Federal Way St. Francis Medical Building B at St. Francis Hospital

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1 Dear Future Patient: Welcome! As a new patient to our office, you are being seen at the request of your primary care physician. We will keep your physician informed as to our consultation and subsequent follow-up treatment. It is important that you continue to contact your primary care physician for medical care outside of our specialty. Pulmonary Consultants, PLLC is a group of eleven physicians who are board certified / eligible in Pulmonary Disease, Critical Care Medicine, and Sleep Medicine. Patients being referred for pulmonary disorders will be seen at one of the following locations: Tacoma 1708 S. Yakima, Suite 20 Federal Way St. Francis Medical Building B at St. Francis Hospital Gig Harbor Milgard Medical Building at St. Anthony Hospital Puyallup Rainier Hematology/Oncology Building Please complete the enclosed information and return it using the enclosed selfaddressed stamped envelope. All scheduling, paperwork, and billing will be generated through our Tacoma office. Your insurance card(s) must be presented at the time of your visit, in order to verify your coverage. Our physicians take care of patients in the Intensive Care Units of all five area hospitals, including St. Francis. Their time spent in our clinic is carefully scheduled with that priority in mind. Patients who are late, do not show for their appointments, or cancel without a 24 hour notice will be difficult to reschedule. Please refrain from using after-shave, colognes, or perfumes when visiting our office. These products may cause breathing difficulties for other patients. Your cooperation is greatly appreciated and we look forward to serving you.

2 DIRECTIONS: TACOMA OFFICE 1708 S. Yakima, Suite 20 Tacoma, WA Directions to Tacoma Office: Pulmonary Consultants Tacoma office is located in the St. Joseph Medical Clinic Building adjacent to St. Joseph Medical Center. From South King County: Heading southbound on I-5 take the City Center exit 133, merge onto I-705 (Spur Freeway). Take the A St exit on the left toward City Center. Keep left at the fork, follow signs for S. 15 St/Pacific Avenue and merge onto S. 15 th St. Turn left onto S. Yakima Ave. Turn into the St. Joseph Medical Clinic parking garage at 1708 S. Yakima. Take the garage elevator to our suite. From Olympia: Head northbound on I-5, Exit at City Center and continue per the directions above from King County. From Gig Harbor: Proceed Eastbound on Highway 16. Follow the fork to Northbound I-5, staying right to take the City Center exit and continue per the directions above. Directions to Federal Way Office: FEDERAL WAY OFFICE th Avenue South, #104 Federal Way, WA Traveling either north or southbound on I-5, take Exit 142-B Federal Way. Drive west to 9th Avenue South. Turn right, go two blocks. Turn left toward St. Francis Hospital. The medical office building is on the right before you reach the driveway for the main entrance to St Francis Hospital. Free Parking is available in the hospital/medical offices parking lots.

3 GIG HARBOR OFFICE Canterwood Blvd. N.W., Suite #300 Gig Harbor, WA Directions to Gig Harbor Office: Take the BURNHAM DR NW exit If coming from Bremerton: Enter the roundabout and stay in the LEFT lane to take the 3 rd exit (to cross over HWY 16). Enter the next roundabout and stay in the LEFT lane to take the 3 rd exit onto CANTERWOOD BLVD NW. If coming from Tacoma: Enter the roundabout and stay in the LEFT lane to take the 3 rd exit onto CANTERWOOD BLVD NW. Turn right at the St. Anthony Medical Pavilion sign (large red sign) Pulmonary Consultants, PLLC is located in the MILGARD MEDICAL PAVILION at the top of the hill on the left. Go to the 3 rd floor via the elevators and Pulmonary Consultants, PLLC will be to the left as you exit the elevator. PUYALLUP OFFICE 2920 South Meridian, Suite 100 Puyallup, WA Directions to Puyallup Office: We are located in the Rainier Hematology-Oncology Building one block north of the South Hill Mall.

4 APPOINTMENT DETAILS You are scheduled for an appointment with: Date: Time: If you must reschedule or cancel your appointment, we require you to notify us at least 1 business day in advance. If you do not provide that notice, we will consider you to have cancelled without notice, which may lead to your discharge from our practice. Call with any questions

5 PFT Screening Questionnaire What Provider sent you here for testing today? What is the main reason you are having breathing testing done: Shortness of breath Cough Taking Amiodarone Other Have you ever had pulmonary function testing before? NO Yes Where/When Have you used any inhalers in the past 4 hours? NO Yes Type/When Patient Name

6 PULMONARY CONSULTANTS RESEARCH: From time to time, physicians at Pulmonary Consultants, P.L.L.C are invited by pharmaceutical companies to participate in clinical trials that evaluate the safety and efficacy of new pulmonary treatments. All clinical trials are regulated by the Food and Drug Administration and are part of the process of eventually bringing new medicines and devices to patients suffering from pulmonary disease. We currently participate in clinical trials on Asthma, COPD (Chronic Obstructive Pulmonary Disease), Bronchiectasis, IPF (Idiopathic Pulmonary Fibrosis) and other lung conditions. All research at Pulmonary Consultants is conducted at our Tacoma office. Patients participating in these trials receive study medication and related medical evaluations free of cost while in the trial and may receive reimbursement for time and travel. If you would like to know more about this or are interested in participating, please check the appropriate box below and submit to us along with other forms in your new patient packet. YES, I am interested in participating or finding out more about Research at Pulmonary Consultants, P.L.L.C. NO, I am not interested. Name: Date of Birth:

7 FEE PAYMENT POLICY The care rendered to you at Pulmonary Consultants, PLLC will result in fees for our services. While it is our intention to assist in the billing of your insurance, the responsibility for payment is yours. There are many different insurance plans and it is impossible for us to know all the covered benefits, co-pays, and deductibles for each one. In addition, your insurance company will not guarantee payment to us. Red Flag Rule: Upon arrival, you will be asked for a photo ID and current health insurance card. If your photo ID does not show current address, a utility bill or other correspondence showing a current address is needed. Contracted Insurances: We are contracted with most of the large insurance plans. Co-pays must be paid at the time of service, as required by your own plan. Patient portions due after your insurance has determined benefits are expected to be paid within 30 days. If your insurance coverage is through a managed care plan a written primary care physician referral is required before your appointment and all subsequent appointments and for any tests that are ordered. We cannot be responsible for obtaining these referrals. Your own involvement in this process is required and appreciated. Medicare Our physicians are participating providers with Medicare. Your supplement will be billed after Medicare pays their portion. We will submit to only one supplemental policy per each individual account. Patient portions are expected to be paid within 30 days. Medicaid Patients with Medicaid coverage are required to present a current medical coupon upon arrival at each visit. If your coupon indicated that you have other insurance, you will need to present that card as well. If you are in the status of applying for Medicaid, you will be required to provide a case manager s name and phone number for verification. Payment will be required until approval has been granted. Upon approval of Medicaid coverage and payment, we will reimburse you for any payments that we received, according to state guidelines. Patients without insurance coverage: Payment at the time of service is required. We offer a 20% discount to patients who pay by cash/check for their services, or 15% if paid by credit card in full at the time of their visit. If necessary, short-term payment plans are available, but must be requested prior to the services being performed.

8 Acknowledgement of Privacy Policies The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to ask each of our patients to acknowledge receipt of our Notice of Privacy Policies. You have the right to request and receive a copy of this notice in written or electronic form. You may contact Pulmonary Consultants for a copy and one will be provided to you at no charge. Authorization to Disclose Protected Health Information (PHI) This authorization is completely voluntary; you do not have to agree to authorize any disclosure. If you do NOT wish to authorize disclosure, please indicate this preference by writing NONE in the space provided. In addition to my healthcare professionals, I authorize Pulmonary Consultants to disclose my PHI to: NAME (please print legibly) RELATIONSHIP TO PATIENT *You may revoke this authorization at any time by requesting to update this form in your records. By signing below, you consent that you have received Pulmonary Consultants Notice of Privacy Policies. You also agree to allow disclosure of your health information to the aforementioned contact(s) listed above (if applicable). PATIENT NAME (printed) PATIENT SIGNATURE DATE Signature of Personal Representative (if applicable) You may be asked to provide us with the relevant legal document giving you this authority. Please describe your relationship to the individual and/or your legal authority to act on behalf of the individual in making decisions related to healthcare: PERSONAL REPRESENTATIVE NAME (printed) PERSONAL REPRESENTATIVE SIGNATURE DATE

9 PATIENT INFORMATION Name: (Last) (First) (Middle Initial) Address: Phone: ( ) - Mobile: ( ) - SSN: - - Birthdate: / / Gender: Marital Status: Female Male Language: Race: American Indian/AK Native Asian Primary Care Physician: Black/African American White/Caucasian Hawaiian/Pacific Islander Decline to answer Phone: ( ) - Ethnicity: Hispanic/Latino Non-Hispanic/Latino Decline to answer Primary Insurance: ID #: Secondary (Supplemental) Insurance: Group #: ID #: Group #: Other Party Insurance: ID #: Group #: Name of Insured: SSN# Birthdate: / / Employer: - - Emergency Contact: Relationship: Alternate Contact: Relationship: Phone: Phone: ( ) - ( ) - I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any services rendered. I attest that this information is true and accurate to the best of my knowledge. I will notify this office of any changes in my health status or the above information. I also authorize payment of medical benefits to be paid directly to the physician and I authorize release of medical records to my insurance carrier(s) and my referring physician. I further permit a copy of this authorization to be used in place of the original. Signature: Date: / /