WORKERS COMPENSATION - NO FAULT. Patient Name Patient Address. Patient's SS# Date of Birth Attorney Name _ Phone Number WORKERS COMPENSATION

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1 WORKERS COMPENSATION - NO FAULT Patient Name Patient Address Patient's SS# Date of Birth Attorney Name Phone Number WORKERS COMPENSATION Insurance Carrier & Address Insurance Carrier Phone Number Fax Case Worker Name Policy Number Claim Number WCB# Employer Employer Address Employer Phone Number Has your employer filed an accident report? YES NO Date(s) unable to work due to accident? Brief description of accident? NO FAULT Accident Date Insurance Carrier Address Policy Number Claim Number Phone Number Representative Name Date(s) unable to work due to accident? AGREEMENT TO PAY MEDICAL COSTS IN THE EVENT OF FAILURE TO PROSECUTE OR IF COMPENSATION OR NO FAULT CLAIM IS DISALLOWED: In the event I fail to prosecute the claim for workers compensation or no fault for the injury OR it is determined by the workers compensation board or no fault that the illness or condition is not a result of a compensable workers compensation or no fault case, I HEREBY AGREE TO PAY THE PHYSICIANS USUAL AND CUSTOMARY FEES FOR SERVICES RENEDERED TO THE ABOVE NAMED CLAIMANT IN THE ABOVE IDENTIFIED CASE. I ALSO AUTHORIZE PAYMENT TO BE MADE DIRECTLY TO THE PHYSICAIN. DATE: SIGNATURE:

2 ASSIGNMENT OF BENEFITS I request that payment of authorized medical benefits be made to Dr Adam D Soyer DO on my behalf for services furnished to me by the provider. I authorize any holder of medical information about me to release to the insurance carrier and its agents any information needed to determine these benefits or the benefits payable for related services. Patient's Signature Date Patient's Name (Print)

3 MEDICAL AUTHORIZATIONS I AUTHORIZE YOU TO GIVE ME REASONABLE AND PROPER MEDICAL CARE BY TODAY'S STANDARDS. INSURANCE POLICY: As a courtesy, we will bill your insurance company for you ifyou have providcd us with the insurance name, policy numbers, address, place of employment and any other pertinent infonnation. You are responsible for all deductibles, co-pays, and charges not covered by your insurance. All Orthopedic DME (casting supplies, splints, etc) not covered by your insurance are the patient's responsibility. Failure to submit payment for your portion ofyour bill may result in referring your account to a collection agency. Patients that cancel appointments in less than 24 hours or miss appointments will be charged a "No- Show" fee. Please keep and make all of your appointments. TO OUR PATIENTS WITH MEDICARE: Medicare law requires us to have you sign this forma and keep it in your file. If you have any questions, feel free to ask our office staff. I request that payment of authorized Medicare benefits be made to Dr Adam D Soyer DO for any services furnished. authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to detennine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance, and non covered services. Co- insurances and the deductible are based upon the charge detennination of the Medicare carrier. TO OUR PATIENTS WITH INSURANCE OTHER THAN MEDICARE: I authorize the release of any medical or other infonnation necessary to process this claim. I also request payment of benefits to the party who accepts assignment. I agree to pay all deductibles and non covered services, if Dr Soyer is out of network for my insurance plan. HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a "Privacy Rule" to help insure that personal health care infonnation is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health infonnation about the patient to carry out treatment, payment, or health care operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate or necessary, we provide the minimum necessary information only to those we feel are in need ofyour health care information regarding treatment, payment or health care operations, in order to provide health care that is in your best interest. We fully support your access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with the physician and not patients), and my have to disclose personal health infonnation for purposes of treatment, payment or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health infonnation, but this must be done in writing. Under this law, we have to right to refuse to treat you should you choose to refuse to disclose your Personal Health Infonnation. If you choose to give consent in this document, at some future time you may request to refuse all or part of your Personal Health Information. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this fonn, please ask to speak with our HfPAA Compliance Officer. You have the right to review our Privacy Notice (Compliance Assurance Notification to Our Patients), to request restrictions and revoke consent in writing.

4 WHO OR WHAT REFERRED YOU TO OUR OFFICE AD FRIEND INTERNET YELLOW PAGES DR REFERRAL OTHER WHY ARE YOU HERE TODAY CIRCLE ONE LEFT SIDE RIGHT SIDE ALLERGIES CURRENT MEDICATIONS PAST MEDICAL HISTORY PAST SURGICAL HISTORY CURRENT HEIGHT CURRENT WEIGHT FAMILY HISTORY (CHECK ALL THAT APPLY): "IMMEDIATE FAMILY" CANCER HEART DISEASE HIGH BLOOD PRESSURE ANEMIA DIABETES ABNORMAL BLEEDING --- DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING PROBLEMS CHECK ALL THAT APPLY SWALLOWING NOSEBLEEDS HEADACHES HEARING TEETH EYESIGHT SKIN PROBLEMS NUMBNESS WEAKNESS PAIN WALKING PAIN/URINATING /BOWELS NAUSEA/VOMIT BLOOD STOOLS/URINE PNEUMONIA DATE: SIGNATURE:

5 Patient's Last Name First M DOB Age Street Address Home Phone # Spouse's Name Patient's Employer Employer's Address Cell # APT # Sex M F Marital Status SMWDSP SS# - - FIT Student Y N Spouse's # - Work # Referring MD Name Referring Address Phone # Fax # Primary Doctor Name Primary Address Phone # Fax # Emergency Contact Relationship to Patient Phone # PRIMARY Insurace Company Street Address Group # Policy # I EffDate Phone # Name of Policy (Card) Holder Relationship to Patient DOB of Policy Holder SS # of Policy Holder Policy Holder Employer Policy Holder Address Work # Do you require referrals? Y N Did you obtain a referral? Y N It is Patient's responsibility to obtain referrals. Patients without referrals will be responsible for the full amount of the visit. SECONDARY Insurance Company Group # I EffDate Street Address Policy # Phone # Name of Policy (Card) Holder DOB of Policy Holder Relationship to Patient SS # of Policy Holder Policy Holder Employer Work # Policy Holder Address Signature Date