P A T I E N T R E G I S T R A T I O N AND A U T H O R I Z A T I O N

Naiiio; Dale of Birth:

Addix'ss:

<ilv: Slate: Zip:

icicpiioiK ' /Home: Cell: Work:

l.iiKTtieney Contact/Name; Telephone:

limp I oyer; PalienI Social Seciirily Number:

I hereby aiiihorize dirccl paymcnl o f medical bencfiis lo Lniversily Neurology Inc. for services rendered. I niutcrsiand llial I am financially responsible for any balance not covered by my insurance provider. 1 agree lo pay all attorney fees, court costs and interest i f my bill is turned over for collection, 1 authorize that this office may use and disclose personal health information for paynicni purposes.

1 hereby authorize University Nciiroloyy Ine. to release any medical or incidental information that may be necessary for cither medical care or in processing applications for financial bciicllts.

I hereby authorize L'niversit> Neuroloyy Inc. office slatTto confirm an appointment by lclcplu>ne or answering machine. I f an appointment needs to be rescheduled and the staff cannot contact you by telephone, wc wi l l send appointment information out via U.S. Mail .

I authorize University Neuroloyy Inc. or other health professionals in this office to discuss a paiicnt's condition o\'cr llic telephone with such palicnt or an immediate family member.

I certify that the information given by me in applying for payment is correct, I authorize release of all records on request. I request that payment o f authorized benefits be rnade on my behalf

University Neurology Inc. requires a 24 hour notice lo cancel an appointment. Patient wi l l be charged $100.(H) should a 24 hour notice not be given.

University Ncurolojiy Inc. w i l l charge patients a $100.00 no show fee.

A photocopy of these assignments shall be valid as the original.

Signature; Date;

University Neurology, Inc. 725 Reservoir Avenue, Suite 308, Cranston, Rl 02910

401.944.9559 tel 401.244.7118 fax Coirt./SMe2

C 5 =

PATIENT CONSENT FORM I TIic Dopartnient of Health and Human Service?, lias established a "Privacy Rule" lo help insure that personal information is protected for privacy. The Privacy Rule was also created in order to provide a Standard for certain health care providers to obtain their patients' consent for uses and disclosures of health Information about the patient to cany out treatment, payment, or health care operations.

As our patient we want you to Icnow that we respect the privacy of your personal medical information tmd will do all we can to secure and protect that privacy. We strive to always take reasonable precaution.'^ to protect your privacy. When it is appropriate and neces.';ary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or heahb care operations, in order to provide health care tiiat is in your best interest. i We also want you to know that we support your full access to your personal medical records, We may have indirect treatment relationships with yon (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health inforination for purposes of Irealmenl, paynieiit, or liealtli care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this mu.st he in writing. Under this law. we have the right to refuse to treat you should you choose to refuse to disclo.sc your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your (PHI). You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. Vou ; have the right to review our privacy notice, to request restrictions and revoke consent in writing after \"ou I have reviewed our privacy notice,

Print Name: Date:

jSig nature:

I C O M P L I A N C E A S S U R A N C E N O ! I F I C A T I O N F O R O U R P A T I E N T S

To our Valued Patients: The misuse of Personal Health Information (PHI) has been identified as a national problem causing

patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIl'/VA) with particular emphasis on the "Privacy Rule." We strive to achieve the veiy highest standards of ethics and integrity in

] performing semces for our patients. It is inir policy to properly determine appropriate uses of PHI in accordance with the governmental

• jrules. laws, and regulations. We want to ensure that our practice never contributes in any way to the growing I problem of improper disclosure of PHI, As part of this plan, we have implemented a Compliance Program that we lielieve will help us prevent any inappropL-liUc use urPHi.

We also know that we are not perfect! because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises onr policy of integrity. More so, we welcome your input regarding any seivice problem so that we may iemed\' tlie

isituation promptly.

Thank you for being one of our highl\i valued patients.

PATIENT H E A L T H HISTORY All questions contained in this questionaire are strictly confidential and will become part of your medical record.

Name: Date of Birth: / /

Relationship Status: • Single • Partnered • Married • Separated • Divorced • Widowed

Referring Doctor: Dale: ^ ^

Pharmacy Name and Telephone:

Reason for Visit:

Is This a Worker's Comp or Personal Injury Case? • Yes • No Do Vou Have an Attorney Assigned? • Yes • No If Yes; Name and Address of Your Atlnrney:

List All Medical Problems, Past and Present: [Kx: High Blood Pressure or Cholesterol, Diabetes, Cancer..

6.

2. 7.

3. 8.

4. 9,

5. 10.

Any Prior Surgeries You Have Had and What Type:

1, 3.

2. 4.

Have You Had a Blood Transfusion? • Yes • No

University Neurology. Inc. 725 Reservoir Avenue, Suite 308, Cranston, Rl 02910

401.944,9559 tel 401.244.7118 fax Con'I. / Side 2

0 3 =

IMPORTANT:This Section Must Be Completed

Health issues Please Explain

• Head/Neck

• Bladder/Bowels

• Chest/Heart „ _

• Back/Spine

• Eyes/Vision ,

• Circulalion/Blood ,,

• Stomach/Intestinal

• Breathing

U Skin

• Ear/Nose/Throat

In Pain? • Yes • No If Yes, Where?

Depression/Anxiety? • Yes • No

Recent Change in Weight? • Yes • No ' •

Do You Smoke? • Yes • No If Yes: • Cigarette • Cigar • Pipe Amount Per Day?

Do You Drink Ak-ohol? • Yes LI No , |||||||<

If Yes, U Beer U Wine J Other How Many Days a Week? • 1 U2 • 3 ^ 4 U5 • ?

Do You Use Street Drugs? • Yes • No Any Past IV Drug Use? • Yes J No

Sexually Active? • Yes • No

Trying for Pregnancy? • Yes • No Contraception Method:

Do You Live Alone? • Yes LI No „,|,,, ,

Medications You Are Taking: Drut̂ Name Strength Amnimt Dailv

Allergies to Medication? If So, List Below:

TO Piiliein of UiiiversUy Niiurology, [iiC,

RROM: University Neurology Bill ing Offiee

KE: Insurance co-payments iin<) Deductibles

Please be advised that effective immediately, all co-payments and insni'ance deductibles will be collected at or prior lo the lime your cai'e is rendered by your doctor. We w i l l not bill you. I f piiyinciii 'm not received at time o f service your appointment will be I'eschcduled,

VVc will cio out best to research your copny and deductible amoiiats from your insurance carrier prior to your appointment. The information we give you has been received directly from your insurance coiviDiiiiy. I f we are in erroi', it resulted from this coiiinumi cation and an appropriate adjustment/refund will be issued,

UfflMATELY IT IS YOUR RESPdNS03IUTY TO KNOW YOUR INSUJIANCE PLAN.

Paymejil can be made by credit card, chock or cash payment. Again, wo wi l l not bill you for tliis. Payment is due at the time of visit.

T liiive I'cud tiic above and ngrec to be responsible for the above payments as outlined in my insurance

Tliank you

policy.

Signature Dale

lojiii 'M V Cr>rrnrAW(t, M 1.1 I:I\K:A Sy.At,\(n.ii, M D 7Jfi [Icti^rvolr Avnnirn Eii l la30U Cra i i ioH, Rl ()?9111

•ICJl S'l.l 3550 Ui\ •101 2A-\ ?1 10 fnd

/ U N I V E R S I T Y

Flunilv History by Family Member

I'lcase provide family member medieal history so we can understand your healthcare needs:

I ' lni i i ly Member U\ (pkiisc circle one): Mother, Father, Brother, Sister, Son, or Daughter

Alcoholism Depression Kii-lnev Infections Allei'tiies/! layfevcr D M Type I Kiiliiey stone Anemia D M Type 2 Migraines Anxiety F,pilepsy Multiple Sclerosis Asthma Fracture Myocardial Infarction Atrial Fibrillalion Gastric ulcer Obesiiv lilood 'fransfusions Gaslroinlestinal Disease Osleoarliiritis C A D Gaslrocsophapeal Kellux Disease Osteoporosis Cancer Gestational Diabetes Pneumonia Ciuxliiic I'iicer Ghiuconia Progressive NcLii'ok)gical Disttrdcr Cardiovascular Diyease Fleart Murmur Pulmonary Disease ( I l l - Mepatitis Kheunialic Fever Chicken I'ox Fligh Cholesterol Rhcuinaloid Arllirit is Cirrhosis Hyperlipidcmia Sliinjiles Colitis 1 lyperleiision S I D COl ' l ) Hypei'iliyroidisin Terminal Illness ('lii'oilic Renal failure I-Iypolhyroidisni Thyroid Disease Crohn's disease Insulin I'ump TIA CVA Joint I'ain rubercLilosis D V f Kidney Disease Valvular Problems

Family Member HI (please circle one): Mother, Father, Brother, Sister, Son, or Daughter Please indicate i f the circled family member above has any o f followint^ medical conditions:

Alcoholism Depression Kitiney Infections Allergies/!-layfevcr D M Type 1 Kidney stone Anemia D M Type 2 Mi(iraincs Anxiety Epilepsy Multiple Sclerosis Asthma Fracture Myocardial Inliirclion Atrial Fibrillation Gastric tilcer Obesity Bkiod Transfusions Gastrointestinal Disease Oslcoarlhi'ilis CAD Gastroesophngcal Rclliix Disease Osteoporosis Cancer Gestational Diabetes Pncinnonia Cai'diac Pacer Glaiiconui Pi'ogressive Ncui'oiogieal Distn'tlci' Cardiovascular Disease Fleart Min-mur Pulmonary Disease CI IF Ilepalilis Khcumatic Fever Chicken Pox Fligh Clioleslcroi Rheumatoid Arthritis Cirrhosis |-Iyperli]>idcmia Shinjiles Colitis Flyperlcnsion STD COPD l-Iypcrlbyroidisni 'I'erininnI Illness Chronic Renal i'ailure Hypothyroid ism Thyroid Disease Crohn's disease Insulin Pump TIA C-VA Joint Pain Tulierculosis DV'I Kidney Disease Valvular Problems ->

Faniil) Member ^3 (piciise circle one): Mother, Father, Brotlier, Sister, Son, or Daughter Please indicate i f tlie circled faroil; member above has any of following medical conditions: , Alcoholism i )e|ir ;ssion Kidne\' Inlections Allergics/1 la\levei' D M Ivpe 1 Kidnev stone Anemia D M Ivpe 2 Migraines

! iAn\iclv Lpilejjsv Multiple Sclerosis , AMilima Fracture Myocardial Inlarction Atrial Fibrillalion Gastric ulcer Obesit\

]Hk»Hl TransiVisions Gaslroinlestinal Disease Osteoarlhrllis CAD Ciaslroesopliagcal Rcllux Disease Osteoporosis

, Cancer Gestational Diabetes Pneumonia 1 C.'iii'diac Pacer Glaucoma Progressive Ncurt)lngical Disorder Cardiovascular Disease Fleart Murmur Pulmonary Disease ClIF 1 Icpaiilis Klicimiatic lever C 'hicken Pox 1 ligh Cholesterol Rheumatoid Arlhr iI i^ t irrhosis 1 hperlipidemia Sliinglcs Colilis 1 lyperlensinn STD

•COPD 11\ pcrlhyroidism Ferminai Illness • ('hronic Rcn:il [''ailure i lypothyroidism T'hyroid Disease ' < 'rohn's disease Insulin Pump T I A : CVA Joint Pain Fubcrculosis t DVT Kidnev Disease Valvular Problems

''amily Member U4 (please circle one): Mother. Father, Brother, Sister, Son. or Daughter *lease indicate i f the circled 'amily member above has any of following medical conditions:

Meoholism 1)epression Kidney Inlections \!leveies,'l-la\ l"e\ er DM Ivpe 1 Kidney stone \neniia DM 'fvpe 2 Migraines \n \ i c t \ l:pilc]is\ Multi]ilc Sclciosis

A.sllnn;L Iraetnre Myocardial Infarction Atrial Fibrillation Gastric ulcer Obesity Rlood Trnnsllisions Ciaslriiintestinal Disease Osteoarthritis C A D Gastroestii>hageal KelUix Disease Osteoporosis Cancer Gestational Diabetes Pneumonia Caidiac Pacer Glaucoma Progressive Neurological Disortler Cardiovascular Disease Fleart Murmur Pulmonary Disease ( I I I I lepatitis Rheumatic Fever ("hicken Pox High Cholesterol Rheumatoid Arthritis Cirrhosis 1 Kpcriipidemia Sliinglcs Colitis I lypertension S f D COPD 1 iyperthyroitlism Terminal Illness ('liionic Rcn;il I'aihirc Hypolhyroidisni Thyroid Disease Crohn's disease bisidin Pump T I A CVA Joint Pain fubcrculosis D V I Kidnev Disease Valvular Problems

Any addhional comments you would like to provide on family medical history:

I . — © 2015 F,pcom World Industries, Inc. - University Neurology, Inc. Rev.030

V E R S I T Y

P E R M I S S I O N T O V E R B A L L Y D I S C U S S P R O T E C T E D H E A L T H I N F O R M A T I O N

Patient Name Date of Birth

'UlllilNliHlixl

I give permission lo the offices of UNTVERSITY NEUROLOGY, INC. to verbally discuss the following for continuance of care:

Information which may include: ' I W 1. Diagnosis 2. Symptoms 3. Medication

I 4. Treatment plans 5. Behavioral health information 6. Chemical dependency 7. Lab/test results 8. Bil l ing and payment information 9. Appointment information via phone or voice mail

The above information may be discussed with the following whether next of kin or a personal designated representative or legal guardian.

1. Name: 'II.

2. Name: ,

I understand that 1 have the right to revoke my permission at any time except where U N I V E R S I T Y N E U R 0 L 0 ( ; Y . I N C . has already made disclosures in reliance with this request. I understand 1 must notify the aforemeniit)ned in writing i f 1 want to revoke my permission.

Signature of Patient or Date Authorized Representative

C^^^ " authorized representative, please attach copies of supporting le}>al documenlalion.

m 4/2013

University Neurology, Inc. 725 Reservoir Avenue, Suite 308, Cranston, Rl 02910

401.944.9559 tel 401,244.7118 fax

VERSITY

IS THIS A WORKERS COMPENSATION CASE? • Yes • No

Date of incident:

Workers comp claim number:.

Adjuster name:

Name of workers comp insurance company:

Phone number of workers comp insurance: _

Name of company you are employed by:

IS THIS A L I A B I L I T Y C A S E ' • Yc-. • No

Date of incident:

Did you slip and fall'.' - Please explain:

IS THIS A MOTOR VEHICLE ACCIDENT? • Yes • No

Date of accideiU;

What state did accident occur in;

Insurance company name and address:.

Insurance company phone number:

Insurance company adjusters name:

DO YOU HAVE A N ATTORNEY I N V O L V E D IN THIS CASE? • Yes • No

I f yes, attorneys name:

Attorney office address:

Attorney office phone number:.

HEALTH C O V E INFORMATION

Name of health insurance:_

Secondary insurance name:.

Member number:.

Member number;

1' P A T 1 F : N T S I G N A T U R E :

Note: Flease be aware that there will be a fee of $ KM) charged for "no-show" appoinlments without a 24 hour cancellation notice from you or a representative. Thank you.

lOSEPH V CtNTUfANTl, M D Board Certified

ERJCA SZABADOS. M D

Board Crriified

725 Reservoir Avenue Suile 30S Cranslon. Rl 02910

401 444 455? let 401 244 7118 fax UniversilyNeurologyInc .cam