o Enclosures 4-5: Organizational Policies and Financial Policy The enclosures are informational only, no action is necessary.

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1 Dear Patient: Welcome and thank you for choosing InterMed Sports Medicine. We are honored that you have entrusted your care with us. InterMed prides itself on providing the highest quality health care to patients from childhood to senior stages of life. In order to best serve your needs and enhance your visit, we have enclosed paperwork for you to complete and present at your initial appointment. Below are the descriptions and/or instructions for each enclosure: o Enclosure 1: Authorization to Release Health Care Information This form authorizes your previously treating providers to send us important information regarding your medical history. Please complete this form and return it to our Health Information department. o Enclosures 2-3: Patient Notification Form and Medical History Form Thoroughly complete these forms and present them at your initial appointment. o Enclosures 4-5: Organizational Policies and Financial Policy The enclosures are informational only, no action is necessary. Please bring your health insurance card and state issued photo identification to your appointment. Your specialist office co-payment will be due at the time of your visit. Please note, if you are covered by an HMO plan, a referral from your Primary Care Provider must be in place. We encourage you to visit our website at to learn more about InterMed and the services we provide. We look forward to meeting you! Sincerely, InterMed Sports Medicine Team Appointment Date/Time: Address: 100 Foden Road East Building, South Portland, ME Phone Number: (207) Parking: Free and onsite Directions: From North: Merge onto I-95 North, Take the exit 45 toward US-1/Maine Mall Rd, Take the Maine Mall Rd exit toward ME- 114/Jetport, Take the ramp toward Jetport, Merge onto Maine Mall Rd. Turn right onto Gorham Rd, Turn Left onto Foden Rd, 100 Foden Rd is on the Right. From South: Merge onto I-295 South, Take the ME- 9/Westbrook St exit, Exit 3, toward Jetport, Stay straight on Gorham Rd until you reach Dunkin Donuts on your Right, Turn Right onto Foden Rd, 100 Foden Rd is on the Right. Wheel chairs available in entryway

2 Enclosure 1 AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION If this form is not filled out in its entirety it may result in a delay in processing. Patient Name DOB Telephone Address I understand that health care information is confidential and will not be released without my authorization unless permitted by law. I understand that I have the right to refuse authorization to disclose all or some health care information, but refusal may result in improper diagnosis or treatment, denial of insurance coverage, or other adverse consequences. I hereby grant my permission for the authorized employees or agents to release my protected health information. Where Records are being Transferred From: To: Physician/Individual: Physician: InterMed, P.A. Address: Address: 100 Foden Road, Suite 203 City/State: City/State: South Portland, Maine Phone: Phone: (Health Information) Fax: Fax: By law, providers are required to release the minimum amount of information necessary to carry out the purpose of a release. Check the box/boxes and use the line beside each document type below to indicate the date or range of dates for written information to be disclosed under this authorization as appropriate. Last 5 years of health records Radiology Films/Reports: Consults: Ongoing Verbal Communication: Physical Exams: Progress Notes: Lab Results: Other (specify): The information and material above may only be used for the following purpose(s): ( ) Transfer of Care: Reason for Transfer: ( ) WC Claim ( ) Ins. Application ( ) Legal Matter(s) ( ) Disability/FMLA ( ) Coordination of Care (NOT Transferring care) I understand that my specific consent is necessary to disclose information pertaining to treatment and/or diagnosis of mental health conditions, substance abuse and/or HIV status. I understand that authorizing the release of such information does not confirm the existence of such history or treatment. Please check the following specific authorizations: AIDS/HIV I DO authorize I DO NOT authorize Alcohol and /or Drug Abuse Treatment I DO authorize I DO NOT authorize Mental Health Treatment I DO authorize I DO NOT authorize This authorization expires (12) months from the date hereof. I have the right to revoke this authorization in writing at any time. Revocation will not cover information/material released prior to that date, but will prevent further release of information. I understand that revocation may be the basis for denial of health benefits or other insurance coverage or benefits. My signature below indicates that I have read this release form and have had all of my questions answered, if any. I understand what this form authorizes. I consent to the release of information as recorded on this form. I authorize the party (ies) listed in section 1 of this form to make subsequent disclosures to the same recipient pursuant to this authorization. I understand that information released might be further released by the receiving party and that if this occurs, InterMed cannot guarantee the protection of this information once disclosed. I understand that I have a right to request a copy of the authorization. X Patient or Representative Signature Date Parent Legal Guardian Other Legally Authorized Representative (specify): 100 Foden Road West, Suite 203 South. Portland, ME Tel: Fax:

3 Enclosure 2 Patient Notification Form Patient s Legal Name: Date of Birth: First MI Last Patient s Mailing Address: If applicable, Name of Parent(s), Legal Guardian(s): Circle One Cell ( ) Okay to leave message? Yes/No Home ( ) Okay to leave message? Yes/No Work ( ) Okay to leave message? Yes/No Circle One **Detailed Message? Yes/No **Detailed Message? Yes/No **Detailed Message? Yes/No **Detailed messages may contain medical and/or prescription information. Patient s Marital Status (Circle One) Single Married Partner Divorced Widowed Patient s Primary Care Physician: Patient s Employer: Occupation: Patient s Health Insurance Company: Policy Number: Emergency Contact Name: Relationship: Emergency Telephone: Cell ( ) Home ( ) Work ( ) Select One: I do not want any information about my healthcare communicated to family members/caregivers. I give InterMed permission to verbally communicate to family members/caregivers listed below. Name: Name: Name: Please check the box next to the specific information that may be verbally communicated to the individual(s) listed above: Prescription Request Referral Request Request/Confirm/Cancel Appointments Other (specify): This authorization expires (12) months from the date hereof. I have the right to revoke this authorization in writing at any time. Revocation will not cover information/material released prior to that date, but will present further release of information. If you would like to grant permission to InterMed to discuss AIDS/HIV, Alcohol and/or Drug Abuse, or Mental Health with anyone but yourself, please request a Medical Release Form. Patient Signature: Date: Parent/Legal Guardian Signature: Date: Office Use Only Data entered into ecw Insurance card scanned Driver s license/picture ID scanned Updated:

4 Enclosure 3 PLEASE BRING THIS COMPLETED QUESTIONAIRE WITH YOU TO YOUR SPORTS MEDICINE APPOINTMENT Name: Date of Birth: / / Date of visit: / / What is your current occupation? Who referred you to InterMed Sports Medicine? Who is your primary care provider? InterMed Staff Only: I have reviewed the past medical history, past surgical history, medications, ROS, allergies, social history and family history with this patient. Physician Signature: Date: WHERE IS YOUR CURRENT INJURY / PROBLEM? Use appropriate symbols shown below to mark the areas on your body where you feel these described sensations. Include ALL areas affected by your pain, and mark the type and area of pain if it radiates or spreads to other areas. BURNING X NUMBNESS O PINS & NEEDLES = STABBING / ACHE ^ Right Left Right Front Back

5 GENERAL SYSTEM REVIEW: Please check if you have had any of the following symptoms or problems: I have never had any of these symptoms or problems. General Issues Extreme fatigue Poor sleep Fever Sweats Rash Chills Appetite changes Undesired weight loss Undesired weight gain Head and neck Nosebleeds Swelling/lumps in neck Hematologic Lymph node enlargement Bleeding disorder Frequent infections Psychological Feeling depressed Feeling anxious Pulmonary-chest Difficulty breathing Chronic cough Wheezing Cardiovascular Chest pain Irregular heartbeat Poor exercise tolerance Swelling in the legs Leg cramps with walking Genitourinary Wetting pants or bed Blood in urine Painful urination Urinary infections Pelvic Pain Sexual difficulties Menstrual problems Dermatologic Color changes Rashes Blisters Open sores Hair changes Gastrointestinal Stomach pain Gastric reflux heartburn Constipation Diarrhea Change in bowel habits Nausea / Vomiting Blood in stool Orthopaedic Problems Joint pain Swelling in joints Walking difficulty Muscle pain Neurological Headaches Numbness Balance problems Dizziness Weakness Paralysis Please list participation in sports, exercise and other recreational activities. HISTORY: Briefly describe the nature of your injury/problem you are being seen for today. Please check any of the following symptoms you are experiencing with your injury/problem: Pain Swelling Locking Troubling climbing stairs Popping Tingling Pain at bedtime Numbness Weakness Joint Stiffness Joint noise/clicking Restricted motion Instability/Giving out Dislocation Catching Cramping Bruising Approximate date your injury or your current problem began: List the NAMES & DATES of providers who have treated you for your injury/current problem. (Circle names of providers who continue to treat you.) Nobody has treated me for my injury/current problem Name: Date of Birth: / / Page 2

6 DIAGNOSTIC TESTS: Please check if you have EVER had any of the following for your injury/current problem. I have had no diagnostic tests X-rays CT scan MRI scan Bone Scan EMG/Nerve Conduction study Other: When? Where? OTHER TREATMENTS: Check any you have had for your current problem. I have had no treatments Still Using? Has it helped? Physical Therapy Yes No Better Worse No change Chiropractic Manipulation Yes No Better Worse No change Osteopathic Manipulation Yes No Better Worse No change Massage Therapy Yes No Better Worse No change Cortisone Injections Yes No Better Worse No change Other Injections Yes No Better Worse No change Acupuncture Yes No Better Worse No change Other: Yes No Better Worse No change Please continue ONLY if your Primary Care Provider is not with InterMed. List drug ALLERGIES or prior bad drug reactions: I have no known medication allergies or reactions. Medication Name (prescription or over-the-counter) Nature of allergy or reaction Latex allergy? Yes No Shellfish allergy? Yes No TOBACCO / ALCOHOL USE HISTORY: I have never used tobacco in any form. Do you smoke or use other forms of tobacco NOW? If yes, how long have you used it? Have you QUIT smoking or using other forms of tobacco? When? I have never used alcohol. Yes No Do you drink alcoholic beverages in any form? Average number of drinks per week? Yes No Yes No Name: Date of Birth: / / Page 3

7 PAST MEDICAL/HEALTH HISTORY: Please check health problems you have now or have had in the past. Please write in any other medical problems that you may have had that are not listed below. I have no medical problems Medical problem(s) Heart disease/heart attack High blood pressure Bleeding/Blood clotting problem Gastroesophageal reflux disease Anemia or blood diseases Depression or mental/nervous problems Chronic Fatigue Syndrome Cancer type(s) & location(s): Strokes or TIA Seizures Multiple sclerosis Headache Osteoporosis Thyroid problems Stomach ulcers Kidney disease Diabetes Liver disease or hepatitis Asthma or lung disease High cholesterol Chronic infections Arthritis (of any kind) Fibromyalgia Other: MEDICATIONS: List all medications, vitamins or supplements you are taking. I take no medications or supplements. Medication name Dosage Prescribing Doctor Why? PAST SURGICAL HISTORY: Have you had any surgery? If so, please list below. I have had no surgeries. Type of surgery? Surgeon name? When? Where? FAMILY MEDICAL HISTORY (include blood relatives only): Family Members: Medical conditions/medical history: Mother Father Sister(s) Brother(s) Child(ren) Name: Date of Birth: / / Page 4

8 Enclosure 4 Welcome! The following information explains some of the policies our office uses. Answering Service: Our phones are live Monday through Friday from 8:00 am until 4:30 pm. By calling you will be connected to our office or our answering service. This is the only number that will be answered by our service after normal office hours. If a call is placed after 4:30 pm the answering service will page the physician on call or contact our weekend clinic if applicable. The physician on call will respond to calls in order of priority. If you do not receive a call back within twenty (20) minutes of placing the call to our answering service, please call again and let the answering service know you have not received a call back. Cancellations and Missed Appointments: Our office attempts to make reminder calls hours in advance of scheduled appointments. Should you need to cancel or reschedule an appointment, we require at least 24 hours notice in order to make the time available to another patient. The third time an appointment is missed or cancelled without proper notice within an 18 month period, it may be necessary for us to consider discharge from the practice. New patients who miss or cancel their initial appointment twice without providing proper notification shall be discharged from InterMed s Sports Medicine practice. Prescription Refills: We ask patients to contact their pharmacies first to fill all ongoing prescriptions. The pharmacy will then fax a request to our office which we will fax back before the end of the current business day. If this is a request for a new medication then we ask you to contact your physician s office to obtain prescription refills. When requesting a refill, call (207) between the hours of 8:00 am-4:30 pm. Having the following information at the time of the call would be helpful: o The medication you are in need of with correct dosage, frequency taken, and quantity requesting. o The name and location of pharmacy. Please allow us until the end of the business day (5:30 pm) to fulfill all prescription requests. If we have any questions we will call you back, otherwise please assume the pharmacy has your refill. Reporting of Test Results: We make every attempt to report test results as soon as they are received. Different tests take varying amounts of time for results to be received. Feel free to ask your physician or their clinical assistant the timeframe in which they expect to receive your results. Once the results have been received, you will be notified by the physician or their clinical assistant via mail, phone or online patient portal. If for any reason you do not receive communication regarding results on a test after two weeks please contact our office.

9 Enclosure 5 Patient Financial Policy Insurance Verification and Co-payments The patient is expected to present an insurance card at each visit. All co-payments and past due balances are due and payable at the time of service. Self-Pay Accounts Self-pay accounts shall exist if a patient has no insurance coverage; there is no insurance card on file, or if the patient has not met his/her yearly deductible or coinsurance. Payment is expected at the time of service. Alternatively for large balances, a payment plan may be worked out with authorized personnel in the Billing Office. Patient Collection Policy Thirty (30) days from the date of the first statement a patient s claim balance will be considered past due. If a patient is unable to pay their balance in full within the thirty (30) days the patients need to call the InterMed Billing Office at to setup a payment plan. If a patient s claim balance becomes 180 days past due the balance will automatically be transferred to the Thomas Collection Agency. At that time patients will need to contact the Thomas Collection Agency ( ) for payment options. Non-participating Insurance Plans As a service and courtesy to our established patients, non-participating health insurance plans will be billed as a non-assigned claim. Any outstanding balances are the responsibility of the patient. Appointments It is the responsibility of the patient to call and cancel scheduled appointments within 24 hours of the appointment. If appointments are not cancelled within 24 hours, InterMed shall reserve the right to charge for the no-show. Accident Cases Patients shall be financially responsible for medical services related to an accident. InterMed will submit claims to the patient s health insurance carrier. All outstanding balances will be the responsibility of the patient. Workers Compensation Cases Patients are responsible for notifying InterMed that certain treatment is injury related. Furthermore, the patient is responsible for supplying InterMed with the appropriate billing information, i.e. insurer, claim #, date of injury, etc. Patient Refunds In order for a patient refund to be issued, there must be no outstanding insurance or patient balances. InterMed will process a refund request within 4 6 weeks. Returned Check Fees Any returned check from the bank for non-payment (insufficient funds) shall result in the patient s account being assessed a $15 fee per check returned.

10 Child Custody Cases Unless otherwise notified and accepted by InterMed, the custodial parent shall be responsible for all outstanding charges and balances. If the parents share custody (joint custody), unless otherwise agreed by the parties, the parent with the first birthday of the year will have the responsibility for any outstanding charges and balances. InterMed will bill the insurance carrier for both custodial and non-custodial parents. Specialty Referrals If your insurance requires you to chose a primary care physician (PCP), you may need to have a prior authorization completed by your PCP prior to seeing an InterMed Specialist (Audiology, Cardiology, Dermatology, ENT, OB/GYN, Physical Therapy, Sports Medicine and certain ancillary services). It is the patient s responsibility to ensure a prior authorization is obtained. All charges incurred without a required prior authorization will be the responsibility of the patient. This financial policy is intended to promote a clear understanding with our patients. If you have any questions or need clarification of any of the above issues, please feel free to contact the InterMed Business Office at (207)