• Last Name*
• First Name*
• Middle Name
• Address*
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP
• Home Phone*
• Cell Phone
• Email*
• Date of Birth*
  Month

  Day

  Year
• Age*
• Social Security #*
• Marital Status (select one)*
  SingleMarriedDivorcedWidowedSeparated

• EMPLOYER INFORMATION

• Patient's Employer*
• Occupation*
• Work Phone
• Employer Address*
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Work-related Injury*
  • Yes
  • No
• Automobile Accident*
  • Yes
  • No
• Date of Injury / Accident
  MM slash DD slash YYYY
• Emergency Contact*
• Relationship*
• Phone*
• Advanced Directive*
  • Yes
  • No
• Copy of Advanced Directive on File*
  • Yes
  • No
• Retired*
  • Yes
  • No

• REFERRED BY - Please tell us who referred you to Dr. Kashyap.

• Referring Physician (where applicable)
• Health Insurance Company (where applicable)
  Ambetter HealthAmerigroupAnthemBlue Cross & Blue ShieldHealth Plan of NevadaMGM HealthcareMedicareMedicaidMultiplanProminence Health PlansSierra Health-Care OptionsSilver Summit HealthplanTricareUMRUnited HealthcareOther
• Online Referral (where applicable)
  WebsiteFacebookYelpZocdocGoogleOther
• Name of Friend or Family Member (where applicable)

• POLICY HOLDER / INSURED INFORMATION - Primary Insurance

• Primary Policy Holder's Relationship to Patient*
  SelfSpouseMotherFatherOther

• UPLOAD INSURANCE CARD AND DRIVER'S LICENSE

• Please upload (or fax or email) a copy of the front and back of your Insurance Card and Driver's License:

  1. Scan or use your mobile phone to take photos of the front and back of your Insurance Card, and your Drivers License.
  2. Click the 'Choose File' button below to upload the photos to this form (you may need to email them to yourself first and then save the attachments to your computer before uploading them here).
  3. Or, rather than uploading here, email the photos to our office at info@galleriawomenshealth.comOR fax them to our office 702-476-9202.
• Upload (or drag and drop), Insurance Card photos/scans and Driver's License below.*
  Drop files here or Select files

  Max. file size: 5 MB, Max. files: 6.

• PHARMACY OF CHOICE DETAILS

• Pharmacy of Choice
• Pharmacy Phone
• Pharmacy Cross Streets

• MEDICAL HISTORY FORM

• Primary Care Physician*
  If you don't have a Primary Care Physician, note "I don't have one"
• Medication Allergies*
• Please list the reason(s) for your appointment today:*
• Duration*

• OBSTETRICAL HISTORY

• *

  Total Pregnancies	Vaginal	Cesarean	Total Children	Full Term	Pre-Term	Abortions	Miscarriages	Ectopic

• GYNECOLOGY HISTORY

• When was your last Pap Smear?
• History of Abnormal Pap
  • Yes
  • No
• When was your last Mammogram?
• History of Abnormal Mammogram
  • Yes
  • No
• When was your last Dexa Scan?
• History of Abnormal Dexa
  • Yes
  • No
• When was your last Colonoscopy?
• History of Abnormal Colonoscopy
  • Yes
  • No

• MENSTRUAL HISTORY

• *

  When was your last menstrual period?	Your age at first menstrual period?	Are your periods regular or irregular?	How often are your periods?	How many days do your periods last?

• Menstrual flow
  • Light
  • Moderate
  • Heavy
• Do you have cramps with your periods?
  • Yes
  • No
• If yes, do you need medication do you take for relief?
  • Yes
  • No
• Menstrual History

  If yes, what medication do you use for relief?	If you are not having menstrual periods, at what age did you last have one?

• If yes, what medication do you need for relief?
• If you are not having menstrual periods, at what age did you last have one?
• Since menopause, any vaginal bleeding?
  • Yes
  • No
• Do you have hot flashes or vaginal dryness?
  • Yes
  • No

• SEXUAL HISTORY

• *

  How many lifetime sexual partners have you had?	Are you sexually active at present?	Do you have loss of libido or arousal?	Do you usually have pain with intercourse?

• Sexual History

  What do you use for intercourse?	Have you been physically or sexually abused?

• History of any of the following sexually transmitted diseases?
  • Trichomonas
  • Gonorrhea
  • Herpes
  • PID
  • Chlamydia
  • Syphilis
  • HIV

• PAST MEDICAL HISTORY

  Have you ever had any of the following problems?
• General
  • Cancer
  • Weight gain
  • Weight loss
  • Fatigue
• Respiratory
  • Asthma
  • Emphysema
  • Bronchitis
  • Tuberculosis
  • Valley Fever
  • Pneumonia
• Feminine
  • Vaginal Dryness
  • Vaginal Irritation
  • Vaginal Laxity
  • Vaginal Pressure
• Urinary
  • Incontinence
  • Kidney Stone
  • Urine in blood
  • Urgency
  • Infections, frequent
• Gastrointestinal
  • Diarrhea, frequent
  • Ulcers
  • Jaundice / Hepatitis
  • Constipation
  • Diverticulosis / itis
• Neurological
  • Seizures
  • Stroke
  • Headaches
• Cardiovascular
  • Hypertension
  • Heart Attack
  • Heart Palpitation
  • Heart Murmur
• ENT / Mouth
  • Hearing Loss
  • Sinus Problems
  • Dental Problems
• Eyes
  • Glaucoma
• Breast
  • Tumor / cyst (benign)
  • Nipple Discharge
• Musculoskeletal
  • Arthritis
  • Osteoporosis
• Psychiatric
  • Anxiety
  • Depression
• Hematological
  • Bleeding / bruising
  • Anemia
  • Blood transfusion
• Any other medical condition not listed
• Medications:
  Include dosages and any over the counter medications.

• PAST SURGICAL

• Past Surgical History: List ALL operations.

  Year of Surgery	Type of Surgery

• SOCIAL HISTORY*

  Marital Status	Occupation	Previous Occupation

• Social History:*

  Tobacco	Alcohol	Drug Abuse	Exercise	# in Household

• OTHER PATIENT / FAMILY MEDICAL HISTORY

  INSTRUCTIONS: Please indicate your family’s history with any medical problems below. Check YES for the medical problem(s) that apply to you and/or your blood relatives. Please list the relative, side of the family, and age of diagnosis. BLOOD RELATIVES TO CONSIDER: parents, children, siblings, half-siblings, aunts, uncles, cousins, nieces, nephews, and grandparents.

• PATIENT / FAMILY CANCER HISTORY

• Breast Cancer*
  • Yes
  • No

• Family Member (Mother, Grandmother, Aunt)	Side of the Family (Mother's or Fathers')	Age at Diagnosis

• Ovarian Cancer (Fallopian Tube, Peritoneal)*
  • Yes
  • No

• Family Member (Mother, Grandmother, Aunt)	Side of the Family (Mother's or Fathers')	Age at Diagnosis

• Uterine (endometrial)*
  • Yes
  • No

• Family Member (Mother, Grandmother, Aunt)	Side of the Family (Mother's or Fathers')	Age at Diagnosis

• Colon Cancer*
  • Yes
  • No

• Family Member (Mother, Grandmother, Aunt)	Side of the Family (Mother's or Fathers')	Age at Diagnosis

• Other Cancers - please specify*
  Examples of other cancers: melanoma, kidney/urinary tract, brain or small bowel
  • Yes
  • No

• Family Member (Mother, Grandmother, Aunt)	Side of the Family (Mother's or Fathers')	Age at Diagnosis

• Are you of Ashkenazi Jewish descent?*
  • Yes
  • No
• Have you or any of your family members had genetic testing for any hereditary risk of cancer?*
  • Yes
  • No
• If 'YES' please explain

• OTHER FAMILY MEDICAL HISTORY

• Diabetes*
  • Yes
  • No
• Who?
• Heart Disease*
  • Yes
  • No
• Who?
• High Blood Pressure*
  • Yes
  • No
• Who?
• Stroke*
  • Yes
  • No
• Who?

• Patient Contact Information

  To be HIPPA compliant we need you to tell us how to contact you with your health information. You need to be very specific regarding how you prefer to be contacted and where we can leave clinical messages and tests of lab results.

  How do you prefer to be contacted? (ONLY INDICATE YOUR PREFERENCE)

• Cell Phone
• Patient Portal
• Work Phone
• Home Phone
• Please read and choose 'YES' or 'NO' below to confirm your choice.*
  • (YES) I hereby give Galleria Women’s Health permission to leave clinical/medical messages, which may include personal and sensitive information on the media source(s) that I have indicated above. I understand that is my responsibility to keep my contact information updated.
  • (NO) I only consent for Galleria Women’s Health to leave a general call back message for me. I understand that it is fully my responsibility to return all calls in a timely manner. I understand that is my responsibility to keep my contact information updated.
• If you are unavailable, is there anyone that you give us permission to leave such messages with?*
  If yes, please provide his/her name and contact information below.
  • Yes
  • No
• Name
• Relationship
• Phone

• HIPAA NOTICE OF INFORMATION PRACTICES

  THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

  
  

  PLEASE READ THIS INFORMATION CAREFULLY

  Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnosis, treatment, and a plan for future care of treatments. This information is often referred to as your health or medical records and serves as a:
  • Basis of planning your care and treatment
  • Means of communication among the health professionals participating in your care
  • Legal document describing the care you received
  • Means by which you or a third-party payer can certify that the services billed were actually provided
  • A source of information for public health officials charged with improving the health of the nation
  • A tool with which we can assess and continually work on to improve the care we deliver and the outcomes we achieve
  • Understanding what is in your record and how your health information is used helps you to ensure its accuracy, make more informed decisions when authorizing disclosure to others; and better understand who, what, when, where and why others may access your health information.
  Understanding your Health Information Rights Although your health record is the physical property of the healthcare provider, the information belongs to you. You have the right to:
  • Request a restriction on certain uses and disclosures of your Information (45 CFR 164.522)
  • Obtain a paper copy of the notice of information practices upon request
  • Inspect and obtain a copy of your health record (45 CFR 164.524)
  • Request to amend your health record (45 CFR 164.528)
  • Obtain an accounting of disclosures of your health information (45 CFR 164.528)
  • Request communications of your health information by alternative means or at alternative locations
  • Revoke your authorization to use or disclose health information except to the extent that action has already been taken
  Our Responsibilities We are required to:
  • Maintain privacy of your health information
  • Provide you with a notice as to our legal duties & privacy practices with respect to your information
  • Abide by the terms of this notice
  • Notify you if we are unable to agree to a requested restriction on disclosure or amendment to your record
  • Accommodate reasonable requests you may have to communicate health information by alternative means or locations
  • We reserve the right to change our practices and to make the changes effective for all protected health information we maintain. If our information practices change, we will notify you the next time you come to our office for treatment.
  • If you believe your privacy rights have been violated, you can file a complaint with the Office of Civil Rights either by calling 800-368-1019 or by writing to U.S. Dept of Health & Human Services 90 70th Street Suite 4-100, San Francisco CA 94103.

  Examples of Disclosures for Treatment, Payment and Health Operations

  We will use and disclose your health information for treatment. For example, information obtained by us will be recorded in your record and used to determine the course of treatment that should work best for you. Members of your healthcare team will then record the actions they took and their observations. In that way, your physicians and other providers will know how you are responding to treatment. Copies of these records, as well as other reports will be provided to other providers participating in your care to assist them in treating you if you are referred to them for consultation.

  We will use and disclose your health information for payment. For example, a bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. Additionally, we may be required to forward additional information to substantiate the medical necessity of the care delivered and that the care for which the claim was submitted was actually delivered. Further, we may disclose health information to the extent authorized and to the extent necessary to comply with Worker's Compensation or other similar programs established by law.

  We will use your health information for regular health operations. For example, members of our quality improvement team may use the information in your health record to assess the care and outcomes in your case and others like it. The information will then be used to continually improve the quality and effectiveness of the healthcare and services we provide.

  Business Associates. There are some services provided in our organization through contracts with business associates. Examples include services by laboratories, copy services, and transcription services. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we've asked them to do. However, to protect your health information we require the business associate to appropriately safeguard your information.

  Notification. We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition.

  Family communication. After careful judgment, we may disclose to a family member or other person you designate, health information relevant to that person's involvement in your care or payment related to your care.

  Funeral directors & organ procurement organizations. We may disclose health information to funeral directors consistent with applicable law. We may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant.

  Food and Drug Administration (FDA). We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

  Public Health. As required by law, we may disclose health information to the public health or legal authorities charged with preventing or controlling disease, injury or disability.

  Law Enforcement and Correctional Institution. We may disclose health information for law enforcement purposes as required by law. Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

  Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority, provided that we or our business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

• PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION

• PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS IN ACCORDANCE TO HIPAA

  I understand that as a part of my health care, Galleria Women’s Health originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, 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 health 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 (s) can verify that services billed were actually provided
• A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

• The right to review the notice prior to signing this consent/disclosure
• The right to request restrictions as to bow my health information may be used or disclosed to carry out treatment, payment or healthcare operations

I understand that Galleria Women’s Health is not required to agree with the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me permitted by Section 164.520 of the Code of Federal Regulations.

I understand that as part of this organization 's treatment, payment or healthcare operations, it may become necessary to disclose my protected health information to another entity (Insurance company, referring physician, consulting physician, hospital, etc.), and I consent to such disclosure for these permitted uses, including disclosures via fax or email.

In addition, I also give consent to Galleria Women’s Health to disclose my protected healthcare information to the following person and/or people:

• AUTHORIZATION TO RELEASE INFORMATION & ASSIGNMENT OF BENEFITS

• The information provided and sent to you in this online form is complete and correct. I authorize release of information necessary to file a claim with my insurance company and I assign benefits to Galleria Women’s Health. I understand that payment for copays and deductibles are required at the time services are rendered. I further understand that I am responsible for the payment of services rendered by Galleria Women’s Health. In the event that my insurance company denies a claim, I will become responsible for all amounts not covered payable to Galleria Women’s Health. As a parent/guardian, I am financially responsible for services rendered to a minor. If my account is turned over for outside collections, I will be responsible for all costs of the outside collection agency. I authorize release of all medical records to referring and primary care physicians and the insurance company, as applicable. I authorize fax transmission of medical records if necessary.

• Agreement & Signature: Authorization To Release Information & Assignment of Benefits

• I fully understand and accept the terms of this consent outlined above.*
  • Yes
  • No
• Date*
  MM slash DD slash YYYY
• Signature of Patient or Legal Guardian*

• FINANCIAL AGREEMENT

• Thank you for choosing Galleria Women’s Health. Please recall that your insurance policy is a contract between you, your employer and your insurance company. We are not a party to that contract. Our relationship is with you. We will submit an insurance claim on your behalf if we have a provider contract with your insurance company. Please read the following agreement carefully, then sign and date below.
  • All co-payments, deductibles and co-insurances are due at the time of service. Payments can be made with cash, debit or credit cards. Personal checks are not accepted.
  • I understand that not all services are covered by my insurance. Fees for NON-COVERED care are due in full at or before the time of service unless prior arrangements have been made.
  • I understand that if l do not inform my doctor of ALL of my insurances (ex. primary and secondary insurances), I will be responsible for all refunded payments requested from my doctor by my insurances.
  • I understand that my doctor will bill my insurance company if they are contracted providers. If payment is not received from my insurance company 90 days from the date of billing, I am financially responsible for any and all services rendered.
  • I understand that there is a $40.00 fee to have each of my Disability or FMLA form(s) completed.
  • I understand that if I do not cancel my appointment at least 24 hours prior to the scheduled time, I will be charged a $25 fee for office visits, $50 fee for ultrasound and office procedures, and a $150 fee for surgeries. I understand that these charges are not billed to my insurance and will be charged to my credit card/debit card on file.
  • I understand that all labs and radiology services will be charged separately from Galleria Women’s Health.
  • I hereby assign to Galleria Women’s Health any insurance benefits available for health care services provided to me. If these benefits are not assigned to the doctors, I agree to forward all health insurance and other third-party payments that I receive for services rendered to me immediately upon receipt.
  • If this account is turned over to a collection agency, I agree to pay the collection and legal fees necessary to collect the balance, including a fifty percent (50%) charge for collection services added to the unpaid balance.
  • I have read the above statements and have no questions.
• Patient's Name*
• Name of Legal Guardian
• Relationship to Patient

• Agreement & Signature: Financial Agreement

• I fully understand and accept the terms of this consent outlined above.*
  • Yes
  • No
• Date*
  MM slash DD slash YYYY
• Signature of Patient or Legal Guardian*
• CAPTCHA