Locate us677 Cathedral Dr.
Rapid City, SD
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Main Clinic 605-343-9224
Appointments 605-342-6905

 
 

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 Black Hills OBGYN Patient Portal

 



 

Patient Registration

To print and complete, click here to download.

 

First Name M Initial Last
Date of Birth Age
Email
 

The email you have listed will be the same email that you would use for the patient portal.
Mailing Address
City State Zip
SS# Marital Status


Maiden Name(s) Employer
Ethnicity



Contact Information

You have the right to request that our practice contact you about your health needs and related issues in a particular manner. Please be advised that this includes lab and test results, diagnosis, appointment and follow up care plans. Please indicate the acceptable means of contacting you.

Please check primary contact:

Home #   Can we leave a message on your machine?
Cell   #     Can we leave a message on your voice-mail?
Work #     Can we leave a message on your voice-mail?
Who should we contact in the event of an emergency?
Phone What is the relationship to you?
Specify your preferred appointment reminder method

Insurance Information

Primary Insurance Company   Effective Date
Policy #   Group #
Employer   Policy Holder's
  Name
Date of Birth   SS#
Policy Holder's Address
Relationship to patient

Secondary Insurance Company   Effective Date
Policy #   Group #
Employer   Policy Holder's
  Name
Date of Birth   SS#
Policy Holder's Address
Relationship to patient

If patient is a minor please indicate who is financially responsible
 

PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS

  1. I understand that as part of my health care, Black Hills Obstetrics and Gynecology originates, records, and maintains health information about me describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this health information may be used or disclosed by Black Hills Obstetrics and Gynecology for treatment, payment, and health care operations. For example, my health 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 can verify that services billed were actually provided; and
    • A tool for routine health care operations, such as assessing quality and reviewing the competence of health care professionals.
  2. I acknowledge that I have been provided with Black Hills Obstetrics and Gynecology’s Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the Notice of Privacy prior to signing this consent. I understand that Black Hills Obstetrics and Gynecology reserves the right to change its Notice of Privacy Practices and prior to implementation will mail a copy of any revised notice to the address I have provided.
  3. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations, and that Black Hills Obstetrics and Gynecology is not required to agree to the restrictions requested but if it does, it is bound by such restrictions.
  4. I understand that I may revoke this consent in writing, except to the extent that Black Hills Obstetrics and Gynecology has already taken action in reliance thereon. This signed consent shall remain in force until the undersigned patient gives written notification, stating otherwise.
  5. By signing this form, I consent to Black Hills Obstetrics and Gynecology’s use and disclosure of my health information for treatment, payment, and health care operations.
  6. I understand that this release of medical information may contain information regarding drug or alcohol abuse, mental health issues and/or HIV (AIDS) and STD (Sexually Transmitted Diseases)



     
     Note, if restrictions are added, you will be considered self pay.

  1. I, the undersigned, hereby assign to the physician(s) associated with Black Hills Obstetrics & Gynecology LLP. all payments for medical services rendered to myself or my Dependant.


Digital Signature: Type full name




Guardian or Legal Representative:
Type full name