Alexander)Orthopaedic)Associates) New)Patient)Information:! Patient!Name:! """""Date:! " Social!Security!# """"""""""""""""Date!of!Birth:!

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1 Alexander)Orthopaedic)Associates) New)Patient)Information: PatientName: Date: SocialSecurity DateofBirth: Pleasecircle:MorF Race: Language Ethnicity SingleMarriedDivorcedWidowed PrimaryHomeAddress: City: State: ZipCode: Occupation: Employer: HomePhone: WorkPhone: CellPhone: SecondaryHomeAddress: City: State: ZipCode: PrimaryCarePhysician: Phone: ReferringPhysician: Phone: ) EMERGENCY)CONTACTS:) Name: Phone: Relationship: Name: Phone: Relationship: Ifyouhaveaspouse: Name: DateofBirth: SocialSecurity Employer: CellPhone: WorkPhone: INSURANCE)INFORMATION) Primary)Insurance: EffectiveDate: Address: City: State: ZipCode: Telephone NameofInsured: Relationshiptopatient: ID Group SubscribersSS: SubscribersDOB: PleaseCircle:HMOPPOOther Secondary)Insurance: EffectiveDate: Address: City: State: ZipCode: Telephone NameofInsured: Relationshiptopatient: ID Group SubscribersSS: SubscribersDOB: PleaseCircle:HMOPPOOther Didyourinjuryoccuratwork?(pleasecircle) YesNoifyes,Dateofinjury Isyourinjuryfromanautoaccident?(pleasecircle) YesNoifyes,Dateofinjury Areyoubeingrepresentedbyanattorney?(pleasecircle) YesNo ifyes,nameofattorney Phone

2 MRI REFERRAL DISCLOSURE In the course of your treatment, an x-ray, MRI, CT, bone scan, bone density scan, or other ancillary studies may be necessary and ordered. Alexander Medical Group, LLC, dba Alexander Orthopaedic Associates in accordance with the Patient Protection and Affordable Care Act, as modified by the Health Care and Education Reconciliation Act of 2010, (PPACA) Section 6003, informs you that it is your choice to have the study done at our facility or at the facility of your preference. A written list of such facilities in the area is provided below. Advanced Medical Imaging Pinellas High Field Imaging Bardmoor Imaging Rose Radiology Central MRI Signet Diagnostic Clearwater Imaging St. Anthony s(baycare) Diagnostic Imaging St. Petersburg General DOC s Imaging St. Petersburg MRI Gateway Tampa Bay Imaging (TBI) Largo Medical Center Total Imaging of Northside Hospital National PET Scan Tyrone Imaging (BayCare) Palms of Pasadena Westcoast Radiology Performance Imaging Please print and sign your name below to acknowledge your understanding of the above statements. Print Name Signature Date

3 AlexanderOrthopaedicAssociatesDisclosureofPolicies FinancialPolicy: AlexanderOrthopaedicAssociatesparticipateswithmanyformsofhealthinsurance,suchasHMO s,ppo s, Workman scompensationandmedicare.however,fewinsurancecarrierscoverallmedicalcostsanda balanceonyouraccountmayresultfromcopayments,coinsurance,deductibles,ornoncoveredservices. Thepatientisresponsibleforfullpaymentofanyandallbalancesdeemed patientresponsibility bytheir insurancecarrier.wewillfilemedicalinsuranceclaimsasacourtesytoourpatients. MotorVehicleandWorker scompensation:inorderforourofficetosubmityourclaimsforyou,youmust provideuswiththefollowinginformation:insurancecompanyname,addressandtelephonenumber,aswell asyourclaimnumber,dateofaccidentandclaimsadjuster sname.intheeventthatyourinsurancedeniesor terminatesyourbenefits,youwillberesponsibleforfullpaymentforservicesrendered.pleasenoteforall Workers Compensationpatients,yourinitialappointmentmustbescheduledbyyournursecasemanageror Worker scompensationadjustor.authorizationmustbereceivedpriortotheinitialofficevisit.motor Vehiclepatients,pleasenotepriortoyourinitialofficevisityourautobenefitsmustbeconfirmedandverified byouroffice. PaymentPolicy: Allcopayments,coinsurance,anddeductiblesarepaidatthetimeofservicetohelpcontrolcostsofmedical care.paymentsmaybemadebycash,check,visa,mastercard,americanexpress,anddiscover.forlarger amounts,suchassurgicalfeesnotcoveredbyinsurance,aoawillworkwithyoutoarrangeapaymentplan. SelfpaypatientsandSurgicalPrepaypatient spaymentswillonlybeacceptedviacreditcard,cashpayment, and/ormoneyorders. TreatmentofPatients: ThroughoutyourtreatmentatAOA,themedicalprovidersmayorderdiagnostictestingtohelpdetermine yourdiagnosisorcreateabettertreatmentplanforyou,thepatient.thesetestsincludelabwork,xrays, MRI s,ctscans,bonescan s,etc.failuretoscheduleorobtaintherecommendeddiagnosticstudiesina timelymannerortoscheduleafollowupappointmenttoreviewthediagnostictestsinatimelymanner;will constituteasabreechofourrecommendationsandisagainstmedicaladvice(ama).therefore,aoa employeesandmedicalproviderswillnotbeheldresponsibleforlackofpatientresponsibilityandpurposeful disregardofourmedicalrecommendations.noncompliancemayresultinanadversecomplicationtothe patient smedicalresult/outcome. AlexanderOrthopaedicAssociatesnotifiesyouthatourprovidersmaybeinvolvedineducation,research, developmentand/orconsultingwithregardstoorthopaedicproductsandtheorthopaedicindustry; thereforetheprovidersmaybenefitdirectlyorindirectlyfromsucheducational,research,developmentand/ orconsultingrelationships.thiswillnotconflictwiththebestinterestofthepatientand/ortheirmedical condition/diagnoses. AlexanderOrthopaedicAssociatesnotifiesyouthatsomeorallprovidersmayormaynotcarryMedical MalpracticeInsurance.

4 AUTHORIZATIONFOR RELEASEOF CONFIDENTIALINFORMATION (PURSUANTTO45.C.F.R ) (T) (F) PatientName: DOB: Last4digitsofSocialSecurityNumber: MR: PatientPhoneNumber: (PersonneltoFillout) Iauthorizetoreleasemedical,psychiatric,alcoholand/ordrugabuse,HIVtesting,ARCand/orAIDSdiagnosis,eating disorderinformationoranyothermedicalrecordsofasensitivenature: (Pursuantto42.C.F.R.2.31) Thiswillauthorize:(Nameoffacility/entitytoproviderecords)Thiswillauthorize: AlexanderOrthopaedicAssociates th StreetNoSuiteA Largo,FL33773 ToReleaseTo: ToReleaseTo: AlexanderOrthopaedicAssociate th StreetNoSuiteA Largo,FL Forthepurposeof Pleasedisclosetheexactinformationselectedbelow: EntireMedicalRecord,excluding Date(s)ofService: Checkallthatapply: LaboratoryReports RadiologyReports ProgressNotes PhysicianOrders NursesNotes MedicationSheets Facesheet HistoryandPhysical DischargeSummary Consultations Note:XTrayfilmsmustbeobtainedfromRadiologyDept. Tobecompletedbythepatientorpersonalrepresentative: Iherebyauthorizetheuseordisclosureofmyprotectedhealthinformationasdescribedabove. OperativeReports Pathology EmergencyReport EKGReport Other(Specify): Thisauthorizationisvoluntary.IunderstandthatabilitytoobtaintreatmentwillnotbeaffectedifIdonotsigntheform,unlessthat treatmentisforafitness7for7dutyevaluationoraresearch7relatedtreatment. I understand that if the organization authorized to receive the information is not required to comply with the federal privacy protectionregulations,thensuchinformationmaybere7disclosedandwillnolongerbeprotected. IunderstandthatIhavearighttorevokethisauthorizationbysendingwrittennotificationsto:AlexanderOrthopaedicAssociates th StreetNoSuiteALargo,FL AnyrevocationwillnotaffectdisclosuresmadepriortoAlexanderOrthopaedicAssociatesreceiptorknowledgeoftherevocation. IunderstandthatIhavearighttoinspectandreceiveacopyoftheinformationdescribedonthisform. Signatureofpatientorpatient srepresentative/powerofattorney Date: Printednameofpatient srepresentative/powerofattorney Relationshiptothepatient: Date: ExpirationDateofthisAuthorization:OneYear

5 AlexanderOrthopaedicAssociates PatientAuthorizationForm HIPPAPrivacyNotice IhavereceivedandreadacopyofAlexanderOrthopaedicAssociatesNoticeofPrivacyPractices(Notice). ByinitialingIhavereadandunderstandtheabove AuthorizationtoReleaseInformation IconsenttotheuseordisclosureofmyprotectedhealthinformationbyAlexanderOrthopaedic Associates(AOA)forthepurposeofdiagnosingorprovidingtreatmenttome,obtainingpaymentformy healthcarebillsortoconducthealthcareoperationsofaoa.asmentionedin(sectionsi,ii,iii,v)ofthe Notice. ByinitialingIhavereadandunderstandtheabove AOADisclosures IacknowledgethatIhavebeennotifiedthatsomeoralloftheprovidersatAOAmayormaynotcarry MedicalMalpracticeInsurance.IalsoacknowledgethatIhavebeennotifiedthattheprovidersatAOA maybeinvolvedineducation,research,development,and/orconsultingwithregardstoorthopaedic productsandtheorthopaedicindustry;therefore,theprovidersmaybenefitdirectlyorindirectlyfrom sucheducational,research,development,andorconsultingrelationships.theabovedoesnotconflict withmybestinterestasapatientataoa.idesiretoenterintoadoctorpatientrelationshipwitha providerataoa.asmentionedin(sectionvi)thenotice. ByinitialingIhavereadandunderstandtheabove FinancialAgreement&PaymentPolicy IunderstandthatIamfinanciallyresponsibleforservicesrenderedbyAOAproviders. Ialsounderstandthatfewinsurancecarrierscoverallcostsforservicesrendered.AOAwillsubmitclaims toyourinsurancecarrier.iwillberesponsibleforthebalanceonmyaccountthatmyinsurancecompany doesnotcover.iwillpayanycopayments,coinsurance,anddeductiblesatthetimeofserviceataoa. Asmentionedin(sectionVII,VIII)intheNotice. ByinitialingIhavereadandunderstandtheabove Authorizationfortreatment ThroughoutyourtreatmentatAOAthemedicalprovidersmayorderdiagnostictesting(labwork,bone scan s,xrays,mri s,ctscans etc)thatwillhelpdetermineyourdiagnosisandfuturetreatment.failure toscheduleorobtaintherecommendeddiagnosticstudiesorfailuretoscheduleafollowupvisitina timelymannertoreviewthediagnosticstudiesanddiscusstheresultswillconstituteasabreechofour recommendations.aoaemployeesandmedicalproviderswillnotbeheldaccountableforyourlackof responsibilityandpurposefuldisregardofourmedicalrecommendations.asmentionedin(sectionix)in thenotice. ByinitialingIhavereadandunderstandtheabove IherebyauthorizethemedicalstaffofAOAtorendermedicalservicesandtreatmentsasdeemed necessary.iunderstandthatfailuretocomplywithourmedicalrecommendationsisagainstmedical advice.(ama) ByinitialingIhavereadandunderstandtheabove Bysigning,Ihaveread,understandandagreetocomplywithAOApoliciessonotedintheNoticeofPrivacyPractices(Notice). Signature Date PrintedName Ifpatientisaminor(under18): Minor sname Guardian sname(printed) Signature Relationship Date

6 Consent for the Release of Protected Health Information to Personal Representatives I,, give my written consent for Alexander Orthopaedic Associates to share information regarding my protected health information and care to the following listed persons: I understand that these persons will be treated as personal representatives of myself. Personal Representatives that Alexander Orthopaedic Associates may share my Protected Health Information with: Name: Relationship: Name: Relationship: Name: Relationship: Do not discuss my Protected Health Information with anyone other than myself at any time. Alexander Orthopaedic Associates may leave a message: At Home At Work On Answering machine Patients Signature Date: Patient s Account Number:

7 AlexanderOrthopaedicAssociates FormFeeAgreement Pleasenote:Thecompletionofinformational/insuranceformsrepresentsanadministrativeservicetoourpatients aboveandbeyondtheprovisionofmedicalcare.recentchangesinhealthcarehaveresultedinthetremendous increaseinthevolumeofinformationrequeststoourpractice.thetimeandeffortinvolvedinprovidingthis detailedinformationresultsinsignificantcosts,especiallywhenmultipliedoverthelargenumberofpatientsour practiceserves.therefusalofinsurancecompaniesandrequestingagenciestocoverthecostsrequiresusto instituteapolicyofchargesforthecompletionoftheformsasfollows: NOCharge: WorkersCompensationrequestedDisabilityandWorkStatusforms AutoInsuranceCarrierrequestsforWorkStatusandTreatmentPlans $15.00: DisabledParkingApplications $35.00/form: CreditCarddefermentforms PrivateDisabilityInsuranceForms SchoolEducationalDisabilityorLimitationForms $35.00/form FamilyMedicalLeaveAct(FMLA)forms $150.00$ Forcompletionofanydictatedletterdescribingmedicalcareandlimitations Foranynarrativereportdetailingdiagnosis,treatment,andfuturemedicalcareincludingworkcapacity statements.functionalcapacityevaluationtestingmaybenecessarypriorto,orinadditiontothenarrative report.thefeeforthefcetestisdeterminedbythefacilitythatthetestingiscompletedat. Ihavereadandunderstandtheabove.BysigningIagreetocomplywiththeFormFeepolicyofAOA.Feessubjectto changewithoutnotice. PatientName(printed)SignatureDate Revise9/7/10

8 Adam D Perler, DPM, FACFAS Podiatric Medicine Foot and Ankle Reconstructive Surgery Room Xray Taken: XR/MRI Brought: Y N PATIENT HISTORY - Please print and fill out completely Name: Date of Birth: Age: Height: Weight: Shoe Size: Hand Dominance: L R Primary Care Physician: Doctor s Phone &/or Fax : ( ) How did you hear about us? Pharmacy name, address and phone number: HISTORY OF INJURY/COMPLAINT Please briefly describe the problem you are experiencing: Side: Right Left Both Area of symptoms: Ankle Achilles Tendon Heel Foot Toes Did your problem result from a specific injury/accident? Y N Injury/Accident Date: How long have you had your condition/problem? Please rate your current pain/discomfort on a scale of 1-10 (1 painful; 10 extreme pain) Is the pain: Constant Occasional Sharp Dull Aching Throbbing Stabbing What symptoms are you experiencing? Burning Tingling Numbness Popping Giving Way Grinding Other: What, if anything, makes your symptoms better? What, if anything, makes your symptoms worse? Have you seen another physician for this condition/injury? Y N If yes, who? What treatments have you tried? Nothing Physical Therapy Exercise Acupuncture Chiropractic Injections Ice and/or Heat Medication: Other: Have you had any of the following tests for your condition/injury? X-Rays MRI Scan CT Scan EMG/NCV Blood Test PAST MEDICAL HISTORY Please check all that apply: e e e e e e e e He e He e e e e e H e He e e e e sorder H e e e e e e e e e e e e -controlled e e e e e e e Alcoholism e e e e e e e e e e e ee e H e

9 HOSPITALIZATION and SURGICAL HISTORY DATE: REASON: COMPLICATIONS: Have you had any complications with anesthesia in the past? Yes No If yes, what type? CURRENT MEDICATIONS Please write additional medications on a separate sheet of paper if there is not enough room provided. MEDICATION: DOSAGE: FREQUENCY: ALLERGIES Are you allergic to any medications? Yes No Are you allergic to: Sulfa Latex Penicillin Other: Please specify the type of reaction you had to the above medication(s): FAMILY HISTORY Please check all that apply and circle any family member affected. DISEASE: FAMILY MEMBER: DISEASE: FAMILY MEMBER: Heart Disease Mother Father Sibling Child Blood Clots Mother Father Sibling Child High Blood Pressure Mother Father Sibling Child Stroke Mother Father Sibling Child Rheumatoid Arthritis Mother Father Sibling Child Anesthesia Reaction Mother Father Sibling Child Diabetes Mother Father Sibling Child Similar Foot Problems Mother Father Sibling Child Cancer/Tumor Mother Father Sibling Child Type: SOCIAL HISTORY What kind of work do you do? (Example: Student, secretarial, construction, teaching) Where do you work or attend school (include grade/level)? What kinds of physical demands do you have on your feet due work, school, or other activities? What type of shoes do you typically wear? Does your problem limit your work or activities? Yes No If yes, how much? How would you describe your daily activity level? Active Moderately Active Not Active Do you exercise regularly? Yes No If yes, what type of activity and how often? Are you on a special diet? Yes No If yes, restrictions? Do you smoke? Yes No Quit If yes, how many packs per day? For how long? Do you drink? Yes No Quit If yes, how often? (Number) drinks per week Do you or have you used recreational drugs? Yes No If yes, what type? How often? When was the Date of last physical examination? Performed by: