Once again welcome to our office!

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1 !"#%&'()(*+,-..(/0&'#., (1,2(3'",4#5& ,,,,,,,,,,,,!!"#%&'()*+,-.'(/!01 23'45&,67890:9 ;<=1#!>1?8>00?? BCD%EFC!"#%&#'((((((((((((((((((()))*++,&#-%&#)."#%)/)#-%'((((((((((((((0(((((((() ) ) Welcome to our practice! Please complete the attached forms before arriving to your appointment. Please arrive 15 minutes prior to appt. This allows us time to input the information into your chart. If forms are not completed, your appointment will be rescheduled. If you need help with any of the forms, please do not hesitate to call our office. We will try to make it as easy as possible for you. If you are coming to us from a prior ; we suggest you have your medical records transferred to our office before your scheduled appointment, so that continuity of care is maintained(especially labs and x-rays). There are so many different insurances and they are constantly changing. It is important that you bring your insurance cards with you to every visit. If your insurance requires a co-pay or deductible, payment is due at the time of the visit. You will be contacted 1-2 days in advance to remind you of your appt. If you need to cancel your appointment, please do so 24 hours in advance. This allows us to free up appointment slots to meet the needs of all our patients. If we do not receive notification of cancellation you will be billed Once again welcome to our office!!

2 RHEUMATOLOGY ASSOCIATES OF NORTH TEXAS, PA REGISTRATION FORM (Please Print) PATIENT INFORMATION Marital Status (circle one): Legal name: Gender: Mr. Single Widowed Last: First: Middle: Mrs. Married Partner M / F Miss/ Ms. Divorced Separated Do you want access to address: Birthplace: Date of Birth: Age: SSN: your records online? Yes No / / Secure Website Street Address: City/State: Zip Code: Cell Phone Number: Home Phone Number: Employer: Work Phone Number: How did you hear about our office?: Preferred Pharmacy (Name and location): Pharmacy Phone Number: Referred by: Name of Primary Care Physician: Name of Orthopedic Surgeon: Phone number: PCP Phone number: e number: IN CASE OF EMERGENCY Name of local friend or relative: Relationship to patient: Phone number: Primary Insurance Company Name: INSURANCE INFORMATION (Please give insurance card to the receptionist) Relationship to patient: Date of Birth: Group Number: Policy Number: Co-payment: Name of secondary insurance (if applicable): / / Relationship to patient: Birth Date: Group Number: Policy Number: Co-payment: / / Name of person responsible for bill: Relationship to patient: Phone number: The above information is true to the best of my knowledge. I authorize Rheumatology Associates of North Texas, PA to apply for benefits on my behalf for covered services rendered by Rheumatology Associates of North Texas, PA. I request my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Rheumatology Associates of North Texas, PA or the insurance company to release any information required to process my claims. Patient Signature Date 4461 Coit Rd., Suite 402 Frisco, TX (214) Fax (214)

3 Rheumatology Associates of North Texas, PA 4461 Coit Road, Suite 402 Phone (214) Fax (214) Please complete the entire patient packet before arriving for your appointment. If the packet is not completed, we may have to reschedule your appointment. If you have any lab results or imaging results from another physician, bring them with you to your appointment or make sure your physician forwards the results to our office before your appointment. CURRENT MEDICATION LIST PRESCRIPTIONS, OVER THE COUNTER MEDICATIONS, VITAMINS Medication Dosage Frequency Reason prescribed Please state the year of your last: Flu Vaccine Pneumonia Vaccine Tetanus Vaccine Shingles Vaccine Hepatitis B Vaccine ALLERGIES Medication Reaction Other Allergies Reaction YOUR PAST MEDICAL HISTORY: Have YOU ever been diagnosed with any of the following diseases? Cancer/Leukemia/Lymphoma Heart Disease Diabetes High blood pressure High Cholesterol Stroke Emphysema/COPD/Asthma Kidney disease Thyroid disease Jaundice/Hepatitis Tuberculosis Pneumonia HIV/ AIDS Headaches Depression Nervous Breakdown Glaucoma Anemia Rheumatic Fever Alcoholism Epilepsy Goiter Rheumatoid Arthritis Psoriasis Migraines Ankylosing Colitis Unspecified Arthritis Osteoporosis Iritis/Uveitis Osteoarthritis Chronic fatigue Sarcoidosis Gout Fibromyalgia Childhood arthritis Spondylitis syndrome Other significant illness (not listed above): Date of Birth:

4 Previous Operations/ Surgical History Type Year Reason Any previous fractures or dislocations? No Yes Describe: Please state the year of your last: Bone Densitometry: Mammogram: Eye exam: Chest x ray: Tuberculosis Test: FAMILY HISTORY (Blood relatives ONLY): Has your mother, father, sibling, child, grandparent, aunt, or uncle had any of the following? (List their relationship to you next to the condition. Be sure to mention if the relative Condition Relationship Condition Relationship Unspecified arthritis Chronic fatigue Osteoarthritis Gout Fibromyalgia Rheumatoid Arthritis Ankylosing Spondylitis Diabetes (type) Bleeding tendency Epilepsy Psoriasis Goiter Other conditions: Osteoporosis Leukemia Cancer (list type) Stroke Colitis Heart Disease High blood pressure Alcoholism Rheumatic fever Asthma Tuberculosis SOCIAL HISTORY: Marital Status: Never Married Married Partner Separated Divorced Widowed Education (circle highest level attended): Grade School College Graduate School Occupation Number of hours worked/average per week Do you exercise regularly? No Yes Frequency Please describe Do you smoke? Never Current Previous Amount per day Age you started: Age you quit: Do you drink alcohol? No Yes Number per week Has anyone ever told you to cut down on your drinking? No Yes Do you drink caffeine? No Yes Cups/glasses per day? Chewing tobacco? Never Current Previous Amount per day Age you started : Age you quit: Recreational drug use? No Yes If yes please list Date of Birth:

5 Describe briefly your present symptoms: HISTORY OF PRESENT ILLNESS Date symptoms began (approximate): Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later) Please list the names of other practitioners you have seen for this problem: Diagnosis given: REVIEW OF SYSTEMS As you review the following list, please check any of those problems which have significantly affected you. Musculoskeletal Morning stiffness How long? Minutes Hours Joint pain Joint swelling List joints affected in the last 6 mos. Muscle weakness Muscle tenderness Muscle spasm Back pain Constitutional Exercise intolerance Fever or chills Night sweats Recent weight loss Amount Recent weight gain Amount Eyes Vision changes Double or blurred vision Redness Dryness Irritation Ears NoseMouth/Throat Difficulty hearing Ear pain Ringing in ears Frequent nosebleeds Sinus pain Dryness of mouth Difficulty swallowing Sores in mouth Teeth problems Bleeding gums Frequent sore throats Snoring Cardiovascular Chest pain Arm pain on exertion Light-headed upon standing Shortness of breath when laying Shortness of breath when walking Swollen legs or feet Color changes of hands in the cold Palpitations Sudden changes in heart beat Heart murmurs Respiratory Shortness of breath Cough Difficulty breathing at night Coughing of blood Wheezing (asthma) Gastrointestinal Nausea / Vomiting Abdominal pain Heartburn Diarrhea Constipation Vomiting blood Abnormal appetite Blood in stools Black/tarry stools Genitourinary Difficulty urinating Blood in urine Pain or burning on urination Cloudy urine Inability to empty bladder Loss of bladder control Increased urine frequency Genital rash/ulcers Date of last period? / / / Integumentary Thickness of skin Tightness of skin Rash Sun sensitive (sun allergy) Abnormal mole Jaundice Nail pits Neurological System Loss of consciousness Weakness Numbness or tingling in hands Numbness or tingling in feet Headaches Dizziness Fainting Seizures Psychiatric Sleep disturbances/restless sleep Feeling unsafe in a relationship Anxiety Panic attacks Depression Alcohol abuse Endocrine Excessive thirst Fatigue Hair loss Increased hair growth Cold Intolerance Hematologic/Lymphatic Blood clot in artery, vein, or lung Bleeding tendency Swollen glands Anemia Transfusion/when Allergic/Immunologic Frequent sneezing Increased susceptibility to infection Runny nose Sinus pressure Hives Itching Date of Birth:

6 Rheumatology Associates of North Texas, PA 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 Health Insurance Portability and Accountability Act (HIPAA) of 1996, revised in 2013, requires us as your health care provider to maintain the privacy of your protected health information, to provide you with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We are required to maintain these records of your health care and are dedicated to maintaining confidentiality. The Act also allows us to use your information for treatment, payment, and certain health operations unless otherwise prohibited by law and without your authorization. Treatment: We may disclose your protected health information to you and to our staff or to other health care providers in order to get you the care you need. This includes information that may go to the pharmacy to get your prescription filled, to a diagnostic center to assist with your diagnosis, or to the hospital should you need to be admitted. If necessary to ensure that you get this care, we may also discuss the minimum necessary with friends or family members involved in your care unless you request otherwise. Payment: We may send information to you or to your health plan in order to receive payment for the service or item we delivered. We may discuss the minimum necessary with friends or family members involved in your payment unless you request otherwise. Health operations: We are allowed to use or disclose your protected health information to train new health care workers, to evaluate the health care delivered, to improve our business development, or for other internal needs. We are required to disclose information as required by law, such as public health regulations, health care oversight activities, certain law suits and law enforcement. Certain ways that your protected health information could be used or disclosed require an authorization from you: use or disclosure for marketing purposes and disclosures or uses that constitute a sale of protected health information. We cannot disclose your protected health information to your employer or to your school without your authorization unless required by law. Other uses and disclosures not described in this notice will be made only with your written authorization, which you may revoke going forward in writing. You have several rights concerning your protected health information. When you wish to use one of these rights, please inform our office so that we may give you the correct form for documenting your request. You have the right to access your records and/or to receive a copy of your records. Your request must be in writing. We are required to allow the access or provide the copy within 30 days of your request. We may provide the copy to you or to your designee in an electronic format acceptable to you, or as a hard

7 copy. We may charge you our cost for making and providing the copy. If your request is denied, you may request a review of this denial by a licensed health care provider. You have the right to request restrictions on how your protected health information is used for treatment, payment, and health operations. For example, you may request that a certain friend or family member not have access to this information. We are not required to agree to this request, but if we agree to your request, we are obligated to fulfill the request, except in an emergency where this restriction might interfere with your care. We may terminate these restrictions if necessary to fulfill treatment and payment. We are required to grant your request for restriction if the requested restriction applies only to information that would be submitted to a health plan for payment for a health care service or item or for health operations, if you have paid for the item or service in full out of pocket, and if the restriction is not otherwise forbidden by law. For example, we are required to submit information to federal health plans and managed care organizations even if you request a restriction. We must have your restriction documented prior to initiating the service. Some exceptions may apply, so ask for a form to request the restriction and to get additional information. We are not required to inform other covered entities of this request, but we are not allowed to use or disclose information that has been restricted to business associates that may disclose the information to the health plan. You have the right to request confidential communications. For example, you may prefer that we call your cell phone number rather than your home phone. These requests must be in writing and may be revoked in writing and must give us an effective means of communication for us to comply. If the alternate means of communications incurs additional cost, that cost will be passed on to you. Your medical records are legal documents that provide crucial information regarding your care. You have the right to request an amendment to your medical records, but you must make this request in writing and understand that we are not required to grant this request. You have the right to an accounting of disclosures. This will tell you how we have used or disclosed your protected health information. You have the right to receive a copy of this notice, either electronic or paper. The copy may be provided electronically with your permission. If you have any questions about our privacy practices, please contact our Privacy Officer at the number below. You have the right to file a complaint with us or with the Office for Civil Rights. We will not discriminate or retaliate in any way for this action. To file a complaint, please contact the applicable party: Privacy Officer Phone number: Office for Civil Rights We are required to abide by the policies stated in this Notice of Privacy Practices, which became effective date: July 1,2013.

8 Rheumatology Associates of North Texas, P.A. PF-2000 Acknowledgement of Receipt of Notice of Privacy Practices Our practice reserves the right to modify the privacy practices outlined in the notice. Signature I have reviewed this office's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I undersand that I am entitled to receive a copy of your Notice of Privacy Practices. Name of Patient (Print or Type) Signature of Patient Date Signature of Patient Representative Relationship of Patient Representative to Patient Signature of Witness HIPAA Privacy Act Information Release Form Please mark below for release of information concerning your healthcare, does not include other physicians: Release information ONLY to me: Yes No Release information to other individual (spouse, parents, siblings, friends. Etc.): Name and relationship: Phone number: Name and relationship: Phone number: Name and relationship: Phone number: May we leave detailed information on answering machine? Home Cell Both None By signing this form you acknowledge that you have provided instructions regarding release of your individual healthcare information. Date Signature of Patient or Legal Guardian Date Patient Name

9 RHEUMATOLOGY ASSOCIATES OF NORTH TEXAS, PA OFFICE POLICIES Thank you for choosing and entrusting your medical care with Rheumatology Associates of North Texas!! GENERAL OFFICE POLICIES: Appointments: Patients are seen by appointment only. All patients need to arrive on time. If you arrive 15 minutes late, rescheduling will be necessary. We attempt to see our patients on time, however if you find yourself waiting, be assured it was unforeseen and have the confidence knowing we will give you the attention you deserve and need when we see you. We pride ourselves in being able to offer same-day appointments on an as needed basis, if requested early in the day. Patients are contacted by phone two days prior to their designated appointment times; this is to ensure open times for other patients that need to be seen. Notify our office 24 hours prior to your appointment avoid the late cancelation fee that is accessed. Office Hours: Our office hours are 9 A.M. to 5 P.M. Monday thru Friday. We are closed for lunch from 12:00 to 1:00pm and the usual holidays. All patients are encouraged to communicate all concerns to the physician through the patient portal, however a physician is available 24 hours a day for urgent matters, please just phone the office and follow the prompts. When leaving a phone message, please leave a call back number that will accept a blocked number call. Terminating Relationship: Unfortunately, it is sometimes necessary to terminate the patient/physician relationship. We reserve the right to discharge you from our practice, if you fail to comply with any of our policies. We will provide written notice of the termination and comply with the regulations stipulated by the Texas Medical Board. FINANCIAL POLICIES: Insurance Cards: You will be asked to present your insurance card at every visit. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the full amount of the services. Upon your insurance changing, please notify the staff, so your new benefits can be verified, and there will be no extra wait time at your next appointment. Benefits: Insurance benefits can be confusing. Our office will attempt to be as knowledgeable as possible regarding your plan; however, it is ultimately your responsibility to know your benefits including limitations and exclusions, since you are responsible for final payment. If you have any questions regarding your benefits, including covered services, deductibles, maximum benefits, please contact the insurance administrator of your employer or your insurance company. Payments: All payments, including copays, co-insurance and deductibles, are due at the time of service, or you will be asked to reschedule your appointment. We accept all forms of payment with the exclusion of American Express. A 25 service fee will be charged for a returned check due to insufficient funds.. Insurance Payments: When billing your insurance, WE ARE NOT responsible for negotiations of a disputed claim. Billing your insurance does not guarantee payment by the insurance company and does not release the responsible party from their financial obligation. When billing your insurance, we may request addition information from you, it is extremely important to get a speedy response. In the case of an insurance partial payment or denial, the balance will be billed to the responsible party. A billing statement will be mailed out once the claim has been adjudicated. Patient balances over 90 DAYS, are subject to be sent to collections, unless payment arrangement are made in advance. A 50 fee will be added to all account balances placed in collections.

10 HMO/POS: You are required to obtain a referral from your Primary Care Physician (PCP) before your appointment. This is a requirement by your insurance carrier. If not carried out the claim will be denied, and you will be responsible for the full cost of the services.. Responsible Party: If the patient is incapacitated, the guardian bringing the patient to the appointment is responsible for all co-payments, co-insurances, and outstanding balances. We will provide a receipt of the payment in order for any proof is necessary. TREATMENT: Treatment is solely based on medical necessity determined by your physician. There may be procedures and labs ordered that are not covered under your insurance plan. It is not our responsibility to verify all treatment is covered before it is provided. Referrals: If a referral is needed for another specialty, we will alert you and send the referral directly to the referring physician. We request if you have not been contacted in one week, you contact the office and we will follow up on the status of the referral and make sure you are scheduled. Hospitalization: Our physicians do not have admitting privileges to the hospital. Medication Policy: Patients must supply a list of all medications they are currently taking, including prescription and non-prescription, along with the dosage. The signature below will grant Rheumatology Associates of North Texas the permission to access your medication history from local pharmacies and hospitals. The information will be used for the purpose of managing your prescriptions safely, avoiding duplications, and any adverse medical reactions. Refill Policy: Notify your pharmacy of the refill request. Have all request faxed to Refills are only granted for medication our physicians prescribe. Prescriptions are not refilled after hours, weekends or holidays. We urge you to please plan accordingly. Be aware a refill of a prescription may prompt a call for an appointment to be scheduled for the management of your condition and the monitoring of your medication. This is solely determined by the prescribing physician. Controlled Substance agreement must be signed, if such medications are prescribed. Thank you for choosing Rheumatology Associates of North Texas, PA. Please advise our staff if you would like a copy of this document for your personal record.. Patient/Legal Guardian Signature Date Print Name

11 Rheumatology Associates of North Texas Medical Records and Forms Our office follows the rules set forth by the Texas Medical Board when preparing and furnishing medical records. A charge for the first twenty pages and.50 per page for every copy thereafter is what they consider to be a reasonable fee. This includes the cost of copying and postage. Payment must be made prior to the release of the records. We ask that you allow 15 business days to process this from the date of the written request. All records require signed authorization from the patient. We charge a flat fee of for completion of FMLA and disability paperwork. We charge for completion of handicap parking placard forms. There is no charge to send records to your primary physician or other physician at your request with prior authorization signed by you. If you require a form or letter to be completed by the physician (other than excuse notes) a 48 hour notice is required. There will be a charge for this service. Thank you for choosing Rheumatology Associates of North Texas, P.A. Please let the receptionist know if you would like a copy of this for your records.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!" " " " " "!!!!!!!!!!!!!!!!!" Patient/Legal Guardian Signature Date "!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!" Print Full Name

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