KNEE CENTER OF WESTERN NEW YORK ORTHOPEDIC CARE AND SURGERY

Patient Demographic Information (Please print and fill out completely) Acct #:

pg 1 of 7

Name:

Address:

Home Phone:

Pharmacy Name/Location:

Email address:

Sex: • Male • Female

Date of Birth:

Work Phone: Cell Phone:

Phone

SS#

Race: • Caucasian • African American • Native American • Asian • Hispanic

Ethnicity: • Hispanic/Latino • Non-Hispanic

Insurance Information Primary Insurance Insurance ID # Policy Holder Name(skip if same as patient):

• Declined Language,

Group: DOB

Secondary Insurance: Insurance ID#

Policy Holder Name (skip if same as patient):

Employer: Address:,

Group:

DOB

Phone:

Is this injury Work Related: • Yes • No WC Ins Carrier Address Carrier Case #:.

WCB Case #:

Motor Vehicle Accident: • Yes • No Date of Accident Policy #

Claim #

_Comp phone #. Fax#

Location of Injury/Body Part_

Responsible Party • (if same as patient, check and skip to next section)

Name Date of Birth SSN

Address (Street) (City)

Home Phone

(State)

Cell Phone

(Zip)

Work Phone

Spouse/Significant Other Name_ Date of Birth

Emergency Contact/HIPPA Contact,

Address

Phone

.Relationship to Patient_

Account #

pg 2 of 7

K N E E C E N T E R O F W E S T E R N NEW Y O R K O R T H O P A E D I C C A R E & S U R G E R Y

FINANCIAL P O L I C Y & INSURANCE W A I V E R

We are committed to providing you with the best care, and in return, expect full and prompt payment for our services. Your clear understanding of the following policies and your responsibility is important to our professional relationship:

- Copayments are due at the time of service. - Our office requires a 24 hour notice when cancelling an appointment, otherwise a $50.00 fee may be charged to your

account. - We participate in most insurance plans. However, insurance is primarily a contract between you and your carrier. We must

comply with the rules and regulations of your policy. Therefore, any balance due, per your carriers notification, is your respnonsibility. Please be aware of your covered benefits.

I UNDERSTAND THAT THE KNEE CENTER OF WNY M A Y NOT ACCEPT M Y INSURANCE AND THAT IT IS M Y RESPONSIBILITY TO VERIFY WITH M Y HEALTH INSURACE WHETHER OR NOT THE KNEE CENTER OF WNY IS A PARTICPATING PROVIDER. I HEREBY AGREE TO PAY THE FULL AMOUNT OF MY OFFICE VISIT/SURGERY AT THE TIME OF SERVICE IF THEY ARE A NON-PARTICIPATING PROVIDER. FOR YOUR CONVENIENCE, WE ACCEPT MASTER CARD, VISA AND DISCOVER CARD FOR PAYMENT OF ALL CHARGES.

RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS I have reviewed & understand the above financial policy & agree with the stated terms. I also authorize direct payment of medical benefits to the Knee Center of WNY, PC & the release of medical infontiation necessary for treatment, payment & healthcare operations.

SIGNED: . DATED:

It has been explained to me that the Knee Center of WNY may not participate with my health insurance plan. I understand that it is my responsibility to verify with myh health insurance whether or not the Knee Center of WNY is a participating provider. I hereby agree to pay the full amount of my office visit/surgery at the time of service i f they are a non-participating provider. I understand that any balance that has not be satisfied at the time of service will be due immediately upon receipt of my first statement. I f payment is not received or other affagnements are not made, further collection activity will commence.

PATIENT INSURANCE WAIVER

SIGNED: DATED:

M I C H A E L A. PARENTIS, M.D. Breanne Finucane, RPA-C

Matthew Mazurczak, RPA-C

K E I T H C. STUBE, M.D. Allison Nixon, RPA-C

Jeffrey Rassman, RPA-C

NORTHTOWNS 180 PARK CLUB LANE, STE 225

WILLIAMSVILLE, NY 14221 (P) 716-839-5858

SOUTHTOWNS 3712 SOUTHWESTERN BLVD. ORCHARD PARK, NY 14127

(P) 716-508-8252

Name; DOB: Acct:

pg3 of?

K N E E C E N T E R O F W E S T E R N NEW Y O R K ORTHOPAEDIC CARE & SURGERY

Acknowledgement of Receipt of Notice of Privacy Practices

By my signature below, I hereby acknowledge receipt of the Notice of Privacy Practices:

Signature: Date:

Medical Information Release Form (HIPAA Release Form)

Name: Date of Birth: / /

Release of Information

• I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: • Spouse • Child(ren) • Other • Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing.

Signed: Date: I I

M I C H A E L A. PARENTIS, M.D. Breanne Finucane, RPA-C

Matthew Mazurczak, RPA-C

K E I T H C . STUBE, M.D. Allison Nixon, RPA-C

Jeffrey Rassman, RPA-C

NORTHTOWNS 180 PARK CLUB LANE, STE 225

WILLIAMSVILLE, NY 14221 (P) 716-839-5858

SOUTHTOWNS 3712 SOUTHWESTERN BLVD. ORCHARD PARK, NY 14127

(P) 716-508-8252

DOCTOR POLICY-PA TIENT COPY

ACCOUNT #

p g 4 o f 7

*YOU WILL NOT BE SEEN WITHOUT AN UPDATED REFERRAL IF ONE IS REQUIRED BY YOUR INSURANCE COMPANY. IF WE DO NOT HAVE A REFERRAL, YOUR APPOINTMENT MAY BE RESCHEDULED. IT IS YOUR RESPONSIBILITY TO CALL YOUR MEDICAL DOCTOR TO OBTAIN A REFERRAL.

•CO-PAYMENTS ARE DUE AT THE T I M E OF APPOINTMENT. WE DO ACCEPT CASH, CHECK, OR CHARGE (MASTER CARD, VISA, AND DISCOVER CARD)

*IF YOU ARRIVE MORE THAN 15 MINUTES LATE, YOUR APPOINTMENT WILL BE RESCHEDULED TO THE NEXT AVAILABLE APPOINTMENT. NO EXCEPTIONS!

•IF YOU NEED TO CANCEL YOUR APPOINTMENT, WE REQUIRE A 24-HOUR NOTICE OR YOU W I L L BE CHARGED A $50.00 NO SHOW FEE. THERE IS A $250.00 NO SHOW FEE FOR SURGERY.

•IF YOU FAIL TO SHOW UP FOR 2 SCHEDULED OFFICE APPOINTMENTS WITHOUT CANCELLING, WE WILL BE UNABLE TO CONTINUE YOUR CARE.

• A L L MEDICATION REFILLS CALLED IN ,\FTER 4PM ON THURSDAYS WILL BE FILLED THE FOLLOWING MONDAY. IT IS YOUR RESPONSIBILITY TO PLAN ACCORDINGLY.

•IF YOU ARE WAITING FOR A RETURN CALL FROM A PHYSICIAN, THIS WILL BE HANDLED AS QUICKLY AS POSSIBLE. NON-EMERGENT CALLS WILL BE RETURNED AFTER OFFICE HOURS IN MOST CASES. ROUTINE CALLS SHOULD BE MADE DURING BUSINESS HOURS.

•OUR OFFICE IS OPEN MONDAY THRU FRIDAY SAM TO 4PM. CALLS MADE AFTER HOURS OR ON WEEKENDS ARE FOR EMERGENCIES ONLY. IF YOU HAVE A CALL BLOCK ON YOUR PHONE, PLEASE TURN IT OFF SO OUR PHYSICIANS MAY RETURN YOUR CALL.

•WE APOLOGIZE FOR OUR PROLONGED WAIT TIMES, BUT WE OFTEN SEE A LARGE NUMBER OF UNSCHEDULED PATIENTS DUE TO EMERGENCIES. ALTHOUGH UNUSUAL, WAIT TIMES CAN BE UP TO 2 HOURS, PLEASE PLAN YOUR DAY ACCORDINGLY.

DISABILITY PATIENTS

THERE IS A $10.00 FEE FOR DISABILITY FORMS TO BE FILLED OUT. THE PAPERWORK WILL NOT BE COMPLETED UNTIL THE FEE IS RECEIVED. PLEASE DO NOT ASK THE PHYSICIAN TO FILL FORMS OUT DURING OFFICE VISITS. FORMS ARE DONE ON A FIRST COME FIRST SERVED BASIS. WE M A Y REQUIRE UP TO 10 DAYS TO PROCESS PAPERWORK.

FINANCIAL POLICY

WE ARE COMMITED TO PROVIDING YOU WITH THE BEST CARE AND I N RETURN EXPECT FULL AND PROMPT PAYMENT FOR OUR SERVICES. YOUR CLEAR UNDERSTANT)ING OF THE FOLLOWING POLICIES IS IMPORTANT TO OUR PROFESSIONAL RELATIONSHIP. Knee Center of Western New York

p g 5 o f 7

Keith Stube MD Jeffrey Rassman RPA-C Allison Nixon RPA-C

Michael Parentis M D Matthew Mazurczak RPA-C Breanne Finucane RPA-C

180 Park Club Lane, Suite 225, WiUiamsville, NY 14221 716-839-5858 3712 Southwestern Boulevard, Orchard Park, NY 14127 716-508-8252

HIPP A-Your Health Information is Protected by Federal Law

What Information is Protected? -Information your doctors and other health care providers put in your medical record. -Conversations your doctor has about your care or treatment with others. -Information about you in your health insurers computer system. -Billing information about you from your clinic/healthcare provider. -You decide i f you want to give permission before your health information may be shared. - I f you believe your health information isn't being protected, you can:

File a complaint with your health care provider or health insurer File a complaint with the US Government

-You can ask your provider or health insurer questions about your rights.

Providers and health insurers are required to follow this law and must keep your information private by: -Teaching people who work for them how your information may and may not be shared. -Taking appropriate and reasonable steps to keep your health information secure.

To make sure your information is protected in a way that does not interfere with your healthcare, you information can be used and shared:

-For your u-eatment and care coordination. -To pay doctors and hospitals for your healthcare. -With family, friends or others you identify who are involved with your healthcare.

For more information: http://www.hhs.gov/ocr/privacy/hippa/understanding/consumers/index.html

KNEE CENTER OF WNY

Name: Age: Height.

Date of Birth: Weight

MEDICAL HISTORY FORM pg 6 of 7

Date: Account #

Primary Care Physician. Main Complaint:

Referred by_ • Left • Right

Location of Pain: Severity DO D l 02

(least) What causes the pain?

• 3 0 4 05 ne nv ae • 9 010 (most)

Pain Duration Current Problem • No Pain • Started Today • Started Yesterday • For a While Days Wks Mos_ Yrs

Pain Quality • No Pain

• Burning • Sharp

• Sore • Stabbing

• 6 Pain Severity

• 1 (none) • 2 ^ 7

• 3 • 4 • Q • 5(moderate) • 10(severe)

P8

Aggravates your Pain • Activity • Bending • Moving

Pain Timing • Continuous • Intermittent • Occasional • Worse at night • Worse w/activity Associated symptoms: •Catching •Giving Out •Popping • Spasms •Stiffness

Alleviates your Pain • Anti-inflammatory • Rest • Heat

• Ice

List any allergies you have to drugs, food or other items:.

Past Medical Problems:

• no known drug allergy

Past Surgical History Operations Performed

REVIEW OF SYSTEMS Gastrointestinal (Gl) • Abdominal Pain • Diarrhea • Nausea • Vomiting • Reflux

Neurologic • Blackouts • Fainting • Headaches • Tingling

Year Hospital

Cardiovascular • Chest Pain • Fainting • Leg Swelling • Ankle Swelling • Exercise Intolerance

Respiratory • Difficulty Breathing • Cough • Congestion • Wheezing

Attorney Name:. Work Related? DYes DNo Uwsuit? DYes DNo Occupation: List prior Job if retired Marital Stams • Single • Married • Widowed • Divorced Do you smoke? DYes DNo Packs per day #years smoked Do you drink alcohol DYes DNo #Drinksperday

Doctor

Musculosketal • Muscle Cramps • Stiffness • Back Pain • Joint Pain • Joint Swelling

Blood/Lymph • Easy Bleeding • Excess Bleeding • Enlarged Lymph • Easy Bruising

# of children, if quit, when

KNEE CENTER OF WESTERN NEW YORK MEDICATION LIST pg7of7

Medication List

Name:

ACCOUNT # Are you currently taking any medications?

If yes, please list below:

• Yes • No

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often

Name Dosage How Often