SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA 02120

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1 SUMON NANDI, MD NEW ENGLAND BAPTIST HOSPITAL 125 PARKER HILL AVENUE FOGG BUILDING, SUITE 501 BOSTON, MA You have been scheduled for an appointment with Dr. Nandi. At your earliest convenience, please fill out all forms in this packet completely and mail them back to our office. If you are unable to make this appointment, please call our office at to reschedule. Please follow the instructions below for your appointment. They are essential to making the most of your clinic visit: 1. Please arrive 1 hour prior to your scheduled appointment time. 2. Please bring your insurance card(s) and a photo ID with you. 3. If your insurance company requires a referral, please contact your primary care physician and have them fax it to the office at Please call , Monday through Friday, 8:00AM-5:30PM, to pre-register for x-rays by telephone. Be sure to have your insurance card(s) available. If you have any questions, please feel free to contact our office. Thank you in advance for your cooperation. Sincerely, Lisa Coleman, Office Manager

2 SUMON NANDI, MD PATIENT INFORMATION NAME: DATE OF BIRTH: AGE: ADDRESS: CITY: STATE: ZIP: HOME PHONE #: ( ) CELL #: ( ) SOCIAL SECURITY #: - - OCCUPATION: MARITAL STATUS: EMPLOYER: EMERGENCY CONTACT / RELATIONSHIP: / HOME PHONE #: ( ) ALTERNATE PHONE #: ( ) WHO REFERRED YOU TO DR. NANDI? PRIMARY CARE PHYSICIAN: ADDRESS: PHONE #: ( ) FAX #: ( ) PHARMACY NAME & ADDRESS: PHONE #: ( ) FAX #: ( ) PRESCRIPTION DRUG INSURANCE: ID #: PHONE #: ( ) GROUP #: INSURANCE INFORMATION: PRIMARY INSURANCE: MEMBER ID#: SUBSCRIBER S NAME & DATE OF BIRTH: / / GROUP #: SECONDARY INSURANCE: MEMBER ID#: SUBSCRIBER S NAME & DATE OF BIRTH: / / GROUP #: WORKER S COMPENSATION: IS THIS A WORK-RELATED INJURY? YES NO DATE OF INJURY: / / INSURANCE COMPANY: INSURANCE COMPANY PHONE #: ( ) FILE/CLAIM #: CASE MANAGER: INSURANCE ADJUSTOR: Authorization/Consent I hereby authorize Sumon Nandi, M.D., to furnish information to my insurance carrier in the course of my treatment, and further authorize payment of surgical and/or medical benefits to the physician(s). In consideration of medical services to be rendered, I understand I am responsible for any unpaid balances, including co-payments and/or deductibles, and payment is due within thirty (30) days of the billing date. I give permission to Sumon Nandi, M.D., to check my prescription eligibility and history. Patient Signature / / Date

3 REASON FOR VISIT: HOW LONG HAVE YOU HAD THIS PROBLEM? HAVE YOU TAKEN ANY ANTI-INFLAMMATORIES? IF SO, PLEASE LIST: WHAT ADDITIONAL TREATMENTS HAVE YOU RECEIVED (PHYSICAL THERAPY, JOINT INJECTIONS, SURGERY)? Using the diagrams below, please indicate specifically where you are having pain: Using the scale below, please indicate how severe your pain is: No Pain (0) Severe Pain (10)

4 DO YOU HAVE PAST MEDICAL HISTORY DIABETES YES NO HEART DISEASE YES NO HIGH BLOOD PRESSURE YES NO LUNG DISEASE YES NO ASTHMA YES NO LIVER DISEASE YES NO KIDNEY DISEASE YES NO ARTHRITIS YES NO BLEEDING PROBLEMS YES NO BLOOD CLOTS YES NO ANY OTHER CONDITIONS: PREVIOUS SURGERIES: CURRENT MEDICATIONS: DOSAGE: FREQUENCY: ALLERGIES TO MEDICATION(S): FAMILY HISTORY DO YOU HAVE A FAMILY HISTORY OF CANCER YES NO DIABETES YES NO ELEVATED CHOLESTEROL YES NO HEART DISEASE YES NO HIGH BLOOD PRESSURE YES NO SOCIAL HISTORY DO YOU SMOKE? YES NO If YES, how much? DO YOU CONSUME ALCOHOL? YES NO If YES, how much?

5 REVIEW OF SYSTEMS IF YOU ARE EXPERIENCING ANY OF THE SYMPTOMS BELOW, CIRCLE THE Y WHERE INDICATED. PATIENTS ARE ADVISED THAT IF ANY OF THE FOLLOWING SYMPTOMS PERSIST, THEY ARE ENCOURAGED TO DISCUSS THEM WITH THEIR PRIMARY CARE PHYSICIAN. CONSTITUTIONAL Y N Fever Y N Weight loss HEAD, EARS, EYES, NOSE, THROAT Y N Changes in vision Y N Headache Y N Tooth/gum problems Y N Nose bleeds CARDIOVASCULAR Y N Chest pain/tightness Y N Heart palpitations Y N Leg swelling Y N Leg pain with walking RESPIRATORY Y N Cough with phlegm or blood Y N Shortness of breath Y N Sleep apnea GASTROINTESTINAL Y N Abdominal pain Y N Diarrhea Y N Bloody stool GENITOURINARY Y N Blood in urine Y N Pain with urination Y N Difficulty urinating Y N Genital discharge MUSCULOSKELETAL Y N Back pain Y N Muscle pain Y N Weakness DERMATOLOGIC Y N Non-healing/slow-healing wounds Y N Rash NEUROLOGIC Y N Seizures Y N Fainting/loss of consciousness PSYCHIATRIC Y N Depression Y N Substance abuse ENDOCRINE Y N Excessive thirst Y N Constant hunger without weight gain HEMATOLOGIC Y N Excessive bleeding Y N Blood clots I certify to the best of my knowledge that the information I have provided is accurate. / / Patient Name (Please Print) Patient Signature Date

6 SUMON NANDI, MD BILLING POLICY HEALTH INSURANCE CARD: Please have your insurance card with you when you register with the office. If your insurance should change, please notify the office as soon as possible. INSURANCE BENEFITS: It is your responsibility to verify your medical benefits with your insurance company. Benefits are subject to the provisions of your policy. REFERRALS: If your insurance requires referrals, you are responsible to provide one at the time of your visit. You will be responsible to obtain future referrals as needed for your treatment(s). You will also be responsible for payment of any visit that does not have a referral at the time of service. MOTOR VEHICLE ACCIDENTS: We will not bill MVA insurance carriers and/or attorneys for services rendered. All visit(s) are to be paid in-full at the time of visit(s). Our office will assist you in obtaining payment from the insurance company by providing any necessary documentation at your request. WORKERS COMPENSATION: Please provide the office with your date of injury, claim number, and your case adjuster s name and telephone number. We reserve the right to cancel your appointment(s) until the workers compensation claim is verified and approved. CONSENT TO RENDER PAYMENT: You hereby authorize the payment of medical benefits to this office for services rendered. We agree to bill your insurance company, however, should the insurance company delay payment or deny claims beyond 60 days of submission; you will be responsible for making the payment in-full after receiving notification from your insurance company. DEDUCTIBLE, CO- INSURANCE, CO-PAYMENT: You hereby agree to pay all copayments, deductibles, and co-insurances if required by your insurance company at the time of your visit. This is your contractual obligation with your insurance company, and we are mandated to collect this. NOTICE OF CANCELLATION: This office requires a twenty-four (24) hour cancellation notice for any scheduled appointments. PATIENT STATEMENTS: All bills are to be paid within thirty (30) days of receipt. I have read the Billing Policy and understand my responsibilities as a patient. / / Patient Name (Please Print) Patient Signature Date