PATIENTINFORMATION
NAME(Last,First,Middle) / SSN# / BIRTHDATE / LANGUAGE / SEX
ADDRESS / SECONDARYBILLINGADDRESS(IfApplicable)
CITY,STATEZIP / HOME/CELLPHONE / CITY,STATEZIP / HOMEPHONE
PREVIOUS PRIMARY CAREPHYSICAN / EMERGENCY CONTACTNAME / EMERGENCY CONTACTPHONE NUMBER
PRIMARYEMPLOYER / SECONDARYEMPLOYER(IfApplicable)
ADDRESS / ADDRESS
CITY,STATE ZIP / CITY,STATEZIP
WORKPHONE / WORKPHONE
RESPONSIBLE PARTY
NAME(Last,First,Middle) / SSN# / BIRTHDATE / LANGUAGE / SEX
LOCALADDRESS / SECONDARYBILLINGADDRESS(IfApplicable)
CITY,STATEZIP / CITY,STATEZIP
HOMEPHONE / HOMEPHONE
RELATIONSHIPTOPATIENT
PRIMARYINSURANCE
NAMEOFINSURANCECOMPANY / POLICY#
NAMEOFINSURED DOB OF INSURED SSN OF INSURED / GROUP#
ADDRESSOFINSURANCECOMPANY / COPAYAMT
$
CITY,STATE,ZIP / DEDUCTIBLE
$
RELATIONSHIPTOPATIENT / EFFECTIVEDATE / EXPIRATIONDATE
SECONDARYINSURANCE(IfApplicable)
NAMEOFINSURANCECOMPANY / POLICY#
NAMEOFINSURED / GROUP#
ADDRESSOFINSURANCECOMPANY / COPAYAMT
$
CITY,STATE,ZIP / DEDUCTIBLE
$
RELATIONSHIPTOPATIENT / EFFECTIVEDATE / EXPIRATIONDATE

IunderstandthatChathamCare,P.C.will usemyhomeaddress/phone#toleavemessagesregarding: Testresults,appointments,etc.,unlessIrequestthatthefollowingalternativecontactbeused:(i.e.cell#offamilymember):

Irequest/authorizeChathamCare,P.C.tofurnishthemedicalcarethat isnecessaryformycondition,butIacknowledgethat noguaranteesastoresultshavebeenmadetome. Iwasprovided acopyoftheNoticeofPrivacyPracticeandpatientfinancialpolicies. Ihaveread,understoodandhadtheopportunitytoaskquestionsandIagreetoabidebytheseterms.

PatientSignatureDate

Patient/GuardianAuthorizationtoDiscloseProtectedInformationtoOthers

PatientName:DOB:Today’sDate:

Tothepatient: Chatham Care,P.C.willattempttofollowyourinstructionstotheextentthehealthcareproviderbelievessuchdisclosurewillnotinterferewithyourtreatment.PleasenotethatChathamCare,P.C.doesnotneedspecificauthorizationtodiscloseinformationfortreatment,operationsorpaymentpurposesconsistentwithitsNoticeofPrivacyPractices.

Authorizationby:PatientLegalGuardian:

*Exceptiflistedbelow,ChathamCare,P.C.manydiscloseallofmyProtectedHealthInformation(includingthatabout alcohol/substanceabuse,humanImmunodeficiencyvirus(HIV)and/orAIDS,orinformationrelatedtopsychiatricorcounseling,and relatedtocommunicabledisease,unlessIlimitbelow)to:

Spouse(name)

Child(ren):Allorbyname

Others(name(s)):

*Limitations-ThefollowingProtectedHealth InformationmayNOTbedisclosed:

IauthorizeChathamCare,P.C.toleavemessagesaboutmeand/ormymedicalcareonmyvoicemail

I authorize Chatham Care, P.C. to retrieve my prescription history from my insurance company ______

Expiration:IunderstandthisAuthorizationwillstayineffectduringmytreatmentatChathamCare,P.C.unlessitisrevoked/revisedbymeinwriting.IunderstandthatChathamCare,P.C.is notresponsibleforinformationthatmightbere-disclosedbythosepersonswhoIhaveauthorizedtoreceiveinformation.

Patient/Guardian Signature: ______Date: ______

(Forminformationtobeenteredintoelectronicmedicalrecordwhen appropriate.Patient mayhaveacopyifdesired.)

February17, 2010

PatientStatisticInformation
EmployeeCategory
Employed Unemployed Retired
Employer / Race / Religion
Occupation / Nationality / Ethnicity
E-mail / Language / MaritalStatus
ReferringDoctor/Howdidyouhearaboutus?

Please completeallboxesabove,thisinformationisusedforstatisticalinformationonlyandisrequiredby thenewhealthcarereformlawsthathaverecentlybeenplacedintoeffect.Thankyouforyourcooperation infillingthisformout.If youhaveanyquestionspleasedonothesitatetoask.

SignatureDate

ReleaseofMedicalRecords

Ihereby authorize theuseordisclosureofmyindividuallyidentifiablehealthinformationasdescribedbelow.Iunderstandthisauthorizationisvoluntary.Iunderstandthatiftheorganizationorpersonsauthorizedtoreceivetheinformationisnotahealthplanorhealthcareprovider;thereleasedinformationmaynolongerbeprotectedby federalprivacyregulations.

PatientName:DOB:

PatientAddress:

Persons/organizationsprovidingtheinformation:Persons/organizationsreceivingtheinformation:

ChathamCare,P.C.907N.EastStreetIndianapolis,IN46202

Fax(317)602-2654

Specificdescriptionofinformationtobeusedordisclosed.(Includingdate(s)):All medicalrecords

Reasonforuseordisclosureofinformation:Toobtainmedicalcarefrom

Thepersonororganizationprovidingtheinformationwill/willnotreceivefinancialorin-kindcompensationinexchangeforusingordisclosingthehealthinformationdescribedabove.[tobecompletedonlyiftheauthorizationisformarketingpurposes]

IunderstandthatIwillnotbedeniedhealthcareorhealthplancoverage,asthecasemaybe,ifIdonotsignthisform.IunderstandthatImayseeandcopytheinformationdescribedonthisformifIaskforit,and thatIgetacopyofthisformafterIsignit.

Iunderstandthatthisauthorizationwillexpireon:

IunderstandthatImayrevokethisauthorizationatanytimeby notifyingthepersonororganizationprovidingtheinformationinwriting,butifIdoitwon’taffectanyactionstakenbeforetherevocationisreceived.

Signature ofPatientorPatient’srepresentative:Date: PrintednameofPatient’s representative:

Relationshipofrepresentativeto Patient,ifapplicable:

*YOUMAYREFUSETOSIGNAUTHORIZATION*

FOROFFICE USEONLY

RevocationDate:

ProcessedBy:Signature:

PatientFinancial Policies

PaymentGuarantee:Forservices renderedbyChathamCare,P.C.,youguaranteepaymentofyouraccount atthetimeservices areprovidedfortheentirecoststhatwillnotbepaidbyaninsurancecarrier, orotherthird partypayer(allcalled“PAYER”),orifatalaterdateafterinitialapproval,your Payer deniesthe claim.You furtherunderstandthatanyout-of-networkchargesmaybeyourresponsibilityasdeterminedbyyourPAYER.Youacknowledgethatifyourdependentisprovidedservicesyouwillberesponsibleforpaymentunderthese sametermsandconditions.The“ResponsibleParty”listedonthePatientDataSheetwillbesentthebilland agreestopayit.IftheResponsibleParty isnotyouandthatpersondoesnotpaythebill,YOUagreetopay thebill.

AssignmentofBenefits:Totheextentthereisthirdpartycoveragefor paymentofservices,youagreethatall medicaland relatedbenefitsPAIDbyPAYERwillbeassignedtoCHATHAMCARE,P.C.onyourbehalf.

BillingInformation:It isessentialthatyouprovideuswithcompleteandaccurateinformationtosubmit billingtoyourinsurancecompany(i.e.homeaddress,phonenumbers).Wewillmakeeveryefforttosubmit claimstoyourinsurance companyandpromptlyprovideyouourstatements.However,ifforanyreasonthe statementisreturnedtoourofficebecauseofaproblemwithanaddressyouprovided;youmaybedismissedandreferredtoacollectionagency.Toavoidthis,pleasekeepyourinformationup-to-date.

Please be sure to bring your government-issued photo identification and your insurance cards to every visit so that we may properly bill your insurance company. If you do not have your insurance card with you, you may be required to make payment in full that day.

InsuranceBilling:Asyourhealthcareproviderwewillfileyourclaimswithyourinsurancecompanyas acourtesyafter servicesare provided,unlessyounotifyusnottofileitwithyourPayer. Itisyour responsibilitytounderstandwhatservicesarecoveredunderyourmedicalinsurancepolicy.Ifyouhaveany questionswhetheraservicewillbecoveredweurgeyou tocontactyourinsurancecompany,beforethe serviceisprovided.

ThecodesthatarelistedfortheservicesthatareprovidedtoyouarebasedontheguidelinesoftheAmericanMedicalAssociation.Thereareseveralfactorsinvolvedwhenmakingthedecisionforthetypeofservices tobebilled.Amongthosedecidingfactorsiswhetheryouareanewpatient(notseenwithinthelastthreeyears)orestablishedpatient,thereasonforthevisit,theamountoftimetheservicetakesandthecomplexityofthemedicalproblem.

Insurancecompaniesmaketheirpaymentdecisionaboutaspecificmedicalserviceby lookingat whatyourinsurancepolicyprovides.Example:Ifthereasonforyourvisitisasportphysicalandyour insurancecompanydoesnotcoverthatservicewecannotgobackandchangethereasonforyour visit.Itisyourresponsibilityto findthisoutaheadoftime.

Sometimesroutineservicessuchasofficevisits,laboratoryservices,mammograms,screenings,andannualphysicalsarenot coveredunderinsurancepolicies.Wesuggestyoucontactyourinsurancecompanytofindoutwhatbenefitsyouhaveunderyour policy beforeservicesarerenderedbyus.Thecustomerservicenumberisusuallyfoundonyourinsurancecard.

Beadvisedthatyourinsurancecompanymayrequireapre-certification,priorauthorization,orreferralforsomeservices,suchas:radiology,surgery,orspecialistvisits.Receivingpriorauthorizationdoesnotguaranteethatyourinsurancecompanywillpayforit.Patientshavetheresponsibilitytoensurethatpriorauthorizationhasbeenobtainedpriortoservicesrendered.

Youshouldnormallyreceivearesponsefromyour insurance companywithin30days.Thisisin theformofan “Explanation ofBenefits”(or“EOB”).Ifyoudonotreceiveit,wewouldappreciateyoucontactingyour insurancecompanytocheckthestatusofyourclaimin ordertoexpeditepayment.Pleasecallour BillingDepartment(the phonenumberislisted onyourstatement),ifyou encounterany difficultywith yourinsurancecompany.Wewilltrytoassistyou.Youareresponsibleforpaymentuntiltheaccountispaidinfull byyourinsurancecompany.

Payment terms:Dependingonyourinsurancepolicybenefits,youmaybe responsibleforaco-payment, coinsurance,deductible,orfortheentireservicesrendered.Wemayrequirepaymentfortheseitemsatthetimeofyourofficevisit.Ifyoufailtomakepaymentatthetimeofservice wemaychargea processing feetocoverourextraexpenseofpreparingandsendingoutabill.

OncewehavereceivedanEOBfromyourinsurancecompany,whichindicatestheamountyouwillberesponsiblefor,astatementforthebalancewillbesenttoyouandpaymentisexpectedbytheDueDateas statedonourbill.

If amountsdueforservicesrenderedbecomedelinquentandtheamountsarereferredtoanattorneyand/orcollectionservice,youagreethatyouwillberesponsibleforallreasonablecostsandexpenses incurredinthecollectionefforts,includinganyinterestchargesdue,courtcostsandattorneyfees.

Notetodivorcedparentsofdependents: Unless youprovideuswithacourtorder,thestatementwillbesenttothe“ResponsibleParty”listedonthePatientDataSheetandthatpersonagreestopaythebill.IftheResponsibleParty isnotyouandthatpersondoesnotpaythebill,YOUagreetopaythebill.Ifthereisa disagreementitisfortheparentstodeterminewhoshouldpaywithoutChathamCare,P.C.involvement.

Self-PayPatients:Self-Pay Patients are those not covered by any insurance policy or third party payer. Payment is YOUR responsibility: Our relationship is with you, to provide quality healthcare to you and/or your dependent. Consequently, all charges incurred are your responsibility. The obligation to ensure payment in a timely manner lies with you. Unfortunately, we cannot always depend on your insurance company to make timely payment on your behalf. We are not responsible for delays, misplaced claims, or the need for additional information from you by your insurance company. If for any reason a check is returned for insufficient funds any charges incurred by Chatham Care, P.C. will be passed on to you and you will be required to reimburse Chatham Care, P.C.

PaymentOptions:Ifyouareunabletomeetyourfinancialobligation, paymentarrangementscanbemade.Financingoptionsmaybeavailable.Contactourfinancialcoordinatortodiscusspaymentoptions,beforeyouraccountbecomesoverdue.Incasesoffinancialhardshipyoumightbe consideredunderourhardshippolicyandyoumayaskusaboutit.

MakingPayments:Patientsmaypaybycash,moneyorder,checkorpersonalcreditcard,whichcaninclude credit cards to pay from your “flexible spendingaccount”and/or“healthsavings account,”ifyou have these.One,orall,ofthesecardsmaybe usedtopayyourbill,andmaybe keptonfilebyusto facilitatebilling.Patientsagreeiftheyhaveacreditbalanceafterpayingforaservice,ChathamCare,P.C. canapplyittoanyoutstandingbalances ontheiraccount.

FeesAssessedbyChathamCare,P.C.:Youmaybechargedfeesforthefollowing:(1)ReturnedChecks, (2)CompletionofForms(e.g.DisabilityorFamilyMedicalLeave)(3)CopyingofMedicalRecords(4) FailuretoCancel Appointment(“NoShow”)- ifyoudonotadviseusofyourinabilitytokeepyour appointmentpriorto24hoursbeforeyourappointment.Thesefeesaresetbyeachlocationandmay changeatanytime.

Youwillbeconsideredanactivepatientaslongasweprovideyou services withina3yearperiod.Youwillhavedeemedyourselfasterminatingourrelationshipifyouhavenocontactwithusforthisperiodoftime.Acceptanceback intothepracticeasanewpatientisatthediscretionoftheindividualprovider/location.

PatientSignatureDate