Carroll County Nephrology, PC

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1 Carroll County Nephrology, PC Phone: Fax: Maria J. Orig, M.D. FASN Bryan D. Quinn, M.D. WELCOME TO CARROLL COUNTY NEPHROLOGY **Please bring the completed enclosed paper work with you to your appointment along with your medications and insurance card(s). Do not mail this information to the office. Please arrive 15 minutes prior to your scheduled appointment time.** We have three office locations for your convenience: CARROLLTON : 157 Clinic Ave, Suite 203 Carrollton, GA Located between Tanner Hospital and Walgreens Pharmacy BREMEN : 108 Redding Dr. Bremen, GA Located behind the Piggy Wiggly shopping center on Hwy 78 VILLA RICA : 403 Permian Way #B Villa Rica, GA Exit I-20 onto Mirror Lake Blvd. and travel north to the first light (intersection at Conners Rd). Turn right onto Conners Rd and travel past the Publix shopping center on your left. Take first right turn onto Permian Way (at the Dollar General store sign) and continue straight to the office. IMPORTANT: Please bring the following information with you to your appointment: Enclosed paperwork Photo identification and insurance card(s) All current medications Date: Thank you, Time: Maria J. Orig, M.D., FASN Bryan D. Quinn, M. D.

2 PATIENT INFORMATION SHEET Patient Name: Last First Middle Initial Date of Birth: SSN: Marital Status (circle one): married single divorced widowed Sex: Male Female Address for Billing: City: State: Zip: Home Phone: Cell Phone: Patient Employer: Occupation: IN CASE OF AN EMERGENCY, NOTIFY: Relationship to Patient: Phone: Responsible Party: Relationship to Patient: Address (if different from above): City: State: Zip: PRIMARY INSURANCE: ID#: NAME OF INSURED: Date of Birth OF INSURED: SSN OF INSURED: SECONDARY INSURANCE (if any): ID#: NAME OF INSURED: Date of Birth OF INSURED: SSN OF INSURED: Referring Physician: Name Phone # X Patient or legally authorized individual signature Date

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BEUSEDAND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE RE VIEW IT CAREFULLY.

3 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BEUSEDAND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE RE VIEW IT CAREFULLY. WHO WILL FOLLOW THIS NOTICE This notice describes our Carroll County Nephrology, PC health care practices and that of: Any health care professional authorized to enter information into your medical record. OUR PLEDGE REGARDING MEDICAL INFORMATION: We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services your receive at the facility/practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the Physician. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information. We. are required by law to: Make sure that the medical information that identifies you is kept private; Give you this notice of our legal duties and privacy practices with respect to medical information about you; and follow the terms ofthe notice that is currently in effect. HOW WE MAY USE & DISCLOSE MEDICAL INFORMATION ABOUT YOU The follow categories describe different ways that we use and disclose medical information. All of the ways we are permitted to use and disclose information will fall within one ofthe categories. For Treatment. We may use medical information about you to provide you with treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care ofyou. For example, a doctor treating you for a broken leg may need to know ifyou have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the dietitian if you have diabetes so that we can arrange for appropriate meals. For Payment. We may use and disclose medical information about you so that the treatment and services you receive at our facility may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about your office visit so your health plan will pay us or reimburse you for the visit. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. For Health Care Operations. We may use and disclose medical information about you for

4 To report neglect; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for contacting or spreading a disease or condition; To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only ifefforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. We may release medical information ifasked to do so by a law enforcement official: In response to a court order, subpoena, warrant, summons or similar process; To identify or locate a suspect, fugitive, material witness, or missing person; About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; About a death we believe may be the result of criminal conduct; About criminal conduct at the facility/practice; and In emergency circumstances to report a crime; the location ofthe crime or victims; or the identity, description or location ofthe person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities. We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, Inmates. If you are an inmate of a correctional Institution or under the custody ofa law enforcement official, we may release medical information about you to the correctional institute or la~ enforcement official. This release would be necessary (1) for the institution to provide you Wlth health care; (2) to protect your health and sqjety or the health and safety ofothers: or 2

5 (3) for the safety and security ofthe correctional institution. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU. You have the following rights regarding medical information we maintain about you: You have the right to Inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to Carroll County Nephrology, Attn: Medical Records. If you request a copy ofthe information, we may charge a fee for the costs ofcopying, mailing or other supplies associated with your request Right to Amend. Ifyou feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the Information is kept by the office. To request an amendment, your request must be make in writing and submitted to Carroll County Nephrology. In addition, you must provide a reason that supports your request We may deny your request for an amendment ifit is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; Is not part ofthe medical information kept by or for the office; Is not part ofthe information which you would be permitted to inspect, and copy; or Is accurate and complete. Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of the disclosures we made of medical information about you. To request this list of accounting of disclosures, you must submit your request in writing to Carroll County Nephrology, Medical Records. Your request must state a time period, which may not be longer than six years and may not include dates before February 26,2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you ofthe cost involved and you may choose to withdraw or modify yotir request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use to disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you.to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery that you had. We are not required to agree to your request Ifwe do agree, we will comply with your request 3

6 health care operations. These uses and disclosures are necessary to operate the health care system and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. For Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care. Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits that may be of interest to you. Individuals Involved in Your Care or Payment of Your Care. We may release medical information about yon to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. As Required by Law. We will disclose medical information about you when required to do so by federal, state or local law. To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. SPECIAL SITUATIONS Organ and Tissue Donation. Ifyou are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Military and Veterans. Ifyou are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. Workers' Compensation. We may release medical information about yon for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following: To prevent or control disease, injury or disability; To report deaths; 4

7 Authorization for Disclosure of Protected Health Information Carroll County Nephrology, PC To the following person or class of persons: To any and all physicians health care providers, health care facilities, or healthcare entities that provide or have provided health care services to the patient named below. Patient name: Date of birth: Note: You refers to the person(s) to whom this authorization is directed. I, me refers to patient. Authorization You are hereby authorized to disclose my protected health information, whether oral, written or electronic healthcare information pertaining to my complete medical record, including but not limited to HIV and AIDS confidential information. You are hereby authorized to disclose my protected health information specifically pertaining to my mental health, including but not limited to psychiatric and psychological information, drug and alcohol abuse treatment information. You are hereby authorized to disclose my protected health information to any physician health care provider or healthcare facility that has provided health care services to me. Additionally, you are hereby authorized to disclose such protected health information to any attorney at law representing such physician, healthcare provider or healthcare facility. Discussion related to my care. You are hereby authorized to discuss my care and treatment with any attorney or representative of an insurance provider if I assert a claim against another physician, health care provider, health care facility or health care entity. This authorization expires in three (3) years after the date of execution shown below. I hereby authorize and direct payment to Carroll County Nephrology, PC for medical benefits under the terms of my insurance. I hereby authorize the release of medical records to the indicated insurance company9ies) for the purpose of proof of treatment, verification of coverage and pre-certification. Patient s Rights I understand I do not have to sign this authorization to receive healthcare benefits (treatment, payment or enrollment) from the person (s) to whom this authorization is directed. I may revoke this authorization in writing at any time. If I do so, it would not affect any actions already taken by someone in reliance on this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance coverage. If I wish to revoke this authorization, I shall do so by sending a letter to the person (s) to whom this authorization is directed. Once the health care provider discloses information, any person or organization that receives it may re-disclose it. Patient privacy laws may no longer protect that information. I must sign an authorization form to take part in a research study, or to receive healthcare when the purpose is to create health information for a third party. Patient or legally authorized individual signature Printed Name (if signed on behalf of patient) Date Relationship (parent, guardian)

8 Carroll County Nephrology, PC Phone: Fax: Maria J. Orig, M.D. FASN Bryan D. Quinn, M.D. Our Pledge Regarding Medical Information We understand that medical information about you and your health is very personal. As such, our staff is committed to protect your medical information. We are required by law to insure that all medical information that identifies you is kept private. To comply with the proper use and disclosure of your medical information, please provide us below with the names of the individuals involved in your care and/or with the payment of your care. Name Relationship Phone Number Name Relationship Phone Number Signature of Patient: Date:

9 Carroll County Nephrology, PC Phone: Fax: Maria J. Orig, M.D. FASN Bryan D. Quinn, M.D. Financial Policy All co pays are due at the time of visit. This includes the 20% coinsurance allowed by Medicare if you do not have a secondary insurance. If you have deductibles under your plan that applies to our visits, you are responsible for paying this in a timely matter. Please contact our billing department if payment arrangements are required. Carroll County Nephrology requires a 24 hour notice for all cancellations. If no one is available when you call, please leave a detailed voice message with your name and date/time of appointment. If appropriate notice is not given, there will be a $25.00 charge. Carroll County Nephrology PC accepts cash, check, money order, VISA and MasterCard as forms of payment. Please be aware there will be a $30.00 charge for non sufficient funds for returned checks marked with non sufficient funds. This is an automatic debit done by our bank. Carroll County Nephrology PC will charge an administrative fee of $15.00 to patients requesting forms (examples: medical records copies, disability, family medical leave,medical equipment forms, etc.), to be completed by staff. The patient is responsible for this fee. Please sign below to indicate that you have read and understand all of the above statements. X Signature of Patient Date

10 Carroll County Nephrology, PC Phone: Fax: Maria J. Orig, M.D. FASN Bryan D. Quinn, M.D. Please provide us with your preferred Pharmacy information: Pharmacy: Phone: Signature: Date:

PATIENT INFORMATION. Name: Date of Birth: Age: Last name First Middle I. Home Address: City: State/Zip: Home Phone: Cell Phone:

PATIENT INFORMATION. Name: Date of Birth: Age: Last name First Middle I. Home Address: City: State/Zip: Home Phone: Cell Phone: THE ELITE LASER VEIN CENTER MICHAEL F. RICHMAN, M.D.,F.A.C.S. Date: PATIENT INFORMATION Name: Date of Birth: Age: Last name First Middle I Soc. Sec. #: Driver License#: Home Address: City: State/Zip: Home