FILE
: I request payment of authorized Medicare benefits be made on my behalf to Pamela A. McQuillin, M.D., P.A.. for any services furnished me by the listed
provider/supplier. I authorize any holder of medical information about me to release to the Center for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits
payable to related services.
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS-1500 form or elsewhere on
other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept
the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the
charge determination of the Medicare carrier.
Medicare Patient's Signature: X____________________________________________________Date_____________________________________
Pamela A. McQuillin, M.D., P.A.
1330 East 8
th
Street, Suite 420
Odessa, Texas 79761-4733
(432) 580-9191
NOTICE OF INSURANCE BUNDLING RULES
You are covered by _________________________________________________________insurance.
Your insurance provider has a policy that does not allow for the payment of two or more unrelated services
that are provided on the same date of service, or they will not pay an office visit on the same date of service
that a procedure is performed, even if the office visit is for another unrelated problem. This includes a Well
Woman Exam or “annual”. A Well Woman Exam only includes preventative services. If you come to your
Well Woman Exam with complaints of health problems, the exam is no longer considered a Well Woman
Exam by your insurance company, and different co-pays and deductibles may apply. Your insurance
company does not allow a Well Woman Exam to be combined with a visit that has health problems. The
combining of problems in a visit is referred to as bundling
of services. These insurance policies are
inconsistent with those established by the American Medical Association.
What this means is, if you have more than one problem on your visit, the insurance company will
reimburse for only one problem, or at best, at a drastically reduced reimbursement for services that are
provided.
For this reason, due to the insurance coverage you have, we can only address one problem per visit
unless
an exception is granted.
If you have additional problems, please be advised that you may have to make additional appointments in
order to be covered under your insurance plan. We would prefer to address all of your problems with a
single visit, but we must comply with your insurance company rules.
Your signature below signifies your understanding of this limit to your insurance coverage and the payment
policies of your insurance carrier.
___________________________________________
Patient Name Printed
___________________________________________
Patient Signature
_________________________________
Date
HIPAA Notice of Privacy Practices
OBGYN – Total HealthCare for Women
Effective Date: September 23, 2013
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.
If you have any questions about this notice, please contact the Privacy Officer, Dr. Eric Pokky at
(432) 332-9191.
OUR OBLIGATIONS:
We are required by law to:
• Maintain the privacy of protected health information
• Give you this notice of our legal duties and privacy practices regarding health information about you
• Follow the terms of our notice that is currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:
The following describes the ways we may use and disclose health information that identifies you (“Health
Information”). Except for the purposes described below, we will use and disclose Health Information only with your
written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.
For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-
related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or
other personnel, including people outside our office, who are involved in your medical care and need the information
to provide you with medical care.
For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from
you, an insurance company or a third party for the treatment and services you received. For example, we may give
your health plan information about you so that they will pay for your treatment.
For Health Care Operations. We may use and disclose Health Information for health care operations purposes.
These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate
and manage our office. For example, we may use and disclose information to make sure the obstetrical or
gynecological care you receive is of the highest quality. We also may share information with other entities that have
a relationship with you (for example, your health plan) for their health care operation activities.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and
disclose Health Information to contact you to remind you that you have an appointment with us. We also may use
and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that
may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health
Information with a person who is involved in your medical care or payment for your care, such as your family or a
close friend. We also may notify your family about your location or general condition or disclose such information to
an entity assisting in a disaster relief effort.
Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a
research project may involve comparing the health of patients who received one treatment to those who received
another, for the same condition. Before we use or disclose Health Information for research, the project will go
through a special approval process. Even without special approval, we may permit researchers to look at records to
help them identify patients who may be included in their research project or for other similar purposes, as long as
they do not remove or take a copy of any Health Information.
SPECIAL SITUATIONS:
As Required by Law. We will disclose Health Information when required to do so by international, federal, state or
local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to
prevent a serious threat to your health and safety or the health and safety of the public or another person.
Disclosures, however, will be made only to someone who may be able to help prevent the threat.
Business Associates. We may disclose Health Information to our business associates that perform functions on our
behalf or provide us with services if the information is necessary for such functions or services. For example, we may
use another company to perform billing services on our behalf. All of our business associates are obligated to protect
the privacy of your information and are not allowed to use or disclose any information other than as specified in our
contract.
Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations
that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or
tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by
military command authorities. We also may release Health Information to the appropriate foreign military authority if
you are a member of a foreign military.
Workers’ Compensation. We may release Health Information for workers’ compensation or similar programs.
These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose Health Information for public health activities. These activities generally
include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or
neglect; report reactions to medications or problems with products; notify people of recalls of products they may be
using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or
condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or
domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities
authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure.
These activities are necessary for the government to monitor the health care system, government programs, and
compliance with civil rights laws.
Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally
required notices of unauthorized access to or disclosure of your health information.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in
response to a court or administrative order. We also may disclose Health Information in response to a subpoena,
discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been
made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1)
in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or
locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain
very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the
result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the
location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical
examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We
also may release Health Information to funeral directors as necessary for their duties.
National Security and Intelligence Activities. We may release Health Information to authorized federal officials for
intelligence, counter-intelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose Health Information to authorized federal
officials so they may provide protection to the President, other authorized persons or foreign heads of state or to
conduct special investigations.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law
enforcement official, we may release Health Information to the correctional institution or law enforcement official.
This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and
safety or the health and safety of others; or (3) the safety and security of the correctional institution.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT
Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of
your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly
relates to that person’s involvement in your health care., If you are unable to agree or object to such a disclosure, we
may disclose such information as necessary if we determine that it is in your best interest based on our professional
judgment.
Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your
Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a
disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can
do so.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES
The following uses and disclosures of your Protected Health Information will be made only with your written
authorization:
1. Uses and disclosures of Protected Health Information for marketing purposes; and
2. Disclosures that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will
be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by
submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information
under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not
be affected by the revocation.
YOUR RIGHTS
:
You have the following rights regarding Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make
decisions about your care or payment for your care. This includes medical and billing records, other than
psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to the
privacy officer. We have up to 30 days to make your Protected Health Information available to you and we may
charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We
may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any
other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If
we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who
was not directly involved in the denial of your request, and we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in
an electronic format (known as an electronic medical record or an electronic health record), you have the right to
request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will
make every effort to provide access to your Protected Health Information in the form or format you request, if it is
readily producible in such form or format. If the Protected Health Information is not readily producible in the form or
format you request your record will be provided in either our standard electronic format or if you do not want this form
or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with
transmitting the electronic medical record.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured
Protected Health Information.
Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend
the information. You have the right to request an amendment for as long as the information is kept by or for our
office. To request an amendment, you must make your request, in writing, to the privacy officer.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of
Health Information for purposes other than treatment, payment and health care operations or for which you provided
written authorization. To request an accounting of disclosures, you must make your request, in writing, to the privacy
officer.
Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we
use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the
Health Information we disclose to someone involved in your care or the payment for your care, like a family member
or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with
your spouse. To request a restriction, you must make your request, in writing, to the privacy officer. We are not
required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health
Information to a health plan for payment or health care operation purposes and such information you wish to restrict
pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will
comply with your request unless the information is needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your
health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with
respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations,
and we will honor that request.
Right to Request Confidential Communications. You have the right to request that we communicate with you
about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by
mail or at work. To request confidential communications, you must make your request, in writing, to the privacy
officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable
requests.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give
you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still
entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.dr-pam.com. To
obtain a paper copy of this notice, please contact the front office at (432) 332-9191.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Health Information we already have as
well as any information we receive in the future. We will post a copy of our current notice at our office. The notice
will contain the effective date on the first page, in the top right-hand corner.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of
the Department of Health and Human Services. To file a complaint with our office, contact the privacy officer. All
complaints must be made in writing. You will not be penalized for filing a complaint.
Acknowledgment of Receipt of Notice of Privacy Practices
Use and disclosure of protected health information is regulated by a federal law known as The Health Insurance Portability and
Accountability Act of 1996 ("HIPAA"). Under HIPAA, providers of healthcare are required to give patients their Notice of Privacy
Practices for Protected Health Information and make a good faith effort to obtain a written acknowledgment that this notice was
received.
Therefore, I, __________________________________ (printed name of patient or personal representative), acknowledge that
Pamela A. McQuillin, M.D., P.A. has provided a written copy of its Notice of Privacy Practices for Protected Health Information to
(check one) myself or specify: _________________________________
(If signing as a personal representative, documentation of your legal right to do so must be provided.)
________________________________ ___/___/20___ _________________________ __________________
Signature of Patient Date Printed Name Relationship to Patient
or Personal Representative (mm/dd/yyyy) (if not self)
_______________________________________________________________
To be completed by Pamela A. McQuillin, M.D., P.A.
We made a good faith attempt to provide the above named patient with a copy of our Notice of Privacy Practices for Protected
Health Information, but we were not successful for the following reason:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________ _____________ _____________________________ ___/___/20___
Signature Title Printed Name Date
(mm/dd/yyyy)
OBSTETRICS AND GYNECOLOGY
Information About PAP Smear Charges
Pathology charges for PAP smears collected in our office are estimates for a normal PAP smear.
If your PAP smear is abnormal, there will be additional charges from the pathology lab that will be billed to
you and/or your insurance company after the additional testing results have been confirmed. These charges
include the fee to re-read the specimen more closely by a pathologist using a manual method, and the
testing of the specimen for the human papilloma virus (HPV).
HPV is responsible for many abnormal PAP smears and is the number one cause of cervical cancer. If your
PAP smear is abnormal, it is important to know if it is due to one of the high risk HPV viruses, as this may
affect your treatment.
A recent study published in JAMA
1
showed that 25% of women aged 14-19 and 45% of women aged 20-24
are infected with at least one HPV virus type.
There is now a vaccine available (Gardasil) that can prevent four of the most common high risk HPV types
from infecting you. This vaccine can prevent most but not all cervical cancer and venereal warts. Please call
us for an appointment if you are interested in preventing this virus from infecting you or your daughters.
Gardasil is only effective if given before an exposure to the HPV virus.
Please visit our web site at www.dr-pam.com for more information on Gardasil.
1. Eileen F. Dunne; Elizabeth R. Unger; Maya Sternberg; Geraldine McQuillan; David C. Swan; Sonya S. Patel; Lauri E. Markowitz
Prevalence of HPV Infection Among Females in the United States
JAMA 2007 297: 813-819
PAMELA A. M
C
QUILLIN, M.D., P.A.
FAX (432) 332-1344 • http://www.dr-pam.com
1330 EAST 8
TH
STREET, SUITE 420 • ODESSA, TX 79761-4733 • PHONE (432) 580-9191
BOARD CERTIFIED IN OBSTETRICS AND GYNECOLOGY
Important Patient Policies
Financial Policies: (Please Initial next to each policy)
_______Payment is due at the time of service unless other arrangements have been made
in advance.
_______As a courtesy to our patients, we participate in and directly bill many health plans.
However, you are ultimately responsible for payment of services. Please be aware of your
specific plan benefits and limitations. If your insurance carrier fails to pay in timely manner,
or fails to pay at all, you will be responsible for the charges.
_______There will be a $35 charge on all returned checks. Returned checks not paid
within 21 days will be referred to the County Attorney’s office for collections.
_______ If your insurance provider decides at a later date that your charges are not
covered, even after they initially approved them, you will be responsible for all charges
reversed by the insurance company. Please note, the insurance companies can reverse
charges several years after the charges were approved and paid.
Policy Regarding Completion of Forms and Medical Records:
______All forms including Disability, FMLA, STD (Short Term Disability), etc. will be
completed as time permits. Please allow 3-5 business days for completion of the forms.
Due to the large increase in the volume of form requests, we must now charge a $25 fee.
This is due prior to completion of any forms. Your insurance company does not cover this
fee.
______A fee of $25 will apply to paper medical record request for the first 20 pages and an
additional $0.50 per page thereafter. Additional fees will apply to other items including
ultrasound images and postage. Electronic records are charged at $25 for 500 pages or
less; $50 for more than 500 pages. A combined fee will be charged if both paper and electronic
records are needed. There is no charge to for us directly provide records to another physician.
Please allow up to 15 days for records to be retrieved.
PAMELA A. M
C
QUILLIN, M.D., P.A.
FAX (432) 332-1344 • http://www.dr-pam.com
1330 EAST 8
TH
STREET, SUITE 420 • ODESSA, TX 79761-4733 • PHONE (432) 580-9191
BOARD CERTIFIED IN OBSTETRICS AND GYNECOLOGY
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
TO INDIVIDUALS/FAMILY MEMBERS
In accordance with Federal government privacy rules implemented through the Health
Insurance Portability and Accountability Act (HIPPA), and in order for Dr. McQuillin
or her staff to discuss your medical condition with members of your family or other
individuals that you designate, we must obtain an authorization from you.
________I do not authorize Dr. McQuillin to verbally release any information
concerning my medical care to any individual except as set forth in HIPAA.
________I authorize Dr. McQuillin to verbally release any or all information concerning
my medical care to the following individuals:
_____________________ ___________________
Name Relation to patient
_____________________ ___________________
Name Relation to patient
_____________________ ____________________
Patient Signature Date
PAMELA A. M
C
QUILLIN, M.D., P.A.
FAX (949) 862-7691 • http://www.dr-pam.com
1330 EAST 8
TH
STREET, SUITE 420 • ODESSA, TX 79761-4733 • PHONE (432) 580-9191
