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1 DUS Family Medical Practice, LLC 7525 Greenway Center Drive, Suite # 105 Greenbelt, MD Phone: (301) Fax: (301) Patient s Last Name: First Name: MI: Address: City: State: Zip Code: Birth Date: Sex (M/F): Marital Status: S M D W Home Phone: Social Sec #: Cell Phone / Best Number To Reach You: Your address: Race: C AA Asian Other Emergency Contact: Phone #: = = = = Primary Insurance Coverage = = = = = = = = = = = = = = = = = Secondary Insurance Coverage = = = = Insurance Name: Insurance Name: Insured Name: Insured Name: Relationship: DOB: Member ID #: Relationship: DOB: Member ID #: Copay: Copay: Group #: Employer: Group #: Employer: = = = = = = = = Guarantor Information (must fill in for all patients 17 years and younger) = = = = = = = = = = = Guarantor Name: Relationship: Address: City: State: Zip: DOB: Social Sec #: Phone #: PATIENT S AUTHORIZATION: I authorize DUS Family Medical Practice, LLC to apply for benefits on my behalf for services rendered by DUS physicians. I request payment from my insurance company be made directly to DUS Family Medical Practice. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of this authorization to be used in the place of the original. This authorization may be revoked, by me, at any time in writing. I understand that nothing herein relieves me of the primary responsibility and obligation to pay for medical services provided, when a statement is rendered. Patient or Guarantor Signature Date

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4 7525 Greenway Center Dr Dr. Zahra Ahmed, MD Suite 105, Greenbelt, MD Dr. Sufia Syed, MD T: Dr. Fariha kamran, MD F: Dr. Lutfunnessa Shafi, MD DUS FAMILY MEDICAL PRACTICE Patient Financial Responsibility Disclosure Statement Your signature below forms a binding agreement between DUS Family Medical Practice (DUSFMP- the provider of medical services) and the patient who is receiving medical services or the Responsible Party for minor patients (those patients under 18 years old). Responsible party is the individual who is financially responsible for payment of medical bills. All charges for services rendered are due and payable at the time of service. MEDICAL INSURANCE: we have contracts with many insurance companies, and we will bill them as a service to you. As the responsible party, you are responsible if your insurance company declines to pay for any reason. The person signing on behalf of the Patient as the Responsible Party must: Inform DUSFMP of the current address and phone number for the patient and the responsible party. Present all current insurance cards prior to each office visit. Verify at each visit that the information is current by signing our data sheet. Pay any required copay at the time of the visit. Pay any additional amount owing within 30 days of receiving a statement from our office. (When DUSFMP receives an explanation of benefits (EOB) from your insurance company, any amounts that you need to pay will be billed to you). Returned Check Policy If payment is made on an account by check, and the check is returned as Non-sufficient Funds (NSF), Account Closed (AC), or Refer to Maker (RTM), the patient or the Patient s Responsible Party will be responsible for the original check amount in addition to a $25.00 service charge. Once notice is received of the retuned check, DUSFMP will send out a letter to notify the Responsible Party of the returned check. If a response is not made within 15 days from the letter date by the Patient of the Responsible Party, the account may be turned over to our collection agency and a collection fee will be added to the outstanding balance- in addition to the $25.00 Check Service Charge. Non-Payment on Account Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or the patient s Responsible Party, understands that DUSFMP has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The patient, or the patient s Responsible Party, understands that they are responsible for all costs of collection including, but not limited to court costs and Attorney fees, and a collection fee will be added to the outstanding balance. By signing below you agree to accept full financial responsibility as a patient who is receiving medical services or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms. Patient Name (please print) Patient Signature Date Responsible Party Name (please Print) Responsible Party Signature Date

5 DUS-Family Medical Practice. HIPAA NOTICE OF PRIVACY PRACTICE 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 Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health operations and other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information that may identify you and that related to your past, present or future physical or mental health or condition and related health care services. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION: Your protected health information that may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician s practice and any other use required by law. TREATMENT: We will use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your healthcare 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. For example, your protected healthcare information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. PAYMENT: We may use and disclose health information about you so that the treatment and services you receive from us may be billed to and payment collected from you, an insurance company or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us for your visit. We may also tell your health plan about your treatment you are going to receive to obtain prior approval or to determine you plan will cover the treatment. HEALTHCARE OPERATIONS: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician s practices. These activities include, but are not limited to, quality assessment activities, employee review activities, and training of medical students, licensing and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues are required by law, communicable diseases, health oversight, abuse or neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors & Organ Donation: Research: Criminal Activity and National Security: Workers Compensation: Inmates: Required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician s practice has taken an action in reliance on the use of disclosure indicated the authorization. YOUR RIGHTS: Following is a statement of your rights with respect to your protected health information You have the right to inspect and copy your protected health information: Under federal law, however, you may not inspect or copy the following records, psychotherapy: information compiled in reasonable anticipation of, or use in, civil, criminal, or administrative section or proceeding and protected health information that is subject to law prohibits access to protected health information. You have the right to request a restriction of your protected health information: This means that you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Our physician is not required to agree to restriction that you may request. If physician believed it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional. You have the right to receive confidential communication from us by alternative means or at any alternative location: You have the right to obtain paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You have the right to receive an accounting of certain disclosures we have made, if any of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by verifying our privacy contract of complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before April 14, We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number. The signature below is only acknowledgement that you have received this Notice of our Privacy Practices: Patient s Name: Signature: Date:

6 DUS Family Medical Practice, LLC 7525 Greenway Center Drive, Suite # 105 Greenbelt, MD Dear Patients, In order to provide optimal care to you, we expect you to make it to your appointment. Regrettably, if you have two consecutive no shows, you will be discharged from our practice. Our office appointments are very important to our patients. We require a minimum of 48 hours notice for all cancelled appointments. Please allow 2 3 working days for all prescription requests to be completed. Prescription requests will be taken during business hours only. Do not call after hours or on weekends for prescription requests. Please allow 7 10 business days for any kind of forms to be filled out. There will be a fee of $35.00 for filling the forms, which will be collected when you drop them off. This is because the doctors take time out of their schedule to fill these forms. For the release of medical records please allow 21 working days. There will be a fee charged depending on how many pages need to be copied or faxed. PRIOR PAYMENT IS REQUIRED FOR THESE SERVICES. There are no exceptions for these office policies. Thank you. Print Name Patient s signature: Date:

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