New Patient Medical Information Survey Revised 3/2013

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New Patient Medical Information Survey Revised 3/2013 We are glad you chose the Augusta Surgical Group to meet your surgical needs. Please take a few minutes to fill out this form, as it will help us provide you with optimal care. Please circle choices or fill in blanks where appropriate. Thank you for your time. Name: _ Date of Birth: Today 's Date: Age: Sex: M / F Home Phone: ------- - Cell/1/Vork Phone : Primary Medical Doctor : Referring Doctor: Cardiologist Nephrologist Dialysis Center Other Doctors & their specialites : What brings you to the office today: For office staff use only: Temp HR BP ---- Ht Wt PE : A/P : Do you currently or have you recently had any of the conditions listed below? Please Circle N for No or Y for Yes Constitutional Gastrointestinal Endocri ne/hematologll Fever N y Nausea N y Swollen lymph nodes N y Chills N y Vomiting N y Allergies N y Weigh t loss N y Abdominal pain N y Easy bruising/bleeding N y Fatigue N y Constipation N y Sweating Blood in stool N y Musculoskeletal episodes N y Diarrhea N y Muscle pain N y Heartburn N y Back pain N y HENT Bloating N y Joint swelling N y Dental problems N y Trouble Joint pain N y Hearing loss N y swallowing N y Congestion N y Psl chiatric Sore throat N y GU Behavior problems N y Hoarseness N y Painful urination N y Nervousness/ Urgency N y anxiety N y E)leS Frequency N y Substance abuse N y Visual Blood in urine N y Depression N y disturbance N y Difficulty Memory loss N y Eye pain N y urinating N y Pelvic pain N y Res(;!irato!}'. Shortness of Skin Breath N y Rash N y Wheezing N y Wound N y Coughing N y Color change N y Masses N y Cardiovascular Neurological Chest pain N y Headaches N y Palpitations N y Dizziness N y Leg swelling N y Seizures N y Irregular Fainting N y Heartbeat N y Focal weakness N y Shortness of Numbness N y Breath lying flat N y Loss of consciousness N y Augusta Surgical Group, P.C. Page 1

New Patient Medical Information Survey Revised 3/2013 Allergies: (List Drugs, Food, Tape, Latex/Rubber products and specific reactions) _ Medications that you are currently taking: 1. 5. 9. 13. 2. 6. 10. 14. 3. 7 11. 15. 4. 8. 12. 16. Last mammogram : _ Last colonoscopy : Other imaging or diagnostic tests: (CT scan, ultrasound ) Do you currently or have you recently had any of the conditions listed below? Medical Conditions (Please circle those that apply) * Arthritis *Asthma *COPD *Bleeding Disorder *Blood Clots *Cancer *Stroke *Diabetes *GERO *Hepatitis *HIV/AIDS *Heart disease *High Cholesterol *High Blood Pressure *MRSA *Kidney Disease *Seizures *Thyroid disease *Others: Recent hospitalizations: Surgical History: (List or circle all operations and approximate dates) *Cardiac Catheterization *Hernia *Pacemaker Gallbladder *Bowel surgery *Reflux/h iatal hernia surgery *Appendectomy *Weight loss surgery *Others : ----- ------ ----- ----- ----- ------- --- - - - OblGyn History: Date of last menstrual period Do you think you may be pregnant? Age at first period_ Age at first delivery Number of pregnancies_ Number of deliveries_ Did you have : natural menopause, hysterectomy, or still menstruating? (please circle one) Family Medical History : (List medical conditions affecting your immediate family) Mother Other- Father- Social History: Occupation Married / Single / Divorced / Widowed TOBACCO ALCOHOL YESorNO o Current smokers : YES or NO o Packs per day o Former smokers : Years quit o Smoked how long Type Amount per week Augusta Surgical Group, P.C. Page 2

New Patient Information Survey Augusta Surgical Group, P.C. Page 3

AUGUSTA SURGICAL GROUP Patient Information Name SSN# Male Female DOB Address City ST ZIP Home Phone Work Phone Cell Phone Primary number I wish to be contacted on Email Need interpreter? Yes No Primary Language Marital Status M S W D Ethnicity Religion Race Emergency Contact Name/Relationship Number Referring Doctor Primary Care Doctor Preferred Pharmacy Name & Location Laboratory Employer Employment Status Employer Phone # Guarantor of Account Self Other Relationship Address City ST ZIP Primary Insurance ID# GRP# Subscriber l Self l Other Relationship DOB SSN# Phone # Secondary Insurance ID# GRP# Subscriber _J Self _J Other Relationship DOB SSN# Phone # All information given is accurate. I give my permission for ASG-Augusta Surgical Group to contact me regarding practice information by the above methods. Print Name Signature Date

AUGUSTA SURGICAL GROUP, P.C., PAYMENT POLICY IMPORTANT MESSAGE TO OUR PATIENTS: Insurance coverage and reimbursement is a very confusing issue. We would like to help clarify some of the most common misconceptions so that you, the patient, will understand what is expected of your insurance companies and you regarding visits to our office and subsequent procedures performed here or at the hospital. Most insurance policies pay for office visits and surgical procedures (or operations ). We will file a claim to your insurance company for any procedures. They will then pay a percentage (after you have met your deductibles) of the fee and, unless, you have a secondary insurance, you will be responsible for the remaining portion of the fee. You will be asked to pay your office visit co-pa y before you are seen. If you do not have a co-pay, we will check on your insurance to see what you will owe. Self-pay patients must pay at time of visit. If surgery is needed, we will have our patient accounts representative discuss this with you before surgery. Medicare operates by a different set of rules. Since your physicians participate in the Medicare program, we are required to file for all services provided to you. Medicare allows a specific fee for each visit or procedure and pays 80% of this allowance. We are then required to bill you for the additional 20% (either through supplemental insurance or your payment) and we are required to write off the difference between our normal fee and the fee Medicare allows. The new Medicare Advantage plans operate mainly with a co-pay and/or coinsurance. This may not apply if we do not participate in your particular Medicare Advantage plan. Each insurance compan y is unique so we need as much information as possible about your present coverage. Many companies are now requiring precertification or preauthorization before they will allow any charges. Please help us help you by providing our staff as much detail as you have regarding your insurance coverage. And remember, you, the patient, are responsible for charges incurred through our office-regardless of insurance coverage. PATIENT SIGNATURE ------ ------ -------- DATE - -----

AUGUSTA SURGICAL GROUP, P.C. PATIENT REGISTRATION FORM ***YOUR SIGNATURE BELOW INDICATES YOUR CONSENT FOR TREATMENTS, AND, HEREBY, AUTHORIZES THE RELEASE OF ANY INFORMATION ACQUIRED IN THE COURSE OF YOUR EXAMINATION OR TREATMENT TO YOUR INSURANCE COMPANY.*** SIGNATURE DATE I HEREBY ASSIGN, TRANSFER, CONVEY AND AUTHORIZE ALL PAYMENTS TO THE PHYSICIAN(S) FOR MEDICAL SERVICES RENDERED TO MYSELF OR MY DEPENDENTS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. SIGNATURE DATE PRIVACY PRACTICES ACKNOWLEDGEMENT: I, HEREBY, ACKNOWLEDGE THAT AUGUSTA SURGICAL GROUP, P.C., HAS PROVIDED ME WITH A NOTICE OF ITS PRIVACY PRACTICES, AS IS REQUIRED BY THE FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA). I UNDERSTAND THAT AUGUSTA SURGICAL GROUP, P.C., WILL, UPON REQUEST, PROVIDE ME WITH A COPY OF THE NOTICE OF PRIVACY PRACTICES. SIGNATURE ------------------------- DATE

Patient's Approval List Augusta Surgical Group, P.C. Date :--- ----- --- Name: Signature : _ Please list anyone that we may discuss about your medical information. If their name is not on this list, we cannot disclose any of your information. Name & Relationship Phone No.

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