First Visit Forms
Please choose the appropriate forms from below:
New Patient Information - provides detailed information regarding your insurance and employment information.
Notice of Privacy Practices - this is for your records only. We have copies of this notice in our office. We will ask you to sign the Acknowledgement of Receipt of Notice of Privacy Practices - you can print this off at home and bring it with you to your appointment already signed, or you can wait and sign it in our office.
Our Office Policy - you can print this off at home and bring it with you to your appointment already signed, or you can wait and sign it in our office. This policy is effective 01/01/12.
Go Green with us and receive statements and other correspondence from our office by E-mail! The benefits to receiving statements by e-mail are that you save paper, it is faster than regular mail, and you can access your statement from anywhere that you have access to internet. All of our emails are processed through a secure server using SSL technology and we use password protected documents.
Please Note: Effective 01/01/12 all patients who have not seen us during their current pregnancy will be automatically opted IN for the Go Green Option. This means that we will no longer be sending out paper correspondence. If you wish to receive paper documents by mail to your home address you can print the Refusal of Electronic Transmission of Information form and sign it, or you can wait and request the document to sign when you come into our office. Should you decide to opt out and sign this form there will be a $1.50 charge added to the bottom of every paper statement we send you. Going Green and receiving email correspondence is absolutely free! Ask our office about Going Green today!
Authorization of Use and Disclosure of Protected Health Information - if you wish for anyone other than yourself and your primary obstetrician to have access to your private health information you will need to fill out this document. You can print this off at home and bring it with you to your appointment already signed, or you can wait and sign it in our office. If you do not wish for anyone outside of yourself and your doctor to have access to your information, then you will not fill out this form.
OB/GYN Referral - If you are looking for a new OB/GYN near you, Dr. Koster would love to help you find a doctor. This form provides us with information on your needs and interest in receiving the type of care and the personal attention you are looking for.
To protect the confidentiality of your personal information provided on the above forms, we use SSL technology (https) to encrypt your information before transmitting from your PC to our server.
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