Once again welcome to our office!

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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 SK\VLFLDQ¶VRIILFH; 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 $40.00.

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RHEUMATOLOGY ASSOCIATES OF NORTH TEXAS, PA

REGISTRATION FORM (Please Print)

4461 Coit Rd., Suite 402 ΠFrisco, TX 75035-0521 Π(214) 297-0099 ΠFax (214) 297-1102

PATIENT INFORMATION Legal name:

Last: First: Middle:

Gender: M / F

ˆ Mr. ˆ Mrs. ˆ Miss/ Ms.

Marital Status (circle one): Single Widowed Married Partner Divorced Separated Do you want access to

your records online? Email address: Birthplace: Date of Birth: Age: SSN: ˆ Yes

Secure

ˆ No

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:

Phone number:

Name of Primary Care Physician:

PCP Phone number:

Name of Orthopedic Surgeon:

6XUJHRQ¶V3KRQe number:

IN CASE OF EMERGENCY

Name of local friend or relative: Relationship to patient: Phone number:

INSURANCE INFORMATION

(Please give insurance card to the receptionist) Primary Insurance Company Name:

6XEVFULEHU¶V1DPH Relationship to patient: Date of Birth: / /

Group Number: Policy Number: Co-payment: $

Name of secondary insurance (if applicable):

6XEVFULEHU¶V1DPH Relationship to patient: Birth Date: / /

Group Number: Policy Number: Co-payment: $

Name of person responsible for bill: Relationship to patient: Phone number: $GGUHVVRISHUVRQUHVSRQVLEOHIRUELOO LIGLIIHUHQWWKDQWKHSDWLHQW¶V 

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.

_____________________________________________________ ______________________________________

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3DWLHQW¶V1DPHBBBBBBBBBBBBBBBBBBBBBB________________ Date of Birth: _______________________________ - 1 -

Rheumatology Associates of North Texas, PA

4461 Coit Road, Suite 402

Phone (214) 297-0099

Fax (214) 297-1102

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 ˆAlcoholism ˆ/XSXVRU³6/(´ ˆChildhood arthritis ‰Epilepsy ˆGoiter ˆRheumatoid Arthritis ‰Psoriasis ˆMigraines ˆAnkylosing Spondylitis ‰Colitis ˆUnspecified Arthritis ˆOsteoporosis ‰Iritis/Uveitis ˆOsteoarthritis ˆChronic fatigue syndrome ‰Sarcoidosis ˆGout ˆFibromyalgia

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3DWLHQW¶V1DPHBBBBBBBBBBBBBBBBBBBBBB________________ Date of Birth: _______________________________ - 2 -

Previous Operations/ Surgical History

Type Year Reason

1. 2. 3. 4. 5. 6.

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 LVRQ\RXUPRWKHURUIDWKHU¶VVLGHRIWKHIDPLO\

Condition Relationship Condition Relationship

Unspecified arthritis Chronic fatigue

Osteoarthritis Osteoporosis

Gout Leukemia

/XSXVRU³6/(´ Cancer (list type)

Fibromyalgia Stroke

Rheumatoid Arthritis Colitis

Ankylosing Spondylitis Heart Disease

Diabetes (type) High blood pressure

Bleeding tendency Alcoholism

Epilepsy Rheumatic fever

Psoriasis Asthma

Goiter Tuberculosis

Other conditions:

SOCIAL HISTORY:

Marital Status: ‰Never Married ‰Married ‰Partner ‰Separated ‰ Divorced ‰Widowed

Education (circle highest level attended):

Grade School 7 8 9 10 11 12 College 1 2 3 4 Graduate School _____________________________

Occupation ________________________________________ Number of hours worked/average per week ___________________

Do you exercise regularly? ެNo ެYes Frequency________________ Please describe _______________________

Do you smoke? ˆNeverˆCurrentˆPrevious 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? ˆNever ˆCurrent ˆPrevious Amount per day______ Age you started :______ Age you quit:_______

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3DWLHQW¶V1DPHBBBBBBBBBBBBBBBBBBBBBB________________ Date of Birth: _______________________________ - 3 -

HISTORY OF PRESENT ILLNESS

Describe briefly your present symptoms:

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 ˆ 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

ˆInability to empty bladder ˆLoss 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 ˆFeeling 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

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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.

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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: 214-297-0099

Office for Civil Rights http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

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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 Date

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.

___________________________________

______________________

Signature of Patient or Legal Guardian

Date

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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

$40.00 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..

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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 VWDII¶Vresponsibility 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:

x Notify your pharmacy of the refill request. Have all request faxed to 214-297-1102.

x Refills are only granted for medication our physicians prescribe.

x Prescriptions are not refilled after hours, weekends or holidays. We urge you to please plan

accordingly.

x 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.

x 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

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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 $25.00 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 $35.00 for completion of FMLA and disability paperwork.

We charge $15.00 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 $35.00 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.

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Patient/Legal Guardian Signature

Date

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