New Mexico Gynecology Consultants, PC

Frances M. Fisk, MD | Angel Toledo, MA | Bonnie Jackson, RN | Carolyn Davis, RT | Brenda Maez ..... Call: (505) 242-5353

Established Patient forms and information
As an established patient, there are several forms you will be required to complete. It is very important that you complete and keep this information updated as incomplete or missing information could effect your medical treatment and expense liabilities. If you need help with any of the questions, please ask for clarification at your visit.
New Patient authorizations
Patient Acknowledgements, Authorizations and Preferred Pharmacy - This acknowledgements and authorizations form is your authorizations of how you want us to contact you concerning billing, laboratory results and any medically related information, notice of privacy practices, clinical trials, and referred pharmacy. You will need to complete this form one time and then only if you need to make changes. If you need help with any of the questions, please ask for clarification at your visit.
Patient information sheet
Patient Information Worksheet - The Patient Information Worksheet is our record of your address, emergency contacts, Insurance, and Notice of Financial Responsibility. You will need to complete this form one time and then only if you need to make changes. If you need help with any of the questions, please ask for clarification at your visit.
Financial Policy
Financial Policy - The Financial Policy for your signature is our record that you understand the financial policy at New Mexico Gynecology and our relationship with you and your insurance company. If you need help with any of the questions, please ask for clarification at your visit.
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Advance Beneficiary Notice of Non-coverage - ABN (Medicare Patients) - If you are a Medicare Patient, please read and complete ABN form. Medicare does not or may not completely cover the costs of several medical, laboratory diagnostic and screening procedures. You will be required to identify the level of medical services you require. If you need help with any of the questions, please ask for clarification at your visit.
Privacy Practices
Notice of Privacy Practices - The Notice of Privacy Practices is our notice to you about the Privacy Practices at New Mexico Gynecology Consultants. This document is to comply with the Privacy Regulations Created as a result of the Health insurance Portability Accountability Act of 1996 (HIPPA). You will be required to sign that you were offered the opportunity to review and receive a copy of the following document in the Acknowledgements and Authorizations form above.