New Patient Packet

If patient is a minor, please provide guarantor information:

EMERGENCY CONTACT INFORMATION

PRIMARY INSURANCE

SECONDARY INSURANCE

CONFIDENTIAL INFORMATION CONSENT

**ATTENTION**

If you are involved in a lawsuit or have an attorney for your injury your injury insurance may not pay for your treatment. You will be responsible for the full amount. Please speak with the Billing Department before being seen.

NO-SHOW POLICY

• We understand that things in life can change and you may need to cancel your appointment. We do, however, expect you, whenever this happens, to give us the courtesy of a phone call to cancel your appointment in advance of your appointment date. If you “no-show” for a scheduled appointment two times or more over a 3 month period you will be discharged from this office as a patient.
• This office is open 8 A.M. to 5 P.M. Monday thru Friday. You can call to cancel or reschedule your appointment.

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have coverage with the insurance listed above and assign payment directly to JEFFREY F. TRAINA, MD all insurance benefits for services rendered. I understand that I will notify JEFFREY F. TRAINA, MD of any changes in my insurance information immediately and that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the staff at ADVANCED ORTHOPEDIC & SPORTS MEDICINE to release any and all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions. I also understand that any incorrect information or false representation of this information may result in either termination of treatment and / or payment of all unpaid balances in full. I also understand that with my insurance coverage there still may be portions that I will be responsible for. All co-pays must be paid at the time of service. Failure on our part to collect co-payments and deductibles from you can be considered fraud.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

FINANCIAL POLICY AGREEMENT

Thank you for choosing our office. We are committed to be a partner in your medical care. Please understand that the payment of your bill is part of this treatment and care. For your convenience, we have developed a written statement of our billing policies. If you need further information regarding these policies, please ask to speak with our billing department. It is important for you to understand that your health insurance coverage is an agreement between you and your insurance company. The doctor's bill for services rendered is an agreement between you and your doctor. WE do however participate with most but not all insurance companies. If we do participate with your insurance company, all services performed in our office, at the hospital, or nursing homes will be submitted to them for payment unless we receive prior notification of non· covered services. Not all services you receive may be covered by your insurance. You must still pay for these services. Having more than one insurer does not necessarily mean that the services you receive will be covered 100%. We will bill your secondary insurance as a courtesy to you. You are responsible for any balances that remain after all insurances have processed your claim.

All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance card in order to verify proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be personally responsible for this claim. We will submit your claim and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly and it is your responsibility to comply with their request. Please be aware that the balance of the claim is your responsibility whether or not the insurance company pays your claim. If your insurance company does not pay your claim in 60 days, the balance will become your responsibility and billed directly to you.

Our office accepts Visa, MasterCard, AMEX and Discover for your convenience, as well as cash and checks. Returned checks will be subject to a service charge of $35.00. Should we need to bill you for services performed, our office will send you a monthly statement. Any outstanding balances are due within 30 days of the statement.

I have received and agree to the terms of JEFFREY F. TRAINA, MD Financial Policy.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Permission to Release Medical Information

As stated in our privacy policy, "With your permission, your medical information may be released to a family member, guardian or other individuals involved in your care.

By signing this you agree that the below-listed persons may be notified about any situation as it relates to the medical care that you receive. Included but not limited to: insurance issues, test results, and appointment dates and times.

Please list all the people that we may release ANY of your information to. Please be advised that if asked to release ANY information over the phone we have the right to deny the person even if they are listed. We must be able to verify identity.

If this information changes, it is your responsibility to notify us so that they may be removed from this list.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I authorize and request the disclosure of all protected information for the purpose of review and evaluation. I expressly request that the designated record custodian under HIPAA identified above disclose full and complete protected medical information including the following:

All medical records, meaning every page in my record, including but not limited to office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurses notes, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, prescription history, statements, questionnaires/histories, photographs, videos, telephone messages and records.

I understand the information to be released or disclosed may include information relating to sexually transmitted, diseases, acquired immunodeficiency syndrome, or human immunodeficiency virus, and alcohol and drug abuse. I authorize the release or disclosure of this type of information.

This protected health information is disclosed for the following purposes continued medical evaluation and/or treatment

You are authorized to release the above records to the following:

Advanced Orthopedic and Sports Medicine Center
Jeffrey F. Traina, M.D.
800 S. 3rd Street
Leesville, La 71446
Phone: 337-404-4075 | Fax: 337-446-2548

I understand that I have the right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization; the information release in response to this authorization may be re-disclosed to other parties; my treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two (2) years from the date of execution, at which time this authorization shall expire.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

ACKNOWLEDGMENT OF RECEIVING NOTICE OF PRIVACY PRACTICES INFORMATION SHEET

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Your signature and date below indicates you were given the above noted information sheet on this date.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

This acknowledgment is to be filed in patient’s medical record.

HIPAA 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.

This Practice is committed 10 maintaining the privacy of your protected health information ("PHI','), which includes information about your heallh condition and Ihe care and Irealment you receive from the Practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality heallh care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. The privacy of PHI in patient files will be protected when the files are taken to and from the Practice by placing the files in a box or brief case and kept within the custody of a doctor or employee of the Practice authorized to remove the files from the Practice's office.

NO CONSENT REQUIRED

The Practice may use and/or disclose your PHI for the purposes of:

• Treatment - In order to provide you with the health care you require, the Practice will provide your PHI to those health care professionals, whether on the Practice's staff or not, directly involved in your care so that they may understand your health condition and needs.
• Payment - In order 10 get paid for services provided to you, the Practice Vlill provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant 10 their billing and payment requirements.
• Health Care Operations - In order for the Practice to operate in accordance with applicable law and insurance requirements and in order for the Practice to continue to provide quality and efficient care, it may be necessary for the Practice to compile, use and/or disclose your PHI.

The Practice may use and/or disclose your PHI, without a written Consent from you, in the following additional instances:

• De-identified Information - Information Ihal does not identify you and, even without your name. cannot be used to identify you.
• Business Associate - To a business associate if the Practice obtains satisfactory written assurance, in accordance with applicable law. that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists the Practice in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment 10 insurance companies or other payers.
• Personal Representative - To a person who, under applicable law, has the authority 10 represent you in making decisions related to your health care.
• Emergency Situations

1. for the purpose of obtaining or rendering emergency treatment to you provided that the Practice attempts to obtain your Consent as soon as possible; or
2. to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.

• Communication Barriers - if, due to substantial communication barriers or inability 10 communicate, the Practice has been unable to obtain your Consent and the Practice determines, in the exercise of its professional judgment. that your Consent to receive treatment is clearly inferred from the circumstances.
• Public Health Activities - Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease and that does not identify you and, even without your name, cannot be used to identify you,
• Abuse, Neglect or Domestic Violence - To a government authority if the Practice is r~quired by law to make such disclosure, if the Practice is authorized by law to make such a disclosure, it'will do so if it believes that the disclosure is necessary to prevent serious harm.
• Healill Oversight Activities - Such activities, which must be required by law, involve government agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community's health care system.
• Judicial and Administrative Proceeding - For example, the Practice may be require to disclose your PHI in response to a court order or a lawfully issued subpoena.
• Law Enforcement Purposes -In certain instances, your PHI may have to be disclosed to a law enforcement official. For example, your PHI may be the subject of a grand jury subpoena, or, the practice may disclose your PHI if the Practice believes that your death was the result of criminal conduct.
• Coroner or Medical Examiner - The Practice may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.
• Organ, Eye or Tissue Donation - If you are an organ donor, the Practice may disclose your PHI to the entity to whom you have agreed to donate your organs.
• Research - If the Practice is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI and that does not identify you and, even without your name, cannot be used to identify you.
• Avert a Threat to Health or Safety - The Practice may disclose your PHI if il believes That such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able 10 prevent or lessen the threat.
• Workers' Compensation - If you are involved in a Workers' Compensation claim, the Practice may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.

Appointment Reminders

• Your health care provider or a staff member may disclose your health information to contact you to provide appointment reminders, If you are not al home to receive an appointment reminder, a message will be left on your answering machine, voice mail, or with the person who answers the call.
• You have, the right to refuse us authorization to contact you to provide appointment reminders, If you refuse us an authorization, it will not affect the treatment we provide to you.

Sign-in Log

This Practice maintains a sign-in log for individuals seeking care and treatment in the office. This sign-in sheet is located in a position where staff can readily see who is seeking care in the office, as well as the individual's location within the Practice's office suite. This information may be seen by and is accessible to, others who are seeking care or services in the Practice's offices.

Amend your PHI as provided by 45 CFR 164.528. To request an amendment, you must submit a written request to tile Practice's Privacy Officer. You must provide a reason that supports your request. The Practice, may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the Practice's denial, you will have the right to submit a written statement of disagreement.

Receive notice of any breach of confidentiality of your PHI by the Practice.

Complain to the Practice or to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W .. Room 509F, HHH Building, Washington, D.C. 20201,202 619-0257, email: ocrmail@hhs.gov if you believe your privacy rights have been violated. To file a complaint with the Practice, you must contact the Practice's Privacy Officer. All complaints must be in writing.

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.

PRACTICE'S REQUIREMENTS

• Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI.
• Is required to abide by the terms of this Privacy Notice.
• Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for your entire PHI that it maintains.
• Will distribute any revised Privacy Notice to you prior to implementation.
• Will not retaliate against you for filing a complaint.

Family/Friends

The Practice may disclose to your family member, other relatives, a close personal friend, or any other person identified by you, your PHI directly relevant to such person's involvement with your cafe or the payment for your care unless you direct the Practice to the contrary. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:

• If you are present at or prior to the use or disclosure of your PHI, the Practice may use or disclose your PHI if you agree, or if the Practice can reasonably infer from the circumstances, based on the exercise of its professional judgment that you do not object to the Use or disclosure.
• If you are not present, the Practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's Involvement with your care.

AUTHORIZATlON

Uses and/or disclosures, other than those described above, will be made only with your written Authorization.

Your Right to Revoke Your Authorization

You may revoke your authorization to us at any time; however, your revocation must be in writing.

Restrictions

You may request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice's Privacy Officer. In your written request, you must inform the Practice of what information you want to limit. Whether you want to limit the Practice's use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.

You Have a Right to

Inspect and obtain a copy of your PHI as provided by 45 CFR 164.524. To inspect and copy your PHI, you are requested to submit a written request to the Practice's Privacy Officer. The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request.a

Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice's Privacy Officer. The Practice will accommodate all reasonable requests.

Prohibit report of any test, examination or treatment to your health plan or anyone else for which you pay in cash or by credit card.

Receive an accounting of disclosures of your PHI as provided by 45 CFR 164.528. The request should indicate in what form you want the list (such as a paper or electronic copy)

Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice's Privacy Officer.

Request copies of your PHI in electronic format if this office maintains your records in that format.