Welcome to Kevin Thomas DPM PC OFFICE POLICY

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1 OFFICE POLICY We strive to give our patients the best care that we can. We know that your time is valuable, as is the doctors ; therefore: we ask that you arrive on time for your appointment. If this is y our first appointment, PLEASE ARRIVE 15 MIN. PRIOR TO YOUR APPOINTMENT TIME. If you are late for your appointment, you may be asked to re-schedule. If you are unable to keep your scheduled appointment, please contact us within 24 hours. (We do have an answ ering machine where you can leave messages). We will provide you with a courtesy call 48 hours in advance to confirm your appointment. If you NO SHOW your appointment, there will be a charge of $40.00 and another appointment cannot be made until this is paid. (Price is subject to change without notification). If your insurance requires you to have a referral, please obtain one from your primary care physician PRIOR to the date of your visit. Without the referral your insurance will not pay for the visit and you will be responsible for the charges. Please bring a calendar with you to assist us in making appointments for te sts or for scheduling another appointment with our office that will be convenient for you. If you are diabetic and covered under Medicare, your insurance requires us to have the date last seen by your primary care physician in order for the visit to be paid. Please bring this information with you. There will be a $35.00 charge for any returned check. This charge and the amount of the check will need to paid in cash or with a money order before another appointment is made. Our office accepts CASH, CHECKS and CREDIT CARDS as form of payments. Office Staff Patient Date Date

2 560 Riverside Drive, A-101 Salisbury, MD Salisbury Phone: Fax: Aurora Street Cambridge, MD Cambridge Phone: Fax: Kevin Thomas, D.P.M. Trina P. Monis, D.P.M. Stephen V. Wilkinson, D.P.M. NAME: FIRST MI LAST AGE_ ADDRESS CITY ST ZIP PHONE: Home Work_ Cell address Date of Birth_ Social Security No. Gender _M_F Employer s Name / Address Primary Dr. Phone # Date Last Seen Emergency Contact Relationship Phone Pharmacy/Address/Phone # Who referred you to this office? Reason you are here today? _ How long have you had this problem / condition? Symptoms you are experiencing? Does anything make your symptoms feel better or worse? Why? Please rate your pain: At rest 1-10_ At worst 1-10_ ( 10 being most painful ) WHEN YOU HAVE TO GO TO THE DENTIST, DO YOU HAVE TO TAKE ANTIBIOTICS DUE TO HEART MURMUR OR ARTIFICIAL JOINTS? YES NO DOES ANY OF THE FOLLOWING APPLY TO YOU? Chest Pain Shortness of Breath Coughing Dizziness Nausea Back Pain Prolonged Bleeding Pregnant WITH / WITHOUT EXERTION WITH / WITHOUT EXERTION Wheezing Fainting Vomiting Joint Pain Immune or Healing Disorders Nursing HAVE YOU EVER BEEN TREATED FOR: Diabetes Heart Trouble Asthma COPD Stomach Ailments Gout Cancer Tuberculosis Rheumatic Fever Kidney Ailments Liver Ailments MRSA Foot Ulcers High Blood Pressure TYPE OTHER MEDICAL PROBLEMS OR SURGERY NOT LISTED: SIGNATURE DATE

3 PATIENT DOB MEDICATIONS INCLUDE DOSAGE ( PILL, LIQUID, INJECTION ) MEDICATIONS YOU ARE ALLERGIC TO MEDICATION REACTION MILD, MODERATE, SEVERE SURGERY HISTORY Procedure_ Date Procedure_ Date Procedure_ Date Procedure_ Date Do you have any artificial joints? ( ) YES ( ) NO PLEASE LIST Do you have an artificial heart valve? ( ) YES ( ) NO SOCIAL HISTORY Please check one: [ ] Married [ ] Single Weight Height Do you smoke? YES NO Do you drink alcohol? [ ] Divorced [ ] Widowed Shoe size Width How many packs per day? For how long? YES NO How often? Substance abuse: YES, I have or have had a substance abuse problem. Specify Are you employed? _YES _NO _RETIRED UNEMPLOYED What is your occupation? Race Ethnicity Preferred Language Patient Signature Date

4 Name:DOB: Insurance Information, please complete and provide cards for scanning PRIMARY INS CO:POLICY HOLDER S NAME: DOB: SECONDARY INS CO:_POLICY HOLDER S NAME: DOB: Do you have an HSA or HRA account?( )No ( )Yes Card # Expiration_ Did your foot problem result from a specific injury ( )No ( )Yes Injury Date _/_/ How did your injury occur? Is this a Worker s Compensation Claim? ( )No ( )Yes Claim # Contact:Phone: Authorization for Treatment/Insurance Authorization/Financial Agreement I hereby grant authority to Dr. Kevin Tho mas and associates to administer medical treatment to me and my dependent minor or student family member. Further, I hereby authorize my insurance carrier to pay medical and/or surgical benefits directly to Kevin Thomas DPM PC. I auth orize Kevin Thomas DPM PC to release any information acquired in the course of my treatment needed for medical insurance claims or consultations. A photocopy of this authorization is to be considered as valid as the original until revoked by me in writing. Participation with your insurance company requires us to collect your copay and deductible amounts. These are due at the time service s are rendered, as are non-covered services. A $10.00 fee may be added if not paid. I und erstand that I am financially responsible for all charges made to my account whether or not an insurance company, attorney, or other third party payer is involved with payme nt. I am responsible for all co-payments and co-insurance amounts, non-covered supplies and services and yearly deductibles. I agree to pay all collection expenses including a $35.00 return check fee, attorney s fees, court costs, filing fees, including charges that may be assessed by any collection agency retained to pursue this matter. As of 6/1/2012 there may be a $40.00 for missed appointments. Initials Statement of Disclosure House Bill 1280 Health Care Practitioners-Referral of Patients Kevin Thomas DPM PC owns Riverside Ambulatory Surgery Center, LLC. If you have health care services scheduled at the above facility please know that a valid medical need exists for this referral and that you have th e option of selecting another health care facility for these services. I acknowledge receipt of this information and the options available to me to select another health care facility should I so choose. Privacy Information Preferences Can we leave voice mail on answering machine? Yes No Will you allow internet based delivery reminders like ? Yes No I authorize discussion of my personal health information with the following person(s): Name: Relationship:_Phone: Name: Relationship:_Phone: Privacy Practice I acknowledge that I was provided a copy of the Priv acy Practice of Kevin Thomas, D.P.M., PC and Riverside Ambulatory Surgery Center, LLC. And that I have read (or had the opportunity to read if I so choose) and understood the Notice. Today s Date //_ Signature: Parent/Guardian Signature:_

5 Riverside Ambulatory Surgery Center, L.L.C. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTMANT TO US. Our Legal Duty We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about your rights concerning your protected health information; we must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this notice at any times, provided that such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected health information that we maintain, including medical information we create or received before we made the change. You may request a copy of our notice (or any subsequent revised notice) at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice. Uses and Disclosures of Protected Health Information We will u se and disclose your prote cted health inf ormation about you for treatment, payment, and health care operations. Following are examples of the types of uses and disclosures of your prote cted health care information that may occur. These examples are not means to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. Treatment: We will use and disclose your protect ed health in formation to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your prot ected health inf ormation may be provided to a physician to whom you have been referred to ensure that the physician has the n ecessary information to diagnose or treat you. In addition, we may disclose your protected health information from time to time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for protected health necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

6 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT I understand that, under the Health Insurance Portability and Accountability Act of 1996 ( HIPPA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow -up among the multiple providers who may be involved in that treatment directly or indirectly. Obtain payment from third-party payers. Conduct normal health-care operations such as quality assessments and physician certifications. I have been given a copy (if requested ) and the opportunity to read it and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy of the Notice of Privacy Practices. I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if y ou do agree, then you are bound to abide by such restrictions. Patient Name Relationship to Patient Signature Date

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