NAFISA TEJPAR, M.D., F.A.C.S N. Orange Ave, Ste 513 Orlando, FL (407)

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1 NAFISA TEJPAR, M.D., F.A.C.S N. Orange Ave, Ste 513 Orlando, FL (407) APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate the trust and confidence you have placed in our practice. In return, we are committed to providing you with the best health care possible. Please bring the enclosed forms FILLED OUT with you, including the patient s PHOTO ID, the day of your appointment. If the patient is a minor, he/she MUST also bring a STUDENT ID to the appointment. We are open Monday through Friday from 9:00 a.m. to 5:00 p.m. YOUR APPOINTMENT TIME: We recognize that your time is valuable, and we make every effort to see you at the appointed time. We appreciate your patience if there is a delay due to unexpected circumstances. If you are going to be late for your appointment, please call before you come, because we might need to reschedule your appointment. If you must cancel or reschedule your appointment, to avoid a charge, please call at least 24 hours in advance, as this will allow another patient to use this time. YOUR IMAGING FILMS, REPORTS AND PREVIOUS TESTS: A: If you are coming about BREAST issues, please make sure you bring with you ALL FILMS and REPORTS for any Mammogram, Ultrasound or MRI that you've had done over the past 5 years. Dr. Tejpar will not be able to see you without your films. You must pick up your films and bring them personally. We do not allow films to be sent to our office by courier. When you pick up your films, please verify that all reports are enclosed. Dr. Tejpar will need all films and reports for your evaluation. This will prevent any delays during your appointment. B: If you are coming for any other condition or illness, please bring office notes, ultrasound, or any other information pertaining to this condition. INSURANCE: If you have Aetna HMO or POS, the CPT Code (for Breast Ultrasound) MUST BE INCLUDED on the Authorization along with the Office Visit or Consult CPT CODE Please verify prior to your appointment that your PCP has issued an authorization for both codes. Without the correct authorization, we will not be able to see you. If your insurance requires a referral from your Primary Care Physician (PCP), you must bring that with you to your appointment. Thank you for choosing NAFISA TEJPAR, M.D. PA for your care. Please feel free to call us anytime with your questions or concerns. We look forward to a long healthy relationship with you. Sincerely, The Team at NAFISA TEJPAR, M.D. PA CHECK LIST: 5 years history of films (Breast Issues only) All Patient Forms filled out Photo ID and Student ID (if a minor) Insurance Card Referral from Primary Care Physician (IF required by insurance)

2 PATIENT INFORMATION 1 Patient Name: ( ) Male ( )Female Telephone: Cell Phone: Date of Birth: SS#: Driver s Lic. #: ( ) Single ( ) Married ( ) Partnership ( ) Divorced ( ) Widowed Address: Employer: Occupation: Employed Since Telephone: Are Calls Allowed? Spouse/Partner Name (or Parent, if patient is a minor): Telephone: Cell Phone: SS#: Date of Birth: Employer: Occupation: Nearest Relative/Friend (not living with you): DOB: Telephone: Relationship: REFERRED BY: FAMILY DOCTOR: First and Last Name First and Last Name INSURANCE INFORMATION Primary Insurance: ( ) PPO ( ) HMO ( ) HSA Telephone: Insurance ID # Group #: ( ) Through Employer ( ) Personal Insured s Name: Date of Birth: Deductible Amount: How much has been met for this year? $ Secondary Insurance: ( ) PPO ( ) HMO ( ) HSA Telephone: Insurance ID # Group #: ( ) Through Employer ( ) Personal Insured s Name: Date of Birth: ASSIGNMENT OF BENEFITS: I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled including Medicare, private insurance, and any other health plan to NAFISA TEJPAR, M.D. This assignment will remain in effect until revoked by me in writing, A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment. In the event this account is assigned to collection. I agree to pay all costs of collection, including reasonable attorney fees. Signature: Date: Nafisa Tejpar, MD, FACS 2501 N. Orange Ave. Suite 513 Orlando, FL Tel:

3 Nafisa Tejpar, MD, FACS Breast Surgeon Diplomate, American Board of Surgery Florida Medical Plaza South Tower Suite N. Orange Ave. Orlando, FL Phone: (407) Fax: (407) Office Payment Policy To Our Patients, It is the policy of this office that payment is due when services are rendered. We supply itemized receipts that enable you to file directly to your insurance company or we will be happy to file the claim on your behalf. For your convenience, we offer the options of paying your co-pay, deductible, deposit, or other out-of-pocket expense by check or major credit card. HMO INSURANCE: Patients with an HMO insurance plan are required to pay their copay amount at time of visit and any deductible that has not been met. It is YOUR responsibility to bring a valid referral from your designated primary care physician in your network. Without a valid referral, we cannot provide service. PPO INSURANCE: Patients with a PPO insurance plan that covers a percentage of all charges (Example: 80/20 or 90/10 Plans) will be required to pay their percentage of the entire bill at time of visit and any deductible that has not been met. MEDICARE: Patients with Medicare and no supplemental insurance plan will be required to pay a yearly deductible, if not already met, and 20 % of all charges for each office visit. PATIENTS SCHEDULED FOR SURGERY: Patients being scheduled for surgery will be required to pay any deductible due, co-pay, or percentage due BEFORE the date of the surgery. Please be aware we allow up to 60 days from the date we bill your insurance company to receive payment or a response to our claim before the patient is billed for any balance. Thereafter, it is the responsibility of the patient or guarantor to pay the balance in full. NOTE: If you give us incorrect insurance information, an invalid referral, or fail to update your insurance information and we have to re-file your insurance, you will be responsible for any and all payment denied by the insurance company due to failure to meet timely filing deadlines as required by law. Once the balance becomes the patients responsibility to pay, a billing charge of $5.00 per month will be added to all accounts over 60 days of age. Your insurance policy is a contract between you, your employer and the insurance company. We are not a party to that contract. This office is always available to work with and assist the patient in any way possible. Thank you. Nafisa Tejpar, MD Signature of Patient or Authorized Representative Date

4 Nafisa Tejpar, MD, FACS Breast Surgeon Diplomate, American Board of Surgery Florida Medical Plaza South Tower Suite N. Orange Ave. Orlando, FL Phone: (407) Fax: (407) Authorization to Use Information for Treatment, Payment, or Health Care Operations and Release to Others I hereby authorize the release or use of my individually identifiable health information ( protected health information ) and medical record information by Nafisa Tejpar, MD, PA (the Practice ) in order to carry out treatment, payment, or health care operations. You should review the Practice's Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing this Consent Form. We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised Notice. You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the practice. I acknowledge and agree that the Practice may disclose my protected health information and medical record information to the following individuals who are either my family members, legal representatives, guardians, health care surrogates, or have power of attorney on my behalf. 1. Name Relationship 2. Name Relationship 3. Name Relationship I agree that the Practice may also disclose the following types of information contained in my medical record (please circle YES, NO or NOT APPLICABLE on the following categories and then sign below) : YES / NO / NOT APPLICABLE YES / NO / NOT APPLICABLE YES / NO / NOT APPLICABLE YES / NO / NOT APPLICABLE HIV/AIDS Information Mental Health Information Substance Abuse Information Sexually Transmitted Disease Information YES / NO / NOT APPLICABLE If Patient is under the age of eighteen (18) Pregnancy Information Signature of Patient or Authorized Representative Date & Time

5 Nafisa Tejpar, MD, FACS Breast Surgeon Diplomate, American Board of Surgery Florida Medical Plaza South Tower Suite N. Orange Ave. Orlando, FL Phone: (407) Fax: (407) Consent Form for Release of Information I agree and consent to Nafisa Tejpar, MD ( the Practice ) releasing information to me in the following alternative manners: 1. Via regular mail with any envelopes being marked personal and confidential and addressed to me. 2. Via telephone, answering machine or voice mail at my home, work or cell phone. 3. Via fax to my designated fax number which is: At all times, you retain the right to revoke this consent. Such revocation must be submitted to the Practice in writing. The revocation shall be effective except to the extent that the Practice has already taken action based on the prior Consent. The Practice may refuse to treat you if you or an authorized representative do not sign this Consent Form. If you or an authorized representative sign this Consent and then revoke it, the Practice has the right to refuse to provide further treatment to you as of the time of revocation (except to the extent that the Practice is required by law to treat individuals). I have read and understand the information in this consent. I have received a copy of this consent and I am the patient or authorized party to act on the behalf of the patient to sign this document verifying consent to the above terms. Date: Time: AM or PM Signature of Patient or Authorized Representative Date & Time Please PRINT Name Please explain Representative's relationship to the Patient and include a description of Representative's authority to act on behalf of the Patient:

6 Nafisa Tejpar, MD, FACS Breast Surgeon Diplomate, American Board of Surgery Florida Medical Plaza South Tower Suite N. Orange Ave. Orlando, FL Phone: (407) Fax: (407) Acknowledgement & Consent Form Our Notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by writing our practice or requesting a copy from our front desk staff. You have the right to request that we restrict how protected health information about you is used or released for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement. By signing this form, you consent to our use and release of protected health information about you for treatment, payment and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made releases in reliance on your prior consent. PRINT Patient Name: Signature of Patient Date: Witness:

7 MEDICAL HISTORY 6 Patient Name: Age: Family Doctor: Telephone: MEDICATIONS CURRENTLY TAKING: (Include names and dosage of all prescription drugs, over-the-counter medications, herbs, etc. (Use the next page, if needed, to include all.) ALLERGIES: List Any Medications You are Allergic To : (Use the next page, if needed, to include all.) Are you allergic to: Latex ( )Yes ( )No Local anesthesia ( ) Yes ( ) No Iodine or Betadine ( ) Yes ( ) No Any problems with anesthesia? ( ) Yes ( ) No Sleep Apnea? ( ) Yes ( ) No PREVIOUS OPERATIONS OR BIOPSIES: (Use the next page, if needed, to include all.) PATIENT HISTORY OF ILLNESSES (NOT family history) YES NO YES NO Diabetes Throat High Blood Pressure Lungs Asthma Heart Seizures Gastrointestinal Pneumonia Joint / Back Pain Bleeding Tendencies Kidney / Bladder Infections Gynecological Cancer HIV Positive Breast Disease Hepatitis (A, B, or C) RECENT TESTS (Within last 6 months) WHEN WHERE FOR WHAT Labs X-Ray Mammogram Ultrasound Other BREAST PROBLEMS (For Women Only) Do you have any family history of breast cancer? ( ) Yes ( ) No If yes, what is relation? Date of last menstrual period: Are you taking birth control pills? ( ) Yes ( ) No Nafisa Tejpar, MD, PA 2501 N. Orange Ave. Suite 513 Orlando, FL Tel:

8 MEDICAL HISTORY ADDENDUM 7 (if you need to list more items from previous page) Patient Name: Age: LIST ANY ADDITIONAL MEDICATIONS CURRENTLY TAKING: (Include names and dosage of all prescription drugs, over-the-counter medications, herbs, etc. (Use the next page if needed to include all.) LIST ANY ADDITIONAL MEDICATION ALLERGIES: LIST ANY ADDITIONAL SURGERIES OR BIOPSIES: Nafisa Tejpar, MD, PA 2501 N. Orange Ave. Suite 513 Orlando, FL Tel:

9 Nafisa Tejpar MD, FACS 2501 North Orange Ave Suite 513 Orlando, Florida Telephone# (407) Fax (407) General Medical Records Release and Authorization for Use and Disclosure of Protected Health Information Date: Patient s Name: DOB: Home Tel#: Other Tel#: I authorize the release of: All Records Office Notes Radiology Reports/X-Rays Surgical Reports Laboratory/Pathology records HIV/AIDS Reports Others Please fax my medical records to Nafisa Tejpar MD PA: Medical Records are from: (Doctor, Office or Hospital Name) Address: Fax#: Phone#: I understand that this consent is revocable upon written notice to the physicians, hospital or agency except to the extent that action by the physician, hospital or agency has been taken in reliance on this authorization, and that this authorization shall remain in for one year from the date of authorization in order to effect the purpose for which it was given. Alcohol, drug abuse information, if present has been disclosed from records whose confidentiality is protected by Federal Law. Federal regulations prohibit making further disclose of it without specific written consent of the undersigned, or as otherwise permitted by such regulations. HIV testing, and or AIDS related diagnosis is further prohibited from further disclosure by State Regulations without the specific consent from the patient. Patient s Signature in full XXX-XX- Patient s Last 4 numbers of SS# Date and time of Authorization Witness (For office use only) Patient s Date of Birth

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