Ob-Gyn Dallas New-Patient Information

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Tara A. Dullye, M.D., F.A.C.O.G.

Obstetrics, Gynecology, & Infertility

____________________________________________________________________________________

Margot Perot Women's and Children's Hospital

8160 Walnut Hill Lane, Suite 219

Dallas, TX 75231

Phone: (214) 369-2400

Fax: (214) 369-7528

www.obgyndallas.com

Dear New Patient,

It is important to me that I give the best possible care to my patients. Part of that care depends upon my having as much information as possible about your medical history and current problems.

The following new-patient information form is a necessary part of the evaluation. By completing the form and also an on-line medical history questionnaire in your own home or other convenient location, you will have time to obtain the required information that might be hard to accurately recall otherwise.

Also, if I am able to reflect upon your information and history in an unhurried manner before your appointment, our discussion in my office may better focus on the areas of concern to you. For these reasons, please complete and return the needed forms as soon as possible prior to scheduling your appointment.

As soon as we receive your completed information, we will contact you to schedule an appointment.

You may provide the following new-patient information to us in one of several ways:

1. Fill in the blanks on the online form below and click on the Submit button only when you are sure the information is as complete and accurate as possible. When you click on the Submit button, the information will be sent within a few minutes directly to our office manager. This is the preferred method.

2. OR, you may fill out the form and then print it out by using your Internet browser print button and then do one of the following:

- fax the printed information form to us at (214) 369-7528; or

- mail or deliver the printed information form to us at 8160 Walnut Hill Lane, Suite 219,

Dallas, TX 75231.

3. OR, you may print out the form by using your Internet browser print button, fill out the form by hand, and then fax, mail or deliver the form to us as instructed under option 2. Because of legibility problems associated with hand-writing, this is the least preferred method.

If you choose to fax, mail or deliver the form to us, we would appreciate it if you can include a copy of your driver's license and insurance card (front and back) with your paperwork.

Once we have received the completed new-patient information form, we will contact you by phone to provide instructions to you on how to complete your on-line medical history questionnaire.

Thank you for taking the time to complete the information form and on-line health history questionnaire and returning the forms to me. I look forward to meeting you.

Sincerely,

Tara A. Dullye, M.D.

PATIENT INFORMATION:

Note: If you choose to fill in this information on-line, please be sure you have all the
information you need and enough time to do so in one sitting since the information
cannot be saved before you click on the Submit button. Once you click on the Submit
button, the information you have entered will be transmitted directly to Dr. Dullye's office
manager. If you find you need to change or update the information after you have
submitted it, you can either reenter the information and click on the Submit button again,
or you can call our office with the required changes.

Last name

First name

Primary address:

Address

City State Zip

Enter alternative address if applicable:

Alternative address

City State Zip

Home phone (or number where patient can normally be reached)

Work phone

Pager number

Cell phone

Email address

Preferred Contact Method:

Date of birth - MM/DD/YEAR Age

Driver's license number Driver's license state

Social Security Number

Marital status: Married Single Divorced Separated Widowed

Primary language spoken by patient:

Patient's race/ethnicity:

Patient's occupation:

If patient is a student, name of school:

School location: and Grade-level:

Preferred pharmacy:

Either 1. Store name:

and Store address: Store city:

Or 2. If mail-order, name of pharmacy:

Reason for visit:

If you have no problems and are presenting for a routine exam, please check box:

Otherwise, if you have a problem, check this box
and please describe it in detail, including how long you have had it:

Nearest relative not living with you:

Name

Relationship

Address

City State Zip

Phone number

Emergency notification:

Name

Relationship

Address

City State Zip

Phone Number

Your primary care physician

Other physicians providing you care:

Referred by

EMPLOYMENT INFORMATION:

Patient's employer

Employer's address

Employer's city State Zip

Employer's phone number

Employer's fax number

Patient's work position

Spouse/Significant Other:

Last name

First name

Social security number

Date of birth - MM/DD/YEAR

Phone number

Cell phone number

Pager number

Email address

Employer

Employer Address

Employer's city State Zip

Employer's phone

Employer's fax

Spouse/significant other's work position

INSURANCE INFORMATION

Guarantor: Patient Spouse/Significant other

If guarantor is neither patient nor spouse/significant other:

Guarantor name

Address

City State Zip

Relationship to patient

Home phone

Work phone

Social security Number

Primary Insurance Carrier:

Company

Dr. Dullye is In Network Out of Network for this carrier

PPO HMO Indemnity Self-pay Medicare

Claims address

Claims city State Zip

Claims phone Claims fax

Policy number

Insurance group number

Insured's last name

Insured's first name

Insured's address

Insured's city State Zip

Insured's phone

Insured's date of birth - MM/DD/YEAR

Insured's sex Female Male

Insured's employer

Insured's employer phone Insured's employer fax

Patient's relationship to insured

Secondary Insurance Carrier:

Check if no secondary insurance carrier

Company name

Dr. Dullye is In Network Out of Network for this carrier

PPO HMO Indemnity Medicare

Claims address

Claims city State Zip

Claims phone Claims fax

Policy number

Insurance group number

Insured's last name

Insured's first name

Insured's address

Insured's city State Zip

Insured's phone

Insured's date of birth - MM/DD/YEAR

Insured's sex Female Male

Insured's employer

Insured's employer phone Insured's employer fax

Patient's relationship to insured

Once you are certain you have filled out the above form completely and accurately, click on
the Submit button below to transmit the information to Dr. Dullye's office manager. Thank you.

Note: On your initial visit to our office, you will be asked to sign a form authorizing Dr. Dullye to release medical information that may be necessary to request reimbursement from insurance companies to whom you have submitted a claim.

You also will be asked to sign your understanding that it is YOUR RESPONSIBILITY to determine if Dr. Dullye is or is not in network with your insurance company/PPO/POS/HMO.

If Dr. Dullye is NOT in network with your insurance/PPO/POS/HMO plan, you will be responsible for a higher deductible or coinsurance payment than if you see a physician who is in network with your plan. You also will be asked to sign your agreement to pay any charges incurred at this visit and will assign all medical and/or surgical benefits, to include major medical benefits to which your are entitled, to Dr. Dullye.

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Last modified: April 01, 2011