For updates on our telephone and office hours, please visit us at

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1 Dear Patient, On behalf of all of us at Beth Israel Deaconess HealthCare, I would like to welcome you to my practice. I am pleased that you have chosen me as your Primary Care Physician (PCP). Beth Israel Deaconess HealthCare strives for an exceptional patient experience, and my office staff and I look forward to partnering with you to achieve your health and well-being goals. It is important to us that your transition into the practice be as smooth as possible. Therefore, we have put together the following information for you. I hope you find it helpful. If you have any questions, please call us at PROVIDER S INFORMATION Dr. Maysabel Aponte is an internist who sees patients 18 years and older, and who provides care to patients in both English and Spanish. HOW TO CONTACT THE OFFICE The practice s phone number is: and the fax number is: Starting in February 2015, you can also the office staff or Dr. Aponte through our secure Patient Portal. For information on Patient Portal registration, please contact the office. For updates on our telephone and office hours, please visit us at EMERGENCY CARE There is a provider on call for our practice 24 hours a day, every day of the year. If you have an urgent clinical concern outside of business hours, please call our office and our answering service will reach out to the on-call provider. If you experience a true medical emergency, please call 911. DIRECTIONS TO THE OFFICE The office is located at 21 Highland Ave, Suite 9 in Newburyport, MA 01950, on the campus of Anna Jaques Hospital. Parking is available onsite. For directions to the office, please call our office or visit: LABORATORY/RADIOLOGY FACILITIES AND RESULTS Laboratory and Radiology services are both conveniently located down the hall from our office. Directions: Head toward the main hospital, past the gift shop to the main lobby. Registration for both laboratory services and diagnostic imaging is found there. The lab is open Monday through Friday 6:30 AM to 6:00 PM and Saturdays 8:00 AM to 12:00 PM. No appointment is needed. There are also satellite lab stations for your convenience. They are as follows: Newburyport Medical Center, located in the building before the hospital on Wallace Bashaw Jr. Drive o The hours are Monday -Friday 8:00 AM-4:00 PM (closed for lunch 12:30-1:00 PM) o The phone number is: Amesbury Health Center, located at 24 Morrill Place in Amesbury, MA o The hours are Monday-Friday 6:30 AM-3:00 PM (closed for lunch 12:30-1:00 PM)

2 o The phone number is: Cherry Street, Newburyport located next to the court house o The hours are Monday-Friday 7:30 AM-4:00 PM (closed for lunch 12:30-1:30 PM o The phone number is: You will be informed of your test results in writing or verbally within two weeks. If the results warrant immediate action, you will be contacted via the telephone. You may also find your results on Patient Portal, once you have created your secure log-in. If you have not received your test results within two weeks, please call our office. PRESCRIPTION REFILLS Please call the office when you are almost out of a medication so we can determine whether you need a refill, follow-up testing, or should be seen in the office for an appointment. Please allow hours for prescription refill requests. LATE POLICY As a courtesy to our other patients, patients who arrive more than 15 minutes late for their scheduled appointment time may be asked to reschedule. We request that patients arrive 5 minutes prior to their scheduled appointment to complete the registration and check-in process. CANCELLATION POLICY We have reserved your appointment time for you. If you no longer need the appointment or need to change the time or date of your appointment, please give us 24-hours notice so we may offer the appointment to another patient. INSURANCE The practice accepts most insurance plans. Because every plan and policy is unique, we recommend that our patients familiarize themselves with their insurance coverage including: co-payment amounts, whether any coinsurance percentages or deductibles apply, whether insurance referrals to specialists are required, and radiology imaging coverage. REFERRALS If you believe you need to be seen by a specialist, please call our office. If you have a new concern, it is likely you will need a primary evaluation by your PCP. If your health insurance requires an insurance referral, please call us at: or, you can request your insurance referral via our Patient Portal. Please provide us with 3 days notice prior to your specialty appointment to allow for processing. BILLING Our billing is done through Medical Care of Boston. Please direct all billing inquiries to the billing department at: A team of customer service representatives are available to help with any questions you may have. Thank you for choosing Beth Israel Deaconess HealthCare. We look forward to a long and healthy relationship with you. Sincerely, Dr. Maysabel Aponte

3 Patient History Today s Date: Patient Name: Date of Birth: Marital Status: Married Widowed Separated Divorced Single Height: Weight: Employment Status: Do you have any health concerns presently? Please indicate whether you have had any of the following: YES NO Anemia or Sickle Cell Disease HIV Infections/AIDS YES NO YES NO Arthritis or Back problems Heart Attack or Heart Failure YES NO YES NO Asthma Heart Murmur that requires antibiotics YES NO before dental work YES NO Bleeding tendencies Heart Rhythm Abnormalities/Pacemaker YES NO YES NO Blood Transfusions Hepatitis, Liver Disease, or Cirrhosis YES NO YES NO Clotting Problems High Blood Pressure YES NO YES NO Bowel Problems Kidney Disease YES NO YES NO Bronchitis, Pneumonia, or TB Seizures or Epilepsy YES NO YES NO Emphysema/COPD Stomach Ulcers YES NO YES NO Cancer, Type Stroke or Mini-stroke YES NO YES NO Chest Pain Thyroid Abnormalities YES NO YES NO Depression Fibromyalgia YES NO YES NO Diabetes Blood clots/dvt YES NO YES NO Elevated Cholesterol YES NO Please list any other medical problems other doctors have diagnosed: Please list any other doctor or specialist that you are currently seeing: 21 Highland Avenue Suite 9 Newburyport, MA

4 Patient History Name/address of the lab that you currently use for blood work: Please list the medications you are currently taking: Medication Name Strength Times per Day Name/address of the pharmacy you use: Please list any allergies you have to medications, food, etc.: Allergen Reaction/Side Effect Have you ever had an adverse reaction to anesthesia? 21 Highland Avenue Suite 9 Newburyport, MA

5 Patient History Surgical History: Procedure Date Hospital/Doctor Do you have a Health Care Proxy? Yes No If so, who is it? Please indicate family medical history: Medical Condition Relative YES NO Alcohol/Drug Abuse Asthma Bleeding Problem Cancer, Type Depression/Psychiatric Illness Diabetes Allergies Heart Attack High Blood Pressure High Cholesterol Liver Disease Kidney Disease Anesthetic Problems Stroke Epilepsy (Seizures) Other 21 Highland Avenue Suite 9 Newburyport, MA

6 Patient History Social History How many children do you have? What are their ages? Who lives at home with you? Do you use seatbelts consistently? Do you use a bike helmet regularly? Do you use sunscreen or protective clothing? Do you use insect repellant? Are you a cigarette smoker? If so, how many packs do you smoke per day? How many years have you been a smoker? Are you interested in quitting? Do you drink alcohol? If so, how many drinks do you have per week? Do you drink coffee, tea, and/or caffeinated soda? If so, how many cups per day? Do you currently use recreational or street drugs? Do you exercise regularly? If so, what exercise and how often? Are you on a diet? If so, please describe. Are you concerned about your weight? In the past month, have you often: Felt little interest or pleasure in doing things? Felt down, depressed, or hopeless? 21 Highland Avenue Suite 9 Newburyport, MA

7 Dear Patients: Effective September 23, 2010, the Patient Protection and Affordable Care Act went into law. The major goal of this new law was to ensure all Americans have access to quality, affordable healthcare while containing costs. Some of the benefits include, but not limited to, guarantee patients their choice of primary care provider without a referral, help cover young adults on their parents plan, prohibit discrimination against children with pre-existing conditions, and restrict use of annual limits. Most importantly, patients will benefit from this new law because insurance companies are no longer allowed to charge patients co-pays or deductibles when they receive preventative screenings, such as: Annual physicals Mammograms Colonoscopies Vaccines (Flu and pneumonia shots) Counseling (i.e. quitting smoking, losing weight, etc.) Please understand that a co-pay or deductible may still be required by your insurance company for the following reasons: 1. If your physician treats you for any NEW problems you are experiencing and discussed during your annual physical. 2. During your annual physical, your physician may need to change your medication or order some tests to deal with your PRE-EXISTING problems. 3. Some screenings may not be free of costs (co-pays / deductibles) for your insurance such as gynecology exams, HPV testing, HIV screening, contraception. 4. Your insurance company may not fall under the Patient Protection and Affordable Care Act. All questions related to your benefit coverage and co-pay requirements will need to be directed to your insurance company. Our physician offices participate in hundreds of health insurance carriers and cannot know what benefits you may qualify for under your particular plan. Please understand you may be billed the co-pay if the above scenarios apply to your visit today. Feel free to contact the Billing Dept. at if you have any questions with your statement. X Patient Signature I acknowledge receipt of this memo and understand co-pays may be billed to me for medical necessary services provided during my annual physical. Thank you for taking the time to read this information.

8 Patient Financial Responsibility Guidelines Beth Israel Deaconess Healthcare (BIDHC) is pleased you have chosen our practice for your medical care. Quality care is a first priority among our providers. To reduce confusion and keep costs of your care to a minimum, BIDHC requests that you please read the following guidelines to understand your financial responsibility and requirements. Patients with Health Insurance Please bring your insurance card to each visit so that the office staff can verify your eligibility. Not all services may be covered by your insurance plan therefore the obligation to understand what services are covered remains with you. Please contact your insurance carrier regarding covered services. If your insurance requires a referral to see one of our MDs for specialty care, please contact your PCP s office. The referral will need to be in place prior to your visit. Co-Payments Co-payments will be expected on each date of service when required by your insurance. Please understand co-payments may be required when problems are addressed during your annual physical visit. If you have questions regarding your co-pay amount, please call your health plan directly. Worker s Compensation (WC) / Motor Vehicle Accident (MVA) Visits Please inform both the scheduling and check-in staff that your visit is due to either a workrelated injury or a motor vehicle accident. WC and MVA insurance carriers require related forms to be filled out in order for reimbursement of your claims to occur. Please bring your employer, worker s compensation, auto insurance carrier and/or attorney information to your office visit. Patients will be billed directly if the above information requested is not provided to our offices. Billing: (617) Mon-Fri 8:00am-4:00pm

9 Patient Financial Responsibility Guidelines Establish PCP with your Health Insurance If your health insurance requires the selection of a Primary Care Physician (PCP), please make sure this is in place prior to your appointment. Patients may be responsible for the visit if the PCP has not been established with your health plan. Self-Pay Patients A deposit for services provided in the physician office is expected at the time of your visit. Any remaining balance will be billed to you. No Shows We require 24 hour cancellation notice if you are unable to keep your appointment. Please understand that you may be charged a No Show fee for missed appointments. Billing Questions We realize that special circumstances may arise and will assist you in every way we can to resolve your outstanding balances. Financial hardship discounts are available. To apply please contact our Billing department. Please understand we reserve the right to transfer delinquent accounts to a collection agency after all efforts have been exhausted to obtain payment from you. Statements sent to you from BIDHC are for the physician s portion of the visit. Hospital, laboratory and radiology services may be billed to you separately from those facilities. Please call them directly when bill questions arise. Please feel free to contact our Billing department with any questions at (617) between the hours of 8:00am-4:00pm, Mon Fri or askapg@bidmc.harvard.edu at your convenience. Billing: (617) Mon-Fri 8:00am-4:00pm

10 MEDICAL CARE OF BOSTON MANAGEMENT CORPORATION Authorization and Insurance Waiver Form Authorization to Pay Insurance Benefits: I hereby direct my insurance carrier to pay Medical Care of Boston Management Corporation (MCB) physician insurance benefits otherwise payable to me. Signature: Date: If You Are a Member of a Managed Care Plan: I understand that I have an obligation to get a referral for specialty services from my Primary Care Physician prior to making an appointment. If a referral is not received by my specialist, I understand that I may be responsible for full payment of services received should this be deemed by my health plan. Signature: Date: Authorization For Release of Information: I hereby authorize Medical Care of Boston Management Corporation (MCB) to release billing and medical record information to my insurance carrier and legal representative for medical services rendered to me by the physicians of MCB. Signature: Date:

11 Welcome to your first visit with Beth Israel Deaconess HealthCare. In order to better understand how you learned about our services, please check all answers which apply to you and return this form to the front desk. Thank you! The Physician I am seeing today is: How did you hear about Beth Israel Deaconess HealthCare? (check all that apply) I Was Referred By Find-A-Doc Team at Beth Israel Deaconess Medical Center Friend or Family Member His/Her Name (optional): Health Insurance Handbook, Call Center or Website Physician not Affiliated with Beth Israel Deaconess Online Angie s List Beth Israel Deaconess HealthCare Website (bidmc.org/pcpnow) Online Advertisement, Website: Online Google Advertisement ZocDoc Other Online Source Beth Israel Deaconess Network Former Patient, Returning to Practice Patient of Beth Israel Specialties, Physician Name: Beth Israel Deaconess Network Employee I am an Employee My Spouse is an Employee I am a Former Employee Advertisement Print Advertisement Billboard Bus Newspaper Subway Station Other Radio Advertisement Television Advertisement Community Outreach Community Event/Fair Speaking Engagement Other Exterior Signage at Practice Newspaper article Mailing to Your Home None of the Above (please explain):