Jeffrey W. Heitkamp, M.D. Diplomate, American Board of Neurological Surgery PATIENT INFORMATION

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1 Jeffrey W. Heitkamp, M.D. Diplomate, American Board of Neurological Surgery PATIENT INFORMATION PATIENT S LAST NAME FIRST NAME MIDDLE INITIAL STREET ADDRESS CITY STATE ZIP CODE SEX BIRTHDATE AGE SSN HOME# WORK# CELL# REFERRING DOCTOR / PCP SMOKER: YES NO EMPLOYMENT STATUS: FULL-TIME PART-TIME NOT EMPLOYED SELF EMPLOYED RETIRED ACTIVE DUTY IS THIS A WORK INJURY: YES NO SINGLE - MARRIED - DIVORCED - WIDOWED IS THIS AN AUTO ACCIDENT: YES NO CIRCLE ONE STUDENT STATUS: FULL-TIME PART-TIME DRIVERS LICENSE #: MEDICATION ALLERGIES: EMERGENCY CONTACT NAME: RELATIONSHIP TO PATIENT: PHONE# PRIMARY INSURANCE INFORMATION PRIMARY INSURANCE POLICYHOLDER POLICYHOLDER S SEX POLICYHOLDER S DOB POLICYHOLDER S SSN PATIENT S RELATIONSHIP TO POLICYHOLDER POLICY EFFECTIVE DATE POLICYHOLDER S EMPLOYER PATIENT S POLICY ID EMPLOYER S ADDRESS GROUP # CITY STATE ZIP SECONDARY INSURANCE INFORMATION SECONDARY INSURANCE POLICYHOLDER POLICYHOLDER S SEX POLICYHOLDER S DOB POLICYHOLDER S SSN PATIENT S RELATIONSHIP TO POLICYHOLDER POLICY EFFECTIVE DATE POLICYHOLDER S EMPLOYER PATIENT S POLICY ID EMPLOYER S ADDRESS GROUP # CITY STATE ZIP PATIENT S SIGNATURE DATE

2 DATE NAME REASON FOR THIS VISIT (MAIN COMPLAINT): HOW LONG HAVE YOU HAD THIS PROBLEM? LIST ANY TREATMENT YOU VE HAD FOR THIS PROBLEM: (P.T., MEDICATION, CHIROPRACTIC, OR INJECTION): LIST ANY PAST SURGERIES: LIST ALL MEDICATION YOU RE CURRENTLY TAKING, BOTH DOSE & FREQUENCY: ARE YOU CURRENTLY TAKING ANY DIET OR HERBAL SUPPLEMENTS? YES NO IF YES, LIST NAME & DOSAGE LIST ANY DRUG ALLERGIES: HEIGHT WEIGHT SMOKE: YES NO IF YES, HOW MUCH DRINK ALCOHOL: YES NO HAVE YOU EVER HAD ANY OF THE FOLLOWING: ANGINA (CHEST PAIN) ASTHMA BLEEDING DISORDER HEART ARRHYTHMIA CONGESTIVE HEART FAILURE MENINGITIS HYPERTENSION DIABETES CORONARY ARTERY DISEASE HEPATITIS HIV POS. SLEEP APNEA SEIZURES SPINAL SURGERY CANCER

3 Jeffrey W. Heitkamp, MD Diplomate, American Board of Neurological Surgery RELEASE OF MEDICAL INFORMATION I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM AND RELATED CLAIMS. SIGNATURE PAYMENT OF MEDICAL BENEFITS I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO THE UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICES RENDERED. SIGNATURE SUPPLIER ARLINGTON ASSOCIATION OF NEUROLOGICAL SURGEONS, P.A. Arlington Association of Neurological Surgeons 1001 N. WALDROP, SUITE 801 * ARLINGTON, TX (817)

4 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION I AUTHORIZE MY PHYSICIAN AND/OR ADMINISTRATIVE AND CLINICAL STAFF TO (CHECK ALL THAT APPLY): USE THE FOLLOWING PROTECTED HEALTH INFORMATION, AND/OR DISCLOSE THE FOLLOWING PROTECTED HEALTH INFORMATION TO {NAME OF ENTITY OR CLASS OF PERSONS TO RECEIVE INFORMATION}: {SPECIFICALLY AND MEANINGFULLY DESCRIBE THE PROTECTED HEALTH INFORMATION TO BE USED OR DISCLOSED SUCH AS DATE OF SERVICE, TYPE OF SERVICE, LEVEL OF DETAIL TO BE RELEASED, ORIGIN OF INFORMATION, ETC.} THIS PROTECTED HEALTH INFORMATION IS BEING USED OR DISCLOSED FOR THE FOLLOWING PURPOSES: {LIST SPECIFIC PURPOSES HERE. AT THE REQUEST OF THE INDIVIDUAL IS ACCEPTABLE IF THE PATIENT MAKES THE REQUEST, AND THE PATIENT DOES NOT WANT OR STATE A SPECIFIC PURPOSE.} THIS AUTHORIZATION SHALL BE IN FORCE AND EFFECT UNTIL {SPECIFY (1) DATE OR (2) EVENT THAT RELATES TO THE PATIENT OR THE PURPOSE OF THE USE OR DISCLOSURE} AT WHICH TIME THIS AUTHORIZATION TO USE OR DISCLOSE THIS PROTECTED HEALTH INFORMATION EXPIRES. ( END OF THE RESEARCH STUDY AND NONE IS ACCEPTABLE FOR AUTHORIZATION FOR RESEARCH PURPOSES.) I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION, IN WRITING, AT ANY TIME BY SENDING SUCH WRITTEN NOTIFICATION TO THE PRACTICE S PRIVACY CONTRACT AT {OFFICE ADDRESS OR ADDRESS.} I UNDERSTAND THAT A REVOCATION IS NOT EFFECTIVE TO THE EXTENT THAT MY PHYSICIAN HAS RELIED ON THE USE OR DISCLOSURE OF THE PROTECTED HEALTH INFORMATION OR IF MY AUTHORIZATION WAS OBTAINED AS A CONDITION OF OBTAINING INSURANCE COVERAGE AND THE INSURER HAS A LEGAL RIGHT TO CONTEST A CLAIM. I UNDERSTAND THAT INFORMATION USED OR DISCLOSED PURSUANT TO THIS AUTHORIZATION MAY BE DISCLOSED BY THE RECIPIENT AND MAY NO LONGER BE PROTECTED BY FEDERAL OR STATE LAW. MY PHYSICIAN WILL NOT CONDITION MY TREATMENT, PAYMENT, ENROLLMENT IN A HEALTH PLAN OR ELIGIBILITY FOR BENEFITS (IF APPLICABLE) ON WHETHER I PROVIDE AUTHORIZATION FOR THE REQUESTED USE OR DISCLOSURE EXCEPT (1) IF MY TREATMENT IS RELATED TO RESEARCH, OR (2) HEALTH CARE SERVICES ARE PROVIDED TO ME SOLELY FOR THE PURPOSE OF CREATING PROTECTED HEALTH INFORMATION FOR DISCLOSURE TO A THIRD PARTY. THE USE OR DISCLOSURE REQUESTED UNDER THIS AUTHORIZATION WILL RESULT IN DIRECT OR INDIRECT REMUNERATION TO MY PHYSICIAN FROM A THIRD PARTY. {IF APPLICABLE BECAUSE THE AUTHORIZATION IS OBTAINED FOR MARKETING PURPOSES.} SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE PRINT NAME OF PATIENT OR PERSONAL REPRESENTATIVE DESCRIPTION OF PERSONAL REPRESENTATIVE S AUTHORITY TO ACT FOR PATIENT { PROVIDE A COPY OF THIS FORM TO THE PATIENT }

5 CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS I CONSENT TO THE USE OR DISCLOSURE OF MY PROTECTED HEALTH INFORMATION BY ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA FOR THE PURPOSE OF DIAGNOSING OR PROVIDING TREATMENT TO ME, OBTAINING PAYMENT FOR MY HEALTH CARE BILLS OR TO CONDUCT HEALTH CARE OF ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA. I UNDERSTAND THAT DIAGNOSIS OR TREATMENT OF ME BY JEFFREY HEITKAMP, MD MAY BE CONDITIONED UPON MY CONSENT AS EVIDENCED BY MY SIGNATURE ON THIS DOCUMENT. I UNDERSTAND I HAVE THE RIGHT TO REQUEST A RESTRICTION AS TO HOW MY PROTECTED HEALTH INFORMATION IS USED OR DISCLOSED TO CARRY OUT TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS OF THE PRACTICE. ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA IS NOT REQUIRED TO AGREE TO THE RESTRICTIONS THAT I MAY REQUEST. HOWEVER, IF ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA AGREES TO A RESTRICTION THAT I REQUEST, THE RESTRICTION IS BINDING ON ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA AND JEFFREY HEITKAMP, MD. I HAVE THE RIGHT TO REVOKE THIS CONSENT, IN WRITING, AT ANY TIME, EXCEPT TO THE EXTENT THAT JEFFREY HEITKAMP, MD OR ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA HAS TAKEN ACTION IN RELIANCE ON THE CONSENT. MY PROTECTED HEALTH INFORMATION MEANS HEALTH INFORMATION, INCLUDING MY DEMOGRAPHIC INFORMATION, COLLECTED FROM ME AND CREATED OR RECEIVED BY MY PHYSICIAN, ANOTHER HEALTH CARE PROVIDER, A HEALTH PLAN, MY EMPLOYER OR A HEALTH CARE CLEARINGHOUSE. THIS PROTECTED HEALTH INFORMATION RELATES TO MY PAST, PRESENT OR FUTURE PHYSICAL OR MENTAL HEALTH OR CONDITION AND IDENTIFIES ME, OR THERE IS A REASONABLE BASIS TO BELIEVE THE INFORMATION MAY IDENTIFY ME. I UNDERSTAND I HAVE A RIGHT TO REVIEW ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA S NOTICE OF PRIVACY PRACTICES PRIOR TO SIGNING THIS DOCUMENT. THE ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA S NOTICE OF PRIVACY PRACTICE HAS BEEN PROVIDED TO ME. THE NOTICE OF PRIVACY PRACTICES DESCRIBES THE TYPE OF USES AND DISCLOSURES OF MY PROTECTED HEALTH INFORMATION THAT WILL OCCUR IN MY TREATMENT, PAYMENT OF MY BILLS OR IN THE PERFORMANCE OF HEALTH CARE OPERATIONS OF THE ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA IS ALSO PROVIDED IN THE WAITING ROOM. THIS NOTICE OF PRIVACY PRACTICES ALSO DESCRIBES MY RIGHTS AND THE ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA DUTIES WITH RESPECT TO MY PROTECTED HEALTH INFORMATION. ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA RESERVES THE RIGHT TO CHANGE THE PRIVACY PRACTICES THAT ARE DESCRIBED IN THE NOTICE OF PRIVACY PRACTICES. I MAY OBTAIN A REVISED NOTICE OF PRIVACY PRACTICES BY ACCESSING THE ARLINGTON ASSOC. OF NEUROLOGICAL SURGEONS, PA WEBSITE, CALLING THE OFFICE AND REQUESTING A REVISED COPY TO BE SENT IN THE MAIL OR ASKING FOR ONE AT THE TIME OF MY NEXT APPOINTMENT. SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE PRINT NAME OF PATIENT OR PERSONAL REPRESENTATIVE DESCRIPTION OF PERSONAL REPRESENTATIVE S AUTHORITY TO ACT FOR PATIENT DATE

6 September 2014 Dear Patients: As of October 6, 2014 the DEA is now requiring pain medications to be written on triplicate prescriptions. Triplicate prescriptions can NOT be called into the pharmacy. The prescription MUST be delivered to the pharmacist in person and is only good for 3 days from the date on the prescription. After that, the prescription is void. These prescriptions will have to be picked up in our office since refills are not allowed on these prescriptions. Driver s license will be required to pick up these prescriptions. Pain medications will ONLY be prescribed for patients requiring surgery. Pain medications may be given prior to surgery and/or following surgery for a predetermined period of time. During your post surgery recovery, the amount of medication will be gradually reduced to help you avoid dependency of the drug. If surgery is not required, you will be referred back to your primary care physician or pain management. Due to this new rule from the DEA, a 72 hours notice will be required to refill these prescriptions. If triplicate is lost/stolen/outdated a new prescription will not be issued until the present one has expired. Printed name of Patient Date Signature of Patient Witness Signature Date

7 PHARMACIES CVS-ARLINGTON Patient Name: ( ) 6151 Matlock Rd ( ) 5900 W Pleasant Ridge Rd ( ) 815 E Abrams St ( ) 3401 S Collins St ( ) 900 W Pioneer Pkwy ( ) 506 N Fielder Plaza ( ) 1811 E Arkansas Ln ( ) 1800 Brown Blvd ( ) 3801 SW Green Oaks Blvd ( ) 2500 W Park Row ( ) 831 E Park Row ( ) SE Green Oaks Blvd ( ) Other location Walgreens-Arlington Kroger-Arlington ( ) 1020 N Collins St ( ) 2580 E Arkansas Ln ( ) 2410 Ballpark Way ( ) 2475 Ascension Blvd ( ) 3400 Matlock Rd ( ) 5330 S Cooper ( ) 100 SE Green Oaks Blvd ( ) 2350 SE Green Oaks Blvd ( ) 2200 E Pioneer Pkwy ( ) 945 W Lamar ( ) 4208 SW Green Oaks Blvd ( ) 301 S Bowen ( ) 617 W Park Row Dr ( ) 5701 W Pleasant Ridge ( ) 5600 New York Ave ( ) 2210 S Fielder Rd ( ) 2420 W Arkansas Ln ( ) Other location ( ) 1116 W Lamar Blvd ( ) 8100 Matlock Rd ( ) W Green Oaks Blvd ( ) Other location Wal-mart-Arlington ( ) 735 W Sublett Rd ( ) Randol Mill Pharmacy ( ) 5401 Park Springs ( ) Ray s Pharmacy ( ) 4801 S Cooper St ( ) 4800 US HWY ( ) 915 E Randol Mill Rd ( ) 2121 N Collins St ( ) 2610 W Pioneer Pkwy Pantego ( ) Other location Tom Thumb-Arlington ( ) 5425 S Cooper ( ) 2611 W Park Row ( ) 2755 N Collins ( ) Other location Albertson-Arlington ( ) 301 Southwest Plaza ( ) 5950 S Cooper St ( ) 6220 US Hwy ( ) Other Location

Personal Medical History Form Please Print

Personal Medical History Form Please Print PATIENT S LEGAL NAME: REFERRED BY: REASON FOR VISIT: TODAY S DATE: BIRTH DATE: PLEASE ANSWER ALL OF THE QUESTIONS AS ACCURATELY AS POSSIBLE. IF YOU DO NOT UNDERSTAND