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Green Valley OB/GYNPLEASE PRINTConfidential Patient InformationNew Patient Established PatientName: DOB: / /Circle One: SingleMarriedDivorcedWidowedSS# - -Current Address: Apt/Unit#:City: State: Zip:Best phone #: Emergency phone#:Employer: Occupation:Who may we thank for referring you today?Spouse/Guarantor (if patient is a minor) Name:Spouse/Guarantor SS#: / /DOB: / /Insurance InformationPrimary Insurance: Phone:Policy Holder’s Name: DOB: / /SS# - - ID# Group#Insurance Address: Employer:Relation to Patient (Please circle one): Self Spouse Mother Father Legal GuardianSecondary Insurance: Phone:Policy Holder’s Name: DOB: / /SS# - - ID# Group#Insurance Address: Employer:Relation to Patient (Please circle one): Self Spouse Mother Father Legal GuardianPLEASE READ THE FOLLOWING CLOSELY:NOTE: There will be a separate bill from the lab for a pap smear interpretation, culturesand any other laboratory test.The above information is complete and correct. I hereby authorize release of informationnecessary to file a claim with my insurance company and I assign benefits, otherwise payableto me, to Green Valley OB/GYN.Patient/Guardian Signature: Date:

Green Valley OB/GYNIMPORTANT NOTICEPLEASE READ CAREFULLY If you are 15 minutes or more late, your appointment will be rescheduled by the front desk. It is important you NOT miss your scheduled appointments. Should youreschedule your appointment three (3) or more times, it is likely you will be considered for dischargefrom our practice. If you are an OB patient between 0-36 weeks and miss two (2) or moreappointments, it is likely you will be considered for dismissal from our practice. You must arrive 15 minutes early prior to an ultrasound appointment. These appointments run on a verytight schedule and there is no grace period for being late. If you arrive later than your scheduledappointment, there will not be any consideration for being seen as a late patient.Please be advised there are no picture or filming opportunities in the ultrasound room. Should youbreak this protocol, your appointment will end immediately. You must present a valid insurance card AND picture ID at the time of check in. Should you not haveyour picture ID AND insurance card, it is necessary your appointment be rescheduled. Co-pays are due at the time of checking in for your appointment. If you do not have your co-pay, yourappointment will be rescheduled by the front desk. You will be notified of any ABNORMAL test results. Please refrain from any outbursts or negative interaction with the Green Valley OB/GYN staff. If youwould like to speak to the manager for your urgent matter, please notify the front desk and we would behappy to arrange for a manager or supervisor to speak with you. Should your behavior warrant thewaiting room patients or staff to be uncomfortable, it is possible you will be immediately dischargedfrom our practice.Patient Signature: Date:

Patient Consent for Use and Disclosureof Protected Health InformationGreen Valley OB/GYNEffective 12/15/2018With my consent, Green Valley OB/GYN may use and disclose protected health information (PHI)about me to carry out treatment, payment and healthcare operations (TPO). Please refer to GreenValley OB/GYN's Notice of Privacy Statement for a more complete description of such uses anddisclosures.I have the right to review the Notice of Privacy Statement prior to signing this consent. Green ValleyOB/GYN reserves the right to revise its Notice of Privacy Statement at any time. A revised Notice ofPrivacy Statement may be obtained by forwarding a written request to Green Valley OB/GYN, Attn:Medical Records, at: 100 N. Green Valley Parkway, Suite 345, Henderson, Nevada, 89074.With my consent, Green Valley OB/GYN may call my home or other designated location and leave amessage on voicemail or in person in reference to any items that assist the practice in carrying outTPO, such as appointment reminders, billing information, insurance items and any call pertaining tomy clinical care, including, but not limited to, laboratory results.With my consent, for purposes of proper pregnancy and delivery treatment, Green Valley OB/GYN willmake a copy of my current obstetric medical record, including medical history and all test and labresults available to the birthing hospital. This information will be available to my baby's pediatricianand other specialists needed for my baby's care. The hospital, the pediatrician and any other neededspecialists may make my personal health information part of their medical record for my baby.Transfer of this information will help the hospital staff, the on-call physician, the pediatrician and anyother needed specialists appropriately care for my newborn baby and me.However, the practice is not required to agree to my requested restrictions, but if it does, it is bound bythis agreement.By signing this form, I am consenting to Green Valley OB/GYN's use and disclosure of my PHI tocarry out TPO.I may revoke my consent in writing except to the extent that the practice has already made disclosuresin reliance upon my prior consent. If I do not sign this consent, Green Valley OB/GYN may decline toprovide treatment to me.Signature of Patient or Legal GuardianDatePlease Print Name of Patient or Legal GuardianDate12/2018 RD

Green Valley OB/GYN100 N. Green Valley Pkwy, Suite 345Henderson, NV 89074702-260-0600Financial PolicyThank you for choosing Green Valley OB/GYN as your health care provider. We are committed to timely, successful andcost-efficient treatment of your health care needs. In order for us to maintain this high standard of health care, it isnecessary for us to strictly adhere to financial policies. Please understand that payment of your bill is considered a part ofyour treatment. The following is a statement of our financial policy, which we require you to read and sign prior totreatment.PATIENT INFORMATION: All patients must complete our Patient Registration From prior to their initial office visitwith the doctor. It is the patient’s (and/or responsible party’s) responsibility to keep this office informed of any changesin information (i.e. change of address, phone number, change in insurance information, etc.) You will be required to updatethis information on an annual basis.PAYMENT INFORMATION: Payment is due at the time of service. For your convenience we accept cash, personalchecks, VISA and MASTERCARD credit and debit cards. Any co-pays and/or deductibles you have with your insuranceare your responsibility and are due and payable at the time of service.INSURANCE: As a courtesy to our patients, we will bill all of your insurances. In order to do so, we must have updatedand accurate insurance information. Please be aware that your insurance policy is a contract between you and yourinsurance company. It is your responsibility to know your benefits. Your account with this office is your responsibilitywhether your insurance company pays or not. If your insurance company has not paid your account in full with 60 days,your account will become a “CASH” account with the balance due and payable immediately and prior to your next visit.SURGERY: If it is necessary to schedule surgery, our policy pertaining to payment for that surgery will be discussed indetail with you at that time.USUAL AND CUSTOMARY RATES: Our practice is committed to providing the highest standard of health care forour patients. We make every effort to align our fees with what is considered to be usual and customary for our area ofspecialty.MINOR PATIENTS: The legal guardian of a minor patient is responsible for full payment of the account. Under nocircumstances will we become involved in a domestic dispute.MISSED APPOINTMENTS: Our practice is extremely busy; therefore, cancellations require a 24-hour notice to ouroffice. If an appointment is missed without notifying our office, there will be a 40.00 “NO SHOW” charge added to youraccount and will be due in full prior to scheduling your next appointment.RETURNED CHECKS: There will be a 25.00 fee for all returned checks. If a check is returned, you will be expectedto pay by cash, credit card, or money order for all subsequent services.DISABILITY/FMLA PAPERS: There will be a 25.00 charge for every completed disability and FMLA forms.Payment is due at time of for submission.COLLECTION POLICY: I agree to be financially responsible for all charges incurred, regardless of insurance coverage.In the event my account is referred to a collection service due to lack of payment on my part, I agree to pay all collectionand legal fees that may be added to my account. If referred to a collection service, I understand that I will be dischargedas a patient.I have read, understand and agree to the above Financial Policy.Signature of patient or responsible partyDateWitnessDateRev 1/31/19 DW

Green Valley OB/GYNLIVING WILL & ADVANCED DIRECTIVEPolicy: Most Living Wills or Advanced Directives express the wishes of a person should they becometerminally ill, or have a serious accident and do not want extraordinary measures used to prolonglife. Green Valley OB/GYN will honor Advanced Directives/Living Wills and will consider them asvalid documents.By signing below, I acknowledge I have read and understand the above policy on AdvancedDirectives/Living Wills:I wish to supply the clinic with a copy of my Advance Directive/Living Will.I do not wish to supply the clinic with a copy of my Advance Directive/Living Will.I do not have an Advance Directive/Living Will.Printed Name: Date of Birth:Patient Signature: Date:DIRECTIVAS AVANZADAS O TESTAMENTOPoliza: La mayoria de los Testamentos O Directivas Avanzadas expresan el deseo de una persona encaso que tengan una enferdad terminal o pue tenga un accidente serio y no quieren qe se usenmedidas extraordinarias para prolonger su vida. Green Valley OB/GYN considera estas DirectivasAvanzadas/Tertamento como documentos validos. Firmando este document reconozco que he leidoy entendido las poliza arriba mencionada.Yo quisiera proveer a la clinica con una copia de mis Directivas Avanzadas o Testamento.Yo No quiero proveer a la clinica con una copia de mis Directivas Avanzadas o Testamento.Yo No tengo las Directivas Avanzadas o Testamento. Me han ofrecido informacion acercadelas Directivas Avanzadas o TestamentoNombre: Fecha De Nacimiento:Firma del Paciente: Fecha:Firma del testigo:

Notice to Patients Regarding Destruction of Health Care Records(a) Pursuant to the provisions of subsection 7 of NRS 629.051:(1) The health care records of a person who is less than 23years of age may not be destroyed.(2) The health care records of a person who has attained theage of 23 years may be destroyed for those records whichhave been retrained for at least 5 years or for any longerperiod provided by federal law; and(b) Except as otherwise provided in subsection 7 of NRS 629.051and unless a longer period is provided by federal law, thehealth care records of a patient who is 23 years of age orolder may be destroyed after 5 years pursuant to subsection1 of NRS 629.051Patient/RepresentativeDate