Once you’ve set up an appointment with us, please fill out all the following forms.

Client Intake Questions*

Client Intake Questions

Office Surgery Health Questionnaire*
Patient Registration*

Personal Information

Consent Form - Medical Photographs*

During your office visit today, a Renew You Gynecology staff member designated by Regina Hill, M.D. will be taking photographs of you for your medical record. We will photograph you throughout the course of your treatment(s) in order to demonstrate your specific condition, subsequest therapy, including surgical procedures when sedated or anesthetized, and the results of such therapy. All photographs will be treated as confidental except as authorized by you in writing and are the sole property of “Renew You Gynecology” and may be disposed of at any time. I give my consent to Renew You Gynecology, or any person designated by Regina Hill, M.D. to use photographs of me for the purpose(s) indicated by my initals below. I understand that this authorization is valid for all pictures taken during the course of my treatment(s). If at any time I wish to revoke this authorization I agree to notify Renew You Gynecology in writing of my wishes.

(i.e. practice brochures, website, newsletter, external advertisements, and social media {Facebook/ Instagram/ Snapchat}. I understand that at no time will my personal information and/or name be used.

and its employed or contract photographers from liability with respect to reputable uses of my said photographic image and verbal testimonials for promotional purposes.

Consent Form - Office Policy and HIPAA Information*

Thank you for choosing our practice for your medical health needs. Our goal is to provide quality care to all our patients with affordable fees. We are dedicated to making healthcare less stressful and more valuable by clarifying financial responsibilities in advance. It is our office policy to check all benefits (based on the service you are coming in for and is not a guarantee of payment), one to two days prior to any service within our office. If the service is subject to any type of copayment, co-insurance or deductible; we do collect this amount at the time of your service. Our policy as well is to bill your insurance carrier as a courtesy to you. Therefore, it is your responsibility to make sure we have current insurance information for you and your family. Ultimately any remaining balance not covered by your insurance is your responsibility, unless your insurance is part of Ohio Medicaid insurance plans. Payment may be made by Cash, Checks, Credit Cards or Health Savings Account Cards. There is a return check fee of $40.00 for all checks returned to us by the bank for insufficient funds. As of September 1, 2019, we will be billing for all “No Show” appointments. You will be expected to call at least 24 hours in advance to cancel your appointment or as a last resort you may call the same day as your appointment in order to avoid the charged fee. The fee for this is $50.00 and will be your responsibility and not your insurance carrier.

This notice of Privacy Practice describes how we as health care providers may use and disclose your protected information to carry out treatment, payment and health care operations and for other purposes that are permitted or required by law. Protected Health Information (PHI) is information about you, including demographic information. That may identify you and that relates to your past, present and future physical or mental health or condition and related to health care services. The Department of Health and Human Services has established a “Privacy Policy” to help insurance that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients’ consent for uses and disclosures of health information about the patient to carry out treatment, payment or health care operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to assure and protect that privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal medical records. We may have direct treatment relationships with you (such as laboratories that only interact with physicians and not patients) and may have to disclose personal health information for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent to this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which replied on this or previously signed consent. If you have any objections to this form, please ask to speak with our Office Manager or Physician.