Appt Date: Day Time. DRIVING DIRECTIONS TO GREENBRAE OFFICE 599 Sir Francis Drake Blvd., #201

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1 MARIN RHEUMATOLOGY, INC. 599 Sir Francis Drake Blvd., #201 Greenbrae, CA Ph , fax PETER H. STEIN, M.D. ARUNDATHI S. MALLADI, M.D. Appt Date: Day Time Welcome to our office. Plan to arrive about 10 minutes early for your first appointment with the attached forms completed. Please be sure to have your medical and prescription cards with you so that we can copy them. We ask that if you have an HMO insurance plan that you contact your Primary Care Physician to have him send us a referral prior to your appointment. In addition, it would be helpful if you would ask your doctor to forward any current lab results, x-ray reports, and office notes. These will help the doctors to better evaluate your condition at your consultation visit. If your insurance plan requires a co-payment then it is necessary we collect it at the time of your visit. Cancellation policy: We understand that sometimes situations arise that will prevent you from notifying us in advance of cancellation and we will do our best to take each situation under consideration. However, you may be charged $75.00 for first appointment NOT cancelled 48 hours prior to your appointment time. We may also charge $25.00 for all follow-up appointments not cancelled 48 hours in advance. We hold this time for you; if you cannot make your appointment it is only fair we offer it to someone else. Should these charges be applied, you will be billed for them. We charge for writing certain types of letters on your behalf and for completing forms such as disability and medical excuses. There are times you may need your medical records copied and mailed and this too will be charged for. The fee for these services is $ DRIVING DIRECTIONS TO GREENBRAE OFFICE 599 Sir Francis Drake Blvd., #201 DRIVING DIRECTIONS FROM THE NORTH Highway 101 south toward San Francisco, take the Sir Francis Drake Blvd. exit Bear to the right going toward San Anselmo and Marin General Hospital Go 4 traffic lights get in the inside left lane and make a left turn onto Bon Air Rd then make an immediate left onto Via Hidalgo, you will see parking under our building. DRIVING DIRECTIONS FROM THE SOUTH Highway 101 north toward San Rafael, take the Sir Francis Drake Blvd. exit Bear to the left going toward San Anselmo and Marin Gen l Hospital Go 4 traffic lights get in the inner left lane and make a left turn onto Bon Air Rd then make an immediate left onto Via Hidalgo, you will see parking under our building DRIVING DIRECTIONS TO NOVATO OFFICE- 165 Rowland Way, Suite 208 DRIVING DIRECTIONS FROM THE NORTH Highway 101 south and exit in Novato at Rowland Blvd. Turn left on Rowland Blvd and proceed to Rowland Way Turn left onto Rowland Way and proceed to 165 Rowland Way, at end of street The medical office building is located just to the left of Novato Community Hospital as you pull into the driveway. Suite 208 is on the second floor DRIVING DIRECTIONS FROM THE SOUTH Highway 101 north and exit in Novato at Rowland Blvd. Turn right on Rowland Blvd and proceed to the first light, Rowland Way Turn left onto Rowland Way and proceed to 165 Rowland Way, at the end of the street The medical office building is located just to the left of Novato Community Hospital as you pull into the driveway. Suite 208 is on the second floor

2 PATIENT REGISTRATION Name Female Male Date of birth Social Security No. Address City St Zip Home phone Cell phone Work phone Race: please mark what best describes you: Caucasian/White African American/Black Chinese Vietnamese Korean Filipino Japanese Native Hawaiian/Pacific Islander American Indian/Alaskan Native Other Unknown Are you of Hispanic or Latino origin? Please mark one statement that best describes you: Yes, I am of Hispanic or Latino origin No, I am not Hispanic or Latino I prefer not to answer Please indicate your preferred spoken language: Would language interpreter services be helpful to you during your medical visit? Employer Occupation Spouse s name Phone Primary Care Physician Phone Referring Physician if different from PCP Phone Health Insurance, primary ID# Health Insurance, secondary ID# Emergency Contact Relation to you Emergency Contact phone ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize the processing of the medical insurance either by electronic or manual method by Marin Rheumatology, Inc. My signature blow authorizes payment of all major medical and/or surgical benefits to which I am entitled from the listed insurer (above on this form) to pay Marin Rheumatology, Inc. I further authorize assignee to release all medical and/or insurance claim information necessary to secure payment(s). I recognize my financial obligation of any co-insurance or deductible and non-covered services that may be required. This agreement will remain in effect unless revoked by me in writing. Signature Date SELF-PAY: I understand that I am legally obligated to pay the full charges for any and all services rendered to me/the patient by Marin Rheumatology, Inc. All accounts, after 60 days from date of service may be subject to interest at the legal rate. Should the account be referred to any attorney or collection agency for collection, I may also be billed actual attorney s fees and collection expenses. Signature Date

3 MARIN RHEUMATOLOGY, INC. PETER H. STEIN, M.D. ARUNDATHI MALLADI, M.D. 599 SIR FRANCIS DRAKE BLVD., STE 201 PHONE GREENBRAE, CA FAX NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a Privacy Rule to help insure that personal health care information is protected for privacy. The Privacy Rule provides standards for health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, secure payment, or perform other 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 secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate or necessary, we provide the minimum necessary information only to those we feel are in need of your health care information in order to provide health care that is in your best interest. We may have indirect treatment relationships with laboratories that mainly interact with the physician and not patients, and insurance companies that need information to authorize testing, treatment, or payment for our services. We may have to disclose personal health information (e.g. diagnosis) in order to perform these functions. You may refuse to consent to the use or disclosure of your personal health information, but this must be done in writing. Under this law, we have the right to refuse to treat you should you refuse to disclose your personal health information. If you choose to give consent in this document, at some future time you may request restrictions on disclosure of all or part of your Personal Health Information. You may not revoke permission for actions that have already been taken which relied on this or a previously signed consent. We fully support your access to your personal medical records. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our Privacy Notice (Compliance Assurance Notification to Our Patients), to request restrictions, and to revoke consent in writing. PRINT NAME DATE SIGNATURE

4 MEDICAL CONDITIONS Last Name First Name Age Please briefly describe the medical conditions and symptoms that have brought you to our office: Please list other major illnesses or conditions for which you have received treatment (current and past). Include name of physician and approximate date. Exclude surgeries. Illness Approximate Date Physician Name State type and date of any injuries: Injury Date Injury Date State type and date of any surgeries you have had: Surgery Date Surgery Date

5 MEDICATIONS VITAMINS SUPPLEMENTS Name of drugs you are NOW taking: How long have How much do they help? Include vitamins, supplements, and over you taken this the counter products Strength No.Pills/Day medication? A lot Some Not at all ALLERGIES OR REACTIONS TO DRUGS Name of Medication Drug Type of reaction (rash, swelling, etc.) MEDICATIONS TAKEN IN THE PAST Drug/Dosage Length of Time Results did this medication help A lot? Some? Not at all? Reaction Advil/Motrin (ibuprofen) Aleve (naproxen) Allopurinol Arava (leflunomide) Azulfadine (sulfasalazine) Cellebrex Cellcept (mycophenolate) Chlorambucil Colchicine Cyclobenzaprine Cytoxan (cyclophosphamide) Darvocet (propoxyphene) Diclofenac Enbrel Humira Imuran (azathioprine) Medrol Methotrexate Plaquenil (hydroxychloroquine) Prednisone Probenecid Remicade Rituxan Tylenol (acetaminophen) Tylenol/codeine Ultram (tramadol) Vicodin (hydrocodone) Other..

6 GENERAL QUESTIONS Please check yes or no Yes No Question Are you currently working? If so, type of work? Are you disabled? Explain Do you have difficulty going up and down stairs? Do you sleep poorly? Do you exercise regularly? Type of exercise: Duration: Do you now smoke? /day /week How long? Did you smoke in the past? How much? How long? Year quit: Do you drink alcohol? Type: ounces/day /wk Year quit: Fatigue Fever/chills Sweat Recent weight loss or gain? Morning stiffness? How long? Hours Yes No Yes No SKIN GASTROINTESTINAL Facial rash Loss of appetite Loss of hair Trouble swallowing Hives Peptic ulcer symptoms Color change in extremities after cold Gastric ulcer duodenal ulcer exposure Skin tightening Abdominal pain Skin ulcers Nausea/vomiting Psoriasis Bleeding from gastrointestinal tract Abnormal nails Blood or mucus in stools Other rashes Diarrhea or constipation circle one Recent tick bite METABOLIC/ENDOCRINE Loss of vision Gout or high uric acid Head pain or eye pain Kidney stones Headaches Diabetes Jaw pain Thyroid disease Dry eyes HEMATOLOGIC/IMMUNOLOGIC Dry mouth Anemia Eye inflammation (iritis or conjunctivitis) Low platelet count/bruising or abnormal bleeding Ringing in ears Transfusions? How many? When? Sores in mouth Frequent infections Swollen glands Skin test for TB? Positive negative date CARDIO/PULMONARY/VASCULAR Hay fever Pleurisy or pain with breathing Contact allergies Angina, arrhythmia, heart attack Food allergies Other chest pain GENITOURINARY Shortness of breath Burning or frequency on urination Edema or fluid retention Urinary infections Cough/wheezing Protein or albumin in urine Leg pain with walking Abnormal kidney function High blood pressure Discharge from urethra FOR WOMEN ONLY Difficulty with sexual function Breast abnormality or discharge NEUROMUSCULAR/PSYCHIATRIC Menstrual abnormality or discharge Seizure Pregnancies-total number Numbness Failed pregnancies-total number Paralysis or stroke Menopause age at onset Tremor Muscle weakness Muscle pain Depression Psychiatric illness

7 FAMILY HISTORY Family member Age If living describe health If deceased describe cause Age at death Father Mother Brothers Sisters Children DISEASES IN YOUR FAMILY Yes No Disease Relationship Yes No Disease Relationship Diabetes Tuberculosis Hypertension Stroke Heart disease Cancer Gout Asthma Rheumatoid arthritis Other forms of arthritis Lupus Psoriasis Hay fever Kidney disease Migraines Epilepsy Alcoholism Thyroid Colitis Abnormal bleeding