SUBURBAN ORTHOPAEDIC SPECIALISTS, P.C. …

1 authorization FOR release OF information ANDASSIGNMENT OF benefits FOR NON-MEDICARE PATIENTSPATIENT name :SS#:I hereby authorize and direct my insurance benefits to be paid directly to my personal physician orSuburban ORTHOPAEDIC also authorize SUBURBAN ORTHOPAEDIC Specialists to release any information necessary to processthis claim. I understand that information will be released to:Billing department of the physician and/or practiceInsurance carrier to process claimI understand that my information , under certain circumstances may be released for one of thefollowing reasons:IThis office is not responsible for any disclosure of your confidential medical information once weprovide this information , AT YOUR request, to your insurer, employer, family member or this full understanding, I indemnify and hold harmless this practice for any disclosure, which isout of my physicians, their staff and/or their billing office my signature, I state that I have read, understand, and agree to this authorization and or Guardian SignatureWitnessDateDateSUBURBAN ORTHOPAEDIC SPECIALISTS.

2 Other health care professionals in order to coordinate my care or treatment Insurance adjuster - if my claim is a work or motor vehicle injury Employer - if my claim is related to a work injury Attorney - if my claim is in a litigation process Health insurance carrier, for chart audit reason, and for claim paymentI understand that SUBURBAN ORTHOPAEDIC Specialists and/or their staff and the billing office willnot release any information to myself or family members over the phone without verification ofmy identity in order to comply with privacy regulations. I also understand that SuburbanOrthopaedic Specialists and/or their staff and the billing office will maintain the utmost respectfor privacy.

3 However, I also understand that there are Physical constraints such as noise and theability for others to overhear information , and other errors that may occur, which may causeinadvertent dissemination of information , as well as the potential for confidential information tobe disclosed after it has been provided to outside sources such as your insurance carrier from theclinical or billing INFORMATIONSUBURBAN ORTHOPAEDIC SPECIALISTS, #:DATE:PATIENT'S FIRST NAMEMILAST NAMEZipAddressStateCityAgePHONE # (Home)Birthdate(Work)(Ext.)Social Security #Sex:MF Marital :Patient's Employer:Spouse name :Phone #If under 18 years old, please give parent's names: MotherFatherFamily physician:Referring physician:Address:Address:Phone #Phone #Reason for office visit:Date of injury (try to give specific date)How injury occurredMEDICAL INSURANCE information :Primary Insurance:Secondary Insurance:AddressAddressCityCityStateZip ZipStateSubscriber's name :Subscriber's name :ID#GRP#ID#GRP#Subscriber's Address:City:State:Zip:Subscriber's Birthdate:Subscriber's Social Security #SexPhone #Subscriber's employer:Phone #-Employer Address:City:Zip:State.

4 * Is this injury due to a motor vehicle accident?YESNO* Is this a worker's compensation injury?YESNOIF YOU ANSWERED YES TO EITHER ONE OF THE ABOVE TWO QUESTIONS, PLEASE REFER TO THE LAST PAGEOF THIS FORM TO SUPPLY US WITH ADDITIONAL INSURANCE ORTHOPAEDIC SpecialistsMedical History FormWeight:Height:Age: name :How Long (yrs) CommentsYesNo1. Past Medical History:Heart DiseaseDiabetesHigh Blood PressureAsthmaStrokeKidney DiseaseStomach UlcersOther2. Past Surgical History: (List any surgical procedures - include year if known )3. Past Hospitalizations:4. Allergies: ( List any allergies to medication or Iodine )5. Medications: ( List any medication you are taking, include dose and times /day if known )Yes6.

5 Cigarette Use:NoNumber Packs per Day7. Alcohol Use:NoneOccasionalDaily8. Family History Medical Problems:YesNoRelationship to youHeart DiseaseHigh Blood PressureDiabetesCancerOther9. Are you presently taking any herbal medication or supplements? YesNoPlease List:* Gingko Biloba, St. John's Wort or Ginseng - Please STOP any ofthese at least 2 weeks before any scheduled surgery! SUBURBAN ORTHOPAEDIC SPECIALISTS, RESPONSIBLYI understand that the physician's billing staff will file all claims forservices rendered to my insurance , however, acknowledge that I am responsible for any balances thatmay be due to the physician because of: co-insurance or co-pay amounts yearly deductible amounts non covered services out of network charges terminated coverage exhausted auto benefits denied workers compensation claim no insurance coverage no referral obtained from primary physician failure to respond to insurance carrier correspondence failure to respond to coordination of benefits inquiryIf I am unable to pay the entire amount (applies to amounts of $ more)

6 , I am responsible to immediately, on receipt of the statement,call the billing office @ 800-322-4606, to arrange a monthly paymentplan, for no less than $ per of patient/responsible partyI understand that I will receive a statement for any balance due,after the claim has been processed by my carrier. I understand andam agreeable that the balance of my statement will be paid in full tothe physician within 30 understand that my failure to pay my balance or arrange paymentsand follow the payment agreement, may result in CollectionAgency ORTHOPAEDIC SPECIALISTS, CONSENT For Use/Disclosure Of Health Care InformationPatient's name :Date of birth:SSN:Previous name :I understand that the patient's health information is private and confidential.

7 I understand that SUBURBAN OrthopaedicSpecialists works very hard to protect the patient's privacy and preserve the confidentiality of the patient's personal understand that SUBURBAN ORTHOPAEDIC Specialists may use and disclose the patient's personal health information to helpprovide health care to the patient, to handle billing and payment, and to take care of other health care operations. [*Ingeneral, there will be no other uses and disclosures of this information unless I permit it. I understand that sometimes thelaw may require the release of this information without my permission. These situations are very unusual. One examplewould be if a patient threatened to hurt someone.]

8 ] SUBURBAN ORTHOPAEDIC Specialists has a detailed document called the "Notice of Privacy Practices".' It contains moreinformation about the policies and practices protecting the patient's privacy. I understand that I have the right to read the''Notice'' before signing this ORTHOPAEDIC Specialists may update this "Notice of Privacy Practices." If I ask, SUBURBAN OrthopaedicSpecialists will provide me with the most current "Notice of Privacy Practice".Under the terms of this consent, I can ask SUBURBAN ORTHOPAEDIC Specialists to limit how the patient's personal healthinformation is used or disclosed to carry out treatment, payment or health care operations.

9 I understand that SuburbanOrthopaedic Specialists does not have to agree to my request. If SUBURBAN ORTHOPAEDIC Specialists does agree to myrequest, I understand that SUBURBAN ORTHOPAEDIC Specialists would follow the agreed may cancel this consent in writing at any time by doing one of the following:I. Signing and dating a form that SUBURBAN ORTHOPAEDIC Specialists can give me called "Revocation of Consent forUse and Disclosure of Health Care information "; orII. Writing, signing, and dating a letter to SUBURBAN ORTHOPAEDIC Specialists. If I write a letter, it must say that I wantto revoke my consent to authorize the use and disclosure of the patient's personal health information for treatment,payment, and health care I revoke this consent, SUBURBAN ORTHOPAEDIC Specialists does not have to provide any further health care services to signature below indicates that I have been given the chance to review a current copy of SUBURBAN OrthopaedicSpecialist's ''Notice of Privacy Practices'' My signatures means that I agree to allow SUBURBAN ORTHOPAEDIC Specialists touse and disclose the patient's personal health information to carry out treatment, payment.

10 And health care or legally authorized individual signatureDateTimeRelationship to patient if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)TREATMENT: Your health information may be used by staff members or disclosed to other health care professionals for the purpose ofevaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will beavailable in your medical record to all health professions who may provide treatment or who may be consulted by staff : Your health information may be used to seek payment from your health plan, from other sources or coverage such as anautomobile insurer or from credit card companies that you may use to pay for services.