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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 having as much information as possible about your medical history and current problems.

 

Enclosed are the following:

 

1. Patient information form

2. Insurance information form and

3. Two request for medical Information forms

 

The enclosed 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 paperwork, we will contact you to schedule an appointment.

 

If you do not feel there is adequate time to mail your forms, you may also fax them to us at (214) 369-7528.

 

It also is helpful if you can include a copy of your driver's license and insurance card (front and back) with your paperwork.

 

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

 

Sincerely,

 

Tara A. Dullye, M.D.

 

 

 

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

PATIENT INFORMATION

 
Last Name:____________________________  Home Phone: (     ) _________________
First Name:____________________________  Work Phone:  (     ) _________________
Address:______________________________  Cell Phone:     (     ) _________________
_____________________________________  Date of Birth: ________________ Age: _____
_____________________________________  Driver's Lic. #: _______________  State: ____
City: _____________ State: ____ Zip:______  Social Security #: _______________________

Marital Status:                                                 Mar    Sing    Div    Wid    Sep

 Primary care physician:
_______________________________________
Nearest relative not living with you: Other physicians providing you care:
Name:________________________________ _______________________________________
Relationship:___________________________ _______________________________________
Address:______________________________ ________________________________________
Phone #: (    ) ____________________ Referred by: _____________________________

EMPLOYMENT INFORMATION

PATIENT

SPOUSE/SIGNIFICANT OTHER
  Last Name:_______________________________
  First Name:_______________________________
  Social Security #:__________________________
  Date of Birth:____________________
Employer:___________________________ Employer:________________________________
Employer Address:____________________ Employer Address:_________________________
____________________________________ _________________________________________
____________________________________ _________________________________________
City:_____________________ State:_____ Zip:_______ City:________________  State:_____ Zip:_______
Phone #: (     )__________________ Phone #: (     )____________________
Fax #:     (     )__________________ Fax #:    (      )____________________
Work Position:________________________ Work Position:___________________________

MISCELLANEOUS INFORMATION

PATIENT

HUSBAND
E-mail Address:_______________________ E-Mail Address:_________________________
Pager #: (     )_______________________ Pager #: (     )_______________________
Emergency Notify:_____________________
Address:_____________________________
City:_____________________ State:_____
Phone #: (      )________________________

 		  

INSURANCE INFORMATION

   Guarantor (If neither patient nor husband):
Name:_________________________________ Home Phone #: (     )_____________________
Address:_______________________________ Work Phone #: (     )______________________
City:________________ State:_____ Zip:_____ Social Security #:________________________
Relationship to Guarantor:____________________  
   

Primary Insurance Carrier

Secondary Insurance Carrier
Company Name:________________________ Company Name:_________________________
PPO___ HMO__ Indemnity___Self pay___Medicare___ PPO___HMO___ Indemnity___ Self pay___ Medicare___
Claims Address:_________________________ Claims Address:__________________________
City:________________ State:_____ Zip:_____ City:________________ State:_____ Zip:______
Phone:(     )__________ Fax:(     )__________ Phone:(     )__________ Fax:(     )___________
Policy #:____________ Group #:____________ Policy #:____________ Group #:____________
Insured's Last Name:______________First:___________ Insured's Last Name:______________First:___________
Address:_______________________________ Address:________________________________
City:________________ State:_____ Zip:______ City:_______________ State:_____ Zip:_______
Phone:(     )_________DOB:__/___/___Sex:___ Phone:(     )_________DOB:__/___/___Sex:___
Insured's Employer:_______________________ Insured's Employer:_______________________
Phone:(     )__________ Fax:(     )___________ Phone:(     )__________ Fax:(     )___________
Patient's Relation to Insured:_______________ Patient's Relation to Insured:________________

I authorize Tara A. Dullye, M.D. to release medical information that may be necessary to request reimbursement from insurance companies to whom I have submitted a claim.

I understand that it is MY RESPONSIBILITY to determine if Dr. Dullye is in network with my insurance company/PPO/OS/HMO, and I have determined that my insurance company/PPO/POS/HMO is:  In Network______    Out of Network______

I also understand that if Dr. Dullye is NOT in network with my insurance/PPO/POS/HMO plan, I will be responsible for a higher deductible or coinsurance payment than if I see a physician who is in network with my plan. I agree to pay any charges incurred at this visit. I assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, to Tara A. Dullye, M.D.

Print Name:_______________________ Signature:________________________ Date:___/____/___

Date: ____________________

Confidential Patient Health History

Name:__________________________________ Date of birth:________________ Age:_________
             Last, First, MI (Maiden)

Occupation:____________________________ Marital Status:______________ Race:__________

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

If you have a problem, please describe it in detail, including how long you have had it:

_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
   

 

 

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Last modified: June 21, 2005