Please arrive 15 minutes prior to your scheduled appointment time.

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1 Miami Valley Cardiologists 122 Wyoming Street Dayton, Ohio (937) (937) Fax mvcdayton.com Dear Patient: Please complete the enclosed forms in full prior to your appointment. Bring these forms along with insurance cards, referrals if necessary, and the bottles of medications you are currently taking. Co-pays are due at the time of service. In addition to cash and checks, we accept Visa, MasterCard and American Express, for your convenience. Please arrive 15 minutes prior to your scheduled appointment time. We appreciate your cooperation. If you have any questions or concerns regarding the completion of these forms, or need directions to our office, do not hesitate to call (937) or visit us at We also ask that you kindly give us at least 24 hours notice if you need to cancel or reschedule your appointment. Thank you, Miami Valley Cardiologists Thomas G. Thornton, MD, FACC Stephen C. Wenzke, MD, FACC Steven R. Jain, MD, FACC Kathy Mattingly, RN, MPAS, PA-C Joseph P. Malone, MD, FACC Mark E. Krebs, MD, FACC Hema L. Pandrangi, MD, FACC Lisa Grow, MPAS, PA-C Stephen C. Schreck. MD, FACC B.K. Srivastava, MD, FACC Eddie D. Davenport, MD, FACC Jessica G. Luckenbill, MPAS, PA-C James M. Pacenta, MD, FACC Mukul Chandra, MD, FACC Mark W. Moronell, MD, FACC Jessica L. Stager, MPAS, PA-C

2 Premier HealthNet Premier Health Specialists Upper Valley Professional Corporation Registration Form PATIENT INFORMATION: *Patient Name: *SS #: *Sex: Male *Date of Birth: / / Aliases/Nicknames: County: *Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Address: Marital Married Widowed Single Divorced *Occupation: Legally Separated Significant Other Name of Legal Guardian: Referring Physician: Ethnic Group: Preferred Language: Race: Religion: Special Needs: Hearing Language Speech Vision Multiple Needs Special Communication Needs Other Primary Care Physician: EMERGENCY PATIENT CONTACTS: Name: Phone: ( ) Alternate Phone: ( ) Relation to Patient: Name: Phone: ( ) Alternate Phone: ( ) Relation to Patient: RESPONSIBLE PARTY (GUARANTOR): *Check if Same as Patient *Relation Self Parent Other to Patient: Spouse Child *Name: *SS #: *Sex: Male *Date of Birth: / / *Home Phone: ( ) Work Phone: ( ) ADVANCED DIRECTIVES: (circle if applicable) Do you have an advanced directive? Living Will: Y / N DNR: Y / N Durable Power of Attorney for health care: Y / N HOW DID YOU HEAR ABOUT OUR OFFICE? CareFinders Friends/Family Physician Advertisement Other PLEASE COMPLETE INSURANCE INFORMATION ON THE REVERSE SIDE 06/14 *Required Field

3 INSURANCE/POLICY HOLDER INFORMATION (SUBSCRIBER): Please present insurance cards to receptionist *Name: *SS #: *Sex: Male *Date of Birth: / / *Home Phone: ( ) Work Phone: ( ) *Primary Insurance: *Effective Date: / / *Member ID: *Group Number: *Patient Relation to Subscriber: Self Parent Other *Relationship to Guarantor: Self Parent Other Spouse Child Spouse Child SECONDARY INSURANCE: *Name: *SS #: *Sex: Male *Date of Birth: / / *Home Phone: ( ) Work Phone: ( ) *Secondary Insurance: *Effective Date: / / *Member ID: *Group Number: *Patient Relation to Subscriber: Self Parent Other *Relationship to Guarantor: Self Parent Other Spouse Child Spouse Child Authorization for Treatment and Disclosure of Information for Treatment, Payment, and Operations AUTHORIZATION FOR TREATMENT I authorize examination, diagnosis, and general treatment (including, but not limited to, the use of x-rays and other non-invasive procedures such as diagnostic tests) to be performed by physicians and staff of PHN/PHS/UVPC. I realize that if a medical procedure or surgery is required, I will be given additional information. CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS I consent to PHN/PHS/UVPC using and disclosing my protected health information to carry out treatment, payment, or health care operations. I understand and have been provided with a tice of Privacy Practices, which provides a more complete description of how my protected health information may be used or disclosed. I understand that I have the right to review the notice prior to signing this consent. I understand that PHN/PHS/UVPC reserves the right to change their notice and information practices and that I may obtain a copy of the revised notice by requesting a copy from the office manager. I have the right to revoke this consent by notifying PHN/PHS/UVPC in writing, except to the extent that Premier HealthNet, Premier Health Specialists or Upper Valley Professional Corporation has taken action in reliance on my consent. I hereby authorize any holder of medical information about me to release to the Centers for Medicare/Medicaid services and its agents any information needed to determine those benefits payable for related services. I hereby authorize Medicare/Medicaid to furnish to PHN/PHS/UVPC any information regarding my Medicare claims under title XVII and XIX of the Social Security Act. FINANCIAL AGREEMENT I realize the bill is my responsibility. I assign and authorize payments be made directly to PHN/PHS/UVPC of all insurance benefits and agree to pay any balance due. I agree, in order for PHN/PHS/UVPC to service my account or to collect any amounts I may owe, PHN/PHS/UVPC may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, and may also contact me by sending text messages or s, using any address I provide to use which could result in charges to me. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. / Signature of patient or patient s representative Date Date of Birth Printed name of patient or patient s representative Relationship to patient or representative s authority to act for the patient. 06/14 *Required Field

4 Samaritan Family Care, Inc./MVHE, Inc./Health Specialists of Dayton, Inc. CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS I consent to Premier HealthNet of Premier Health Partners {PHNPHP} using and disclosing my protected health information to carry out treatment, payment, or health care operations. I understand and have been provided with a tice of Privacy Practices, which provides a more complete description of how my protected health information may be used or disclosed. I understand that I have the right to review the notice prior to signing this consent. I understand that PHNPHP reserves the right to change their notice and information practices and that I may obtain a copy of the revised notice by requesting a copy from the office manager. I have the right to revoke this consent by notifying PHNPHP in writing, except to the extent that PHNPHP has taken action in reliance on my consent. I understand that this consent supercedes any and all consents signed including the Authorization for Release of Information contained in the PHNPHP Registration Form. Signature of patient or patient s representative Date Printed name of patient or patient s representative Relationship to patient or representatives authority to act for the patient Printed name of patient (if different from above)

5 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I, the below-identified person, do hereby authorize the release of my medical information, as indicated herein between the following parties. RECORDS FROM: SEND TO: (Physician Name if applicable) I authorize this release of information for the following reason: Consult/Second Opinion Relocating Out of Town Specialist Care Change of Insurance Selecting new Physician Other (specify) (not for insurance reasons) I direct that all information obtained in association with this release be held in strict confidence by the recipient and further direct that it is not to be further disclosed without my specific written authorization. However I understand that the person or entity receiving my information may not be subject to any Federal privacy regulations. I understand that this Authorization is voluntary and that I may refuse to sign it; my refusal to sign will not affect my ability to obtain treatment. I understand that this authorization shall remain in effect for sixty (60) days from the date of my signature below unless I specify an earlier expiration date in this space. I understand that, except to the extent that action has been taken based on my authorization, I may withdraw this authorization at any time by written notification to the parties involved. It is my desire that only the following information indicated below be released as a result of this authorization: Any and all records from all sources in our possession (specify dates of treatment: ) Complete Chart Laboratory Results Radiology Reports Demographic Sheet Operative Reports Therapy Reports History & Physical Pathology Reports Immunization record Medications Prescribed Consults Reports Other (specify) Emergency Room Progress tes Record of center only (specify date of treatment:, I am also making the following additional qualification: IF the information specified above contains information related to treatment for drug and / or alcohol abuse, for psychiatric and / or mental conditions, or HIV test results or diagnosis, I am including this type of information to be released in association with this authorization. Date Patient or Guardian signature Witness To assist you, I am providing the following additional identifying information: Print name when treated Street Address Phone # Date of birth City State Zip code Social security # (last 4 digits only) - OPTIONAL Dates of treatment State reason if patient is unable to sign: Records to be: Mailed Faxed Picked up Date completed: By: Form. PCN-020 (6/2009)

6 Medicare as a Secondary Payer Questionnaire (MSPQ) Medicare Patients Only As a requirement of Medicare, you will be requested to complete this questionnaire at each visit. t applicable for Medicare Managed Care plans. 1) Do you have Medicare Part B? (If no, stop here) 2) What is your spouse s name? 3) Are you currently less than 65 years? 4) Are you 65 years and older and still working? If yes, employer? If yes, do you have insurance through your employer? If no, retirement date: 5) Is your spouse currently working? If yes, do you have insurance through their employer? If yes, employer? If no, retirement date: 6) Are you currently in End Stage Renal Disease? 7) Are you entitled to benefits through the Department of Veterans Affairs (DVA)? 8) Are you covered by Federal Black Lung Program? 9) Is your visit related to an accident or injury while on the job? 10) Is your visit related to an accident or injury not on the job? (for example: auto accident, slip and fall, malpractice, product liabilities, homeowners?) Patient Name Date Patient s representative if applicable Relationship to patient or representative s authority to act for the patient If you answered yes to any questions above, please see Registration personnel.

7 Miami Valley Cardiologists Quality, Reputation, Integrity Welcome to the office of Miami Valley Cardiologists. In order to better serve you, we request that you complete the following medical questionnaire. Name Date of Birth List Past or Present Medical Conditions: List All Prior Surgeries and Date of Surgery: List Any Allergies: List Significant Medical Conditions of Primary Family Members: Mother: Father: Sisters: Brothers: Please Check the Appropriate Selection: Marriage Married Single Widow/Widower Divorced Tobacco Use: Never Past Present (Packs per day: Number of years: ) Alcohol Use: Never Rare Occasional Frequent Occupation: Do you exercise regularly? If yes, list type of exercise: Fevers se bleeds Anemia Muscle pain Headache Cough Blood in stool Arthritis Weight change Lung disease Blood in urine Thyroid disorder Fatigue Wheezing Bleeding disorder Swelling Falls Hypertension Easy bruising Leg pain Dizziness/vertigo Shortness of breath Loss of appetite Rashes Lightheaded Chest pain Abdominal pain Vision change Blackouts Palpitations Nausea/vomiting Weakness/Paralysis

Chong S Kim, MD ENT and Facial Plastic Surgeon

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