Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX Phone-214) Fax-214)

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1 Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX Phone-214) Fax-214) Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas Shires III, M.D. Ernest E. Beecherl, M.D. Robert M. Hagood, M.D. James M. Sanders, M.D. Attention: It is the responsibility of the patient to verify with their insurance company that our physicians are participating providers with their particular insurance plan. The provider is not always current and it is impossible for our office to verify every patient s insurance. This will keep the patient from possibly owing a large out of pocket expense. Referrals: Patients whose insurance requires a referral are responsible to contact their primary care physician and have them initiate it with your insurance provider. If the patient requires a referral and we have not received it by the time of your visit, the patient will be responsible for the total charge of the visit at the time of service. Signature of patient Date

2 Southwest General Surgical Associates Patient Consent Form USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS I understand that as part of my healthcare, Southwest General Surgical Associates originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for the future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals. Southwest General Surgical Associates ' NOTICE OF PRIVACY PRACTICES provides specific information and complete description of how my personal health information may be used and disclosed. I have been provided a copy of or access to NOTICE OF PRIVACY PRACTICES and understand that I have the right to review the notice prior to signing this consent. I understand that Southwest General Surgical reserves the right to change the NOTICE OF PRIVACY PRACTICES. Prior to implementation of the revised NOTICE OF PRIVACY PRACTICES the revised NOTICE will be mailed to me if I provide my address below.i understand I have the right to restrict the use and /or disclosure of my personal health information for treatment, payment or healthcare operations and that Southwest General Surgical Associates is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that Southwest General Surgical Associates has already taken action in reliance on my prior consent. This consent is valid until revoked by me in writing. I request the following restrictions on the use and/or disclosure of my personal health information: I further understand that any and all records, whether written, oral or in electronic format are confidential and cannot be disclosed without my prior written authorization except as otherwise provided by law. I have been provided and have reviewed Southwest General Surgical Associates NOTICE OF PRIVACY PRACTICES dated January 4, 2002 Signature of Patient or Legal Representative, Date Print Name of Patient or Legal Representative Witness, Date Print Name or Witness

3 Southwest General Surgical Associates, PA Name: SS#: Home Work Cell Address: City, State, Zip: Sex: M / F Age: Birth date: Marital Status: Patient Employer/School: Occupation: Who referred you to this office? Primary Care Physician: Preferred Pharmacy: Responsible Party Information Name: Relationship: DOB: Address: Employer: City, State, Zip: Name: Home SS#: Emergency Contact Information Work Relationship: Insurance Information (please provide your insurance card to the receptionist) Carrier Name: Cardholder Name: Policy Number: Group #: Secondary Insurance Information Carrier Name: Cardholder Name: Policy Number: Group #: Assignment and Release: I certify that I, and/or my dependent has insurance coverage with and assign directly to Southwest General Surgical Associates, PA all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance; I authorize the use of my signature on all insurance submissions. Southwest General Surgical Associates, PA may use my health care information and may disclose such information to the above named insurance companies and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signed: Date:

4 New Patient Medical History Date Patient Name DOB Age Primary Care Physician Referring Physician Other Physicians Chief Complaint (reason for your visit today) Allergies (please specify symptoms) Do you take Aspirin, Plavix, or blood thinner such as Coumadin? (please specify) CURRENT MEDICATION LIST: Date Medication Dosage

5 Medical History Specify if indicated Cancer Diabetes Heart Disease Lung Disease Liver Disease Kidney/Bladder High Blood Pressure *Other (please explain) Past Surgeries Date and type of surgery Abdominal Heart Head and Neck OB/Gyn Breast Orthopedic *Other (please explain) Social History Type of Employment Smoking Yes / No If Yes, How many If previous smoker, year quit Alcohol Use Yes / No If Yes, How many

6 Family History (check ALL that apply, Specify if indicated; mother, father, brother, sister) Cancer Diabetes Heart Disease Lung Disease Liver Disease Kidney/Bladder High Blood Pressure Other (please explain) Review of Systems (Please check ALL that apply) General Cardiovascular Genitourinary Chills Chest pain at rest Blood in urine Fatigue Chest pain with exercise Difficulty urinating Fever Pain in leg muscles when walking Painful urination Headache Difficulty lying flat Night sweats Irregular heartbeat Musculoskeletal Weight loss Palpitations Joint stiffness Weight gain Leg cramps Gastrointestinal Muscle aches Allergy Abdominal Pain Bone pain Congestion Blood in stool Hives Change in bowel movements Peripheral vascular Itching Constipation Cold hands or feet Rash Decreased appetite Decreased sensation Diarrhea Pain in hands or feet Ophthalmologic Difficulty swallowing Blisters or wounds Blurred vision Heartburn Diminished visual acuity Nausea Skin Vomiting New mole or skin lesion Endocrine Cold when others are hot Hematology Neurologic Hot when others are cold Easy bruising Balance difficulty Prolonged bleeding Difficulty Speaking Respiratory Dizziness Cough Women Only Fainting Coughing up blood Irregular menses Loss of strength Pain with deep breathing Vaginal discharge Memory Loss Shortness of breath at rest Seizures Shortness of breath during exercise Acute loss of vision Men Only Breast Hard testicle Psychiatric Nipple discharge Hernia Anxiety Breast lump Penile discharge Depression Breast pain

7 AUTHORIZATION TO DISCLOSE HEALTH INFORMATION I hereby authorize the use or disclosure of information from the medical record of: Patient Name: Date of Birth: Social Security#: I authorize: Phone Number: Fax Number: To disclose the above named individual s health information. This information may be disclosed TO and used by the following individual or organization: Southwest General Surgical Associates 8230 Walnut Hill Lane, Suite 408 Dallas, TX Phone Fax For the purpose of: Please release the following: [ ] Problems List [ ] X-Ray / Imaging reports from (date) to [ ] Progress Notes [ ] X-Ray Films [ ] History/Physical Exam [ ] Lab results from (date) to [ ] Medication List [ ] EKG report [ ] Immunization Records [ ] Genetic Testing Information [ ] List of Allergies [ ] Other Diagnostic Reports [ ] Other (specify) I understand that the information in my health record may include information relating to sexually transmitted disease, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I understand that the information released is for the specific purpose stated above. Any other use of this information without the written consent of the patient is prohibited. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the individual or organization releasing information. I understand that the revocation will not apply to information already released in response to this authorization. I understand that the revocation will apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition:. If I fail to specify an expiration date, event or condition, this authorization will expire in 6 months. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to ensure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by the federal confidentiality rules. If I have any questions about disclosure of my health information, I can contact Southwest General Surgical Associates office manager. Signature of patient or Legal Representative Date COMPLETE ONLY IF INFORMATION IS TO BE RELEASED DIRECTLY TO THE PATIENT: I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand and have been advised that I should contact my physician regarding entries made in my medical record to prevent my misunderstanding of the information contained in these entries. I will not hold Southwest General Surgical Associates liable for any misinterpretation of the information in my medical record as a result of not consulting my physician for the correct interpretation. Signature of Patient or Legal Representative Date Relationship to patient (if legal representative) Witness Date request complete # of pages copied Reviewed only Charges$ Cash Check# Initials:

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