PREFERRED METHOD OF APPOINTMENT REMINDER O PHONE O TEXT O EMERGENCY CONTACT NOT RESIDING WITH YOU Name: Relationship:

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1 Mario Rossbach MD & Zack Nash MD General and Vascular Surgeons PATIENT INFORMATION Primary Care Physician: Today s Date: Referring Doctor (If different from above ): Patient Name: O Male O Female Last First, M.I. Street Address: Street / P.O. Box City State Zip Code Mailing Address: (If different from above) Street/P.O. Box City State Zip Code Address Date of Birth: Age: Marital Status: S M D W Drivers License #: Home Phone: Social Security#: Cell Phone: EMPLOYER: Work Phone: PREFERRED METHOD OF CONTACT: O HOME O CELL O WORK PREFERRED METHOD OF APPOINTMENT REMINDER O PHONE O TEXT O EMERGENCY CONTACT NOT RESIDING WITH YOU Name: Relationship: Home Phone #: Cell Phone#: Spouse / Parent Name: DOB: Social Security #: (circle one) Employer: Phone#: Primary Insurance INSURANCE INFORMATION (Please present all insurance cards and photo I.D. to receptionist) Secondary Payment is expected at the time services are rendered unless other arrangements have been made. If you do not have any health insurance you must speak with the business office prior to leaving. We currently accept cash, checks and credit cards. I request and authorize that payment of authorized Medicare/Insurance benefits furnished to me be made payable to the physician or physicians and/or New Braunfels Cardiology. I authorize release of any medical information necessary to obtain payment of insurance benefits. I also understand that I am financially responsible for any balance not covered by my insurance and that a copy of this signature is as valid as the original. Signature: Date: PLEASE BE ADVISED WE DO EMPLOY MID-LEVEL PROVIDERS AND YOU MAY BE SCHEDULED WITH ONE OF THEM FOR YOUR FOLLOW UP IF REQUESTED BY YOUR PHYSICIAN.

2 NEW BRAUNFELS CARDIOLOGY Financial Policy We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies. 1. Payment is due at the time of service unless arrangements have been made in advance with your insurance carrier. We accept Cash, Checks, Money orders and Credit Cards. 2. Keep in mind that your insurance policy is basically a contract between you and your insurance company. As a service to you, we will file your insurance claim if you assign benefits to the doctor-in other words, if you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period of time, we will have to look to you for payment. If we later receive a check from your insurer, we will refund any overpayment to you. 3. We have made prior arrangements with many insurance companies and other health plans to accept assignment of benefits. We will bill them, and if you are required to pay a co-pay/deductible, it is due at the time of your visit. 4. If you are insured by a plan that we do not have prior arrangements with, we will prepare and send the claim for you. You will be responsible for any amount due that is not covered by your insurance company. 5. Not all insurance plans cover all services. In the event your insurance plan determines a service to be not covered you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. 6. Some insurance companies require referral authorization. It is ultimately the patient s responsibility to know your insurance coverage/benefits and requirements. If an authorization was needed and was not done you will be liable for the full amount of the services in the event that your insurance does not pay. 7. No-show appointments will be charged a $40.00 fee. I have read and understand the practice s financial policy and I agree to be bound by its terms. I also, understand and agree that such terms may be amended by the practice from time to time. Signature of patient (or responsible party, if minor) Date Please print the name of the patient Date of birth

3 NEW BRAUNFELS CARDIOLOGY ATTENTION ALL PATIENTS We are committed to providing you with the best possible medical care. In order to do this, we need you to be aware of your own individual insurance coverage/benefit s and if New Braunfels Cardiology and/or its physicians are contracted with your insurance. We have too many insurance plans that we file with and cannot know whether or not New Braunfels Cardiology and/or its physicians are contracted with each and everyone s insurance. It is the patient s responsibility to find this information out prior to becoming a patient with this practice or if changing insurance. As a patient, please be aware, many insurances require a Referral or Pre-Authorization prior to the service being done. Please take appropriate steps to have this done prior to your visit.

4 Patient Name: Date of Birth Social Security # Phone: (H) (W) Records to be requested from: Facility / Physician Phone / Fax To release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the person(s) or entity listed below. HIV / AIDS: I consent to the release of any positive or negative test result for AIDS or HIV infection, antibodies to AIDS or infection with any other causative agent of AIDS with the rest of my medical records. Initial: Date: Mental health/substance Abuse: I consent to the release of my medical records related to treatment for mental health and /or substance abuse with the rest of my medical records. Initial: Date: We are requesting the following records: Release my protected health information to: New Braunfels Cardiology 1626 E. Common New Braunfels, TX The reasons or purpose for this release of information are as follows: I understand that you will provide this information within 15 days from receipt of request and that a fee for preparing and furnishing this information may be charged according to rulings set forth by the Texas State Board of Medical Examiners. I understand that I have the right to revoke this authorization, in writing, at any time by sending a written notification to the following person at the practice: Darla Wright I understand that a revocation is not effective to the extent that the practice has relied on this authorization in its actions. Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to context a claim under the policy or the policy itself. I understand that my health records may be released electronically. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal HIPPA privacy regulations. The practice will not condition my treatment, payment and enrollment in a health plan or eligibility for benefits on whether I provide authorization for the requested use or disclosure. Signature of Patient or Personal Representative 1626 E. Common St. New Braunfels Texas Fax nbc @yahoo.com

5 Mario Rossbach MD & Zack Nash MD General and Vascular Surgeons Date: CURRENT MEDICATIONS Patient Name: DOB: Please list all medications that you are currently taking (including insulin, over the counter medications, vitamins, diet supplements, herbal supplements etc.). MEDICATION Do you currently take Aspirin? DOSAGE 81mg/325 mg TIMES TAKEN PER DAY REASON DATE STARTED 1626 E. Common St New Braunfels Texas Fax

6 Patient Name: Date: Age: DOB: Gender: M / F Ht: Wt: Bra Size: Family doctor: Other physicians currently treating you: Reason for today s visit: Are you allergic to any medications: No Yes (Are you allergic to Shellfish, Iodine or Radiographic Dye): No Yes Have you ever been diagnosed with any of the following medical conditions? Check all that apply. Heart Attack Atrial Fibrillation Diabetes COPD/Emphysema Coronary Artery Disease Peripheral Vascular Disease Thyroid Disorder Pulmonary Embolism Congestive Heart Failure Heart Murmur Seizure Disorder Sleep Apnea High Blood Pressure Rheumatic Fever Kidney Disease Acid Reflux High Cholesterol Stroke/TIA Asthma Hepatitis A, B or C Please list any other medical conditions you have been diagnosed with: Have you ever had any of the following tests or procedures: Give approximate date if known. Check all that apply. EKG Date: Valve Surgery Date: Treadmill Stress Test Date: Pacemaker Implantation Date: Nuclear Stress Test Date: Defibrillator Implantation Date: Cardiac Cath Date: Heart Bypass Date: Angioplasty (balloon/stents) Date: (How many vessels) Other surgical history (please include approximate dates if known): Family History: Please indicate if any of your relatives listed below have a history of: Heart Attack, Stents, Angioplasty, Bypass Surgery, High Blood Pressure or Cholesterol, Heart Arrhythmia or Stroke. Father Mother Brother (s) No Yes If yes, age of onset Type of Health Problem(s) Sister (s) List any other IMMEDIATE family members with any of the conditions listed above, include age of onset: Age and Cause of Death Do you currently use tobacco? No Yes If yes, what type: Cigarettes Chewing Tobacco Pipe Cigars Do you have a past history of tobacco use? No Yes If yes, when did you quit: Do you drink alcoholic beverages? No Yes If yes, please list type of alcohol, how often and how much is consumed: Do you use or have you ever used illicit/recreational drugs? No Yes Comments: Do you have an Advanced Directive or Living Will? Y / N Please make sure we have a copy of this in your permanent file.

7 HIPAA Notice of Privacy Practices Mission Cardiovascular Consultants 1626 E COMMON ST NEW BRAUNFELS TEXAS 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 Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. 1. Uses and Disclosures of Protected Health Information Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

8 Your Rights Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. ATTENTION: ALL MEDICAL RECORDS ARE STORED ELECTRONICALLY AND HAVE BEEN FOR 6 YEARS. IF YOU HAVE ANY QUESTIONS, PLEASE CHECK WITH THE FRONT DESK. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number. Signature below is only acknowledgement that you have received this Notice of our Privacy Practices: Print Name: DOB: Signature DATE:

9 Mario Rossbach MD & Zack Nash MD General and Vascular Surgeons Date: I, am giving my written authorization to let the following people have permission to speak to Mission Cardiovascular Consultants/New Braunfels Cardiology physicians or staff about my medical condition and/or financial issues Signature Date of Birth I give my permission to leave a message on my answering machine/voic for: Appointment reminders, scheduling changes, billing information, results, and testing. YESNO 1626 E. Common St. New Braunfels Texas Fax nbc @yahoo.com

10 Mario Rossbach MD & Zack Nash MD General and Vascular Surgeons Date: Name: DOB: ARE YOU AT RISK FOR PERIPHERAL VASCULAR DISEASE? Your answers to these questions will help you know. DO YOU HAVE? Cardiovascular (heart) problems such as high blood pressure, heart YES NO attack, stroke, or high cholesterol? Diabetes YES NO A family history of diabetes or cardiovascular problems? (immediate family such as parent, sister, brother) Aching, cramping, tightness, or pain in your legs or thighs when you walk or exercise but then goes away when you rest? If yes, which leg (L R ) and location YES YES NO NO Pain in your feet or toes? YES NO If yes, please indicate which foot (L R ) and location Any ulcers or sores on your feet or legs that are slow in healing? YES NO If yes, please indicate which foot/leg(l R ) and location An inactive lifestyle? YES NO Do you smoke? YES NO Have you ever smoked? YES NO Are you more than 25 pounds overweight? YES NO Do you eat fried or fatty foods three times a week or more? YES NO Doctor use only (below): Schedule Test YES NO Calculate your score / (Total the yes responses) The higher your score, the more important it is to discuss the responses to this questionnaire E. Common St. New Braunfels Texas Fax nbc @yahoo.com

11 Mario Rossbach MD & Zack Nash MD General and Vascular Surgeons Welcome to New Braunfels Cardiology Enclosed you will find your patient information packet. Please complete the attached forms and sign at the bottom of the pages where indicated. Bring the following with you to your appointment: Completed forms; Your drivers license or a current picture ID; Your Medicare and/or insurance cards; and Current list of all prescription and over the counter medications you are taking. Plan to arrive at least 15 minutes prior to your scheduled appointment time. You are scheduled on at AM/PM with Dr.. If you are unable to keep your appointment, we require 24 hours advance notice, otherwise you will be charged for that missed appointment. Please note that if you have insurance we will be happy to file with your primary and secondary insurances, however, we do not file with third insurances. Any unpaid balances are the patient s responsibility. If you require payment arrangements, please contact our billing office, prior to your appointment. We look forward to caring for you. The Office Staff of New Braunfels Cardiology 1626 E. Common St. New Braunfels Texas Fax nbc @yahoo.com