PATIENT INFORMATION. Male Female ( ) / / Street Address / P.O. Box: City: State: Zip Code:

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1 Today s : PATIENT INFORMATION Patient s Last Name: First: Middle: Mr. Miss Mrs. Ms. Dr. Home phone no.: Cell phone no.: Work phone no.: Birth : Marital Status (check one) Single Separated Married Widowed Divorced Domestic Partners Age: Sex: Male Female / / Street Address / P.O. Box: City: State: Zip Code: Address: Social Security no.: Drivers License no. Weight / Height Ethnicity: African American Asian Caucasian Hispanic Hispanic or Latino Native American Patient Declined Unknown Other: Race: American Indian or Alaska Native Asian Black or African American Patient Declined Native Hawaiian or Other Pacific White Unknown Other Race : Preferred Language: English Spanish Chinese (Mandarin) Chinese (Cantonese) French German Russian Japanese Italian Portuguese Unknown Patient Declined Preferred Contact Method: Home Phone Cell Phone Mail to Home Address Referring Physician Primary Care Physician Name: Name: Address: Phone: ( ) Address: Phone: ( ) Found us by: Primary Care Physician Other Physician Insurance Plan Hospital Family Friend Web Other PHARMACY Pharmacy Name: Phone: ( ) Address: Fax: ( ) Employer Name: INSURANCE INFORMATION (Please give your insurance card(s) to the receptionist.) Employer Phone no: Name of Insured (if different from patient) Last Name: First: Middle: Address (if different from patient): Home phone no.: Cell phone no.: Birth : Social Security no.: Relationship to patient: / / IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Phone:

2 CURRENT MEDICATIONS (Please list ALL medications you currently take, please include the frequency, dosage and medical condition.) Check this box if you are providing an attached list of medications Name of Medication / Dosage/Frequency: Condition(s): 1. for 2. for 3. for 4. for 5. for 6. for Please list any Vitamins, Dietary Supplements or Herbal health products: ALLERGIES (Please include any medications, latex, foods, shellfish, tape products, or other solutions.) Allergy: Reaction(s): SURGICAL HISTORY (Please list any prior surgeries/and or hospitalization along with any complications.) SURGERY/HOSPITALIZATION YEAR COMPLICATIONS (IF ANY) Reviewed by MD/Initials

3 MEDICAL HISTORY AND REVIEW OF SYSTEMS (Have you had or are you currently having problems with the following?) PROBLEMS Arthritis/Joints Bleeding problems/ Blood transfusions Bone/Muscle Cancer Diabetes Digestion/GI problems: Ulcers; Diverticulitis; etc. Ears, Nose, Throat Epilepsy/Seizures Eyes/ Glaucoma Fainting/Blackouts Gout Hayfever/Allergies Heart: attack; chest pain; irregular rhythms; palpitations; murmur; valve disorder; stenting or bypass Hepatitis High Blood Pressure HIV/AIDS Kidney/Bladder problems Liver disease Loss of balance/dizziness Lungs/Respiratory, Asthma or breathing problems Numbness/Tingling Polio/ Rheumatic fever Prostate problems Psychological problems Skin/Breast Problems Thyroid (hypo or hyper) Describe all YES responses FAMILY HISTORY (Please list history of diseases including any related to your current problem including arthritis or other musculoskeletal problems.) Mother Father Sister/Brother Sister/Brother Other FAMILY MEMBER ALIVE DISEASE HISTORY SOCIAL HISTORY Occupation: Employer: last worked: Exercise? >3 days/wk <3 days/wk occasionally never Type: Special Diet? Describe: Smoke Status? Never Smoker Current every day smoker # packs per day for yrs; Former Smoker Quit yrs ago, Current someday smoker Smoker current status unknown Unknown if ever smoked Patient advised / informed of smoking risk: Drink Alcohol? If yes, how often and amount? History of substance abuse? What? Reviewed by MD: Initials

4 INSURANCE RESPONSIBILTY No I understand that I am responsible for payment of ALL charges not paid by the insurance company / companies. I request that payment of authorized benefits be made on my behalf to Megan M Wood, M.D. for any services, Including therapy, rendered at Dallas Hand Center. No I understand that if my insurance company applies my claim towards any deductible, I will be responsible for this balance as detailed in the insurance company explanation of benefits (EOB). No I understand that if my insurance company denies my claim, I will be responsible for this balance as detailed in the insurance company explanation of benefits (EOB). No I understand that I am responsible for any co-payments and/or coinsurances, and that payment is due at time of services. No I understand the policy of this office is to allow 90 days for insurance settlement, at which time payment is expected, and I remain responsible for my account. I understand that I am responsible for fees incurred if my account is transferred to a 3 rd party collection service. Authorization for charges I hereby authorize Megan M Wood, M.D.,. to charge credit card for overdue balance less than $300.xx Mastercard Visa Number: Expiration / _20 CCD (Security code) : Acknowledgement and Authorization to Treat I hereby acknowledge that the information given is true to the best of my knowledge and I understand the Terms and Agreements made with Dallas Hand Center / Megan M Wood, M.D. / Nicole White, OTR I,, Legal Guardian/ Parent/ Self, authorize medical treatment by Dallas Hand Center / Megan M Wood, M.D. / Nicole White, OTR (Print Name) Signature of Patient / Guardian Patient Consent for Release of Confidential Medical Information Please list below the names of the person/persons to which we may release your Medical Health Information. Name / Relationship: I,, Legal Guardian/ Parent/ Self, authorize release of my Medical Health Information to my PCP and/or Referring Physician. I agree to be contacted by Cell phone / text voic / message Signature of Patient / Guardian

5 Today s : Patient name: Chief Complaint What is your chief complaint? Which side is affected? Right Left Bilateral Please choose: Work related Automobile accident Home Sports Other Is this an injury? Yes No If yes, what is the date of accident / injury / onset: Is this a chronic problem? Yes No If yes, how long have you been having this problem: Have you been treated for this complaint? Yes No If yes, by whom and what treatment have you received? What is your current pain level?: What was your maximum pain level?: Describe your injury and/or the symptoms you are experiencing (may be used for processing of insurance claims) : Do you think a third party will be liable for this injury? Lawsuit / litigation Pending? If yes, please provide name, address and telephone number: To my knowledge the information I have provided to Megan M Wood, M.D. is true and correct. Patient Signature Signed

6 : Name: Notice of Privacy -- HIPPA This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your PHI, which is information about you, including demographics, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Your PHI 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, paying your health care bills, supporting the operation of our practice, and any other use as required by law. Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party such as physician to whom you have been referred, an anesthesia provider, or a home health care agency. Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant HI be disclosed to your health plan. Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of our practice, such as quality assessment, employee review, physician training, licensing, and conducting or arranging for other business activities. For example, we may call you by name in the waiting room. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may use or disclose your PHI, without your authorization, in the following situations: As Required By Law, Health Oversight, Research, Public Health Issues, Communicable Diseases, Abuse or Neglect, FDA Requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Criminal Activity, Military Duty, National Security, Workers Compensation, Inmates and any other required uses and disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with Section Other permitted and 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 our practice has taken an action in reliance on the use or disclosure indicated in the authorization. You have the right to inspect and copy your PHI. However, under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in anticipation of or use in civil, criminal, or administrative action or proceeding; and PHI that is subject to law that prohibits access to PHI. You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your PHI not be disclosed to family 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. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in you best interest to permit use and disclosure of your PHI, it will not be restricted. You then have the right to use another physician. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us. You may have the right to have your physician amend your PHI. If we deny your request for amendment, you have the right to file a statement of disagreement with us, and we may prepare a rebuttal to your statement and will provide you a copy. You have the right to receive an accounting of certain disclosures we have made of your PHI. 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. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint by notifying our Private Officer. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of PHI and provided individuals with this notice of our legal duties and privacy practices with respect o PHI. If you have any objections to this notice, please ask to speak with our Privacy Officer. This notice became effective on October 1, Acknowledgement of Receipt of Notice of Privacy Practices I acknowledge that I have received the Notice of Privacy Practices from Dallas Hand Center / Megan M Wood, M.D. Signature of Patient / Guardian Print Name of Patient / Guardian