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2110 Scenic Drive Georgetown, Texas 78626 512.948.7611 888.524.4073 Fax

Welcome to Hillcountry Arthritis Center

We look forward to providing you with the best in quality care and services. Our goal is to provide you with information and assistance that will make your visit to our facility as pleasant as possible. In order to effectively serve you, we request that you read the following office policies. This notification is to make you aware of what is expected from you financially and to allow you the opportunity to better understand our office procedures. Please direct any questions you have to our front office staff. Thank you in advance for your time. Dr. Rahmani's practice is limited to Rheumatology only for patients ages 18 and over with a referral from a physician. He will not be practicing general Internal Medicine; therefore you will need to continue to see your Primary Care Physician for all your other health care needs. If you are a new patient, please arrive 30 minutes before your scheduled appointment time to allow sufficient time for the check-in process. If you are an established patient, please arrive 15 minutes early. If you are more than 15 minutes late for your appointment, we may request you to reschedule your appointment for the convenience of those patients that arrive on time. Due to the high demand for new rheumatology appointments, if you do not show for your new patient appointment and do not call to reschedule prior to your appointment, you will not be rescheduled. Sometimes our patients cannot attend scheduled appointments. Please let us know when you cannot make your appointment. Cancellations must be done 24 hours prior to your appointment time. We greatly appreciate as much advance notice as possible. Advance notice allows us to schedule another patient into that appointment time. We charge a $25 fee for all scheduled appointment no shows and for appointments cancelled without 24 hour notice. Please understand that canceling appointments repeatedly interferes with a physician's ability to provide the patient with the highest quality of care. Because of this, Dr. Rahmani may, at his discretion, elect to discontinue a relationship with any patient who frequently cancels or does not show for scheduled appointments. Request for prescription refills received after 3:00pm will be taken care of the following day. Please allow us 24-48 hours on your refills. You will need to watch your medication so that you have at least 2 to 3 days worth of medication when you call. Most of the prescriptions are done via fax, so please call your pharmacy when you need a refill and they will fax us a request. Dr. Rahmani will not prescribe narcotics, or refill narcotics after hours or on the weekends. Please make certain you have the medication you need at least 2 hours before the close of our normal business day. Our office hours are: Monday-Friday 9:00 am - 5:00 pm. We close from 12:00 pm - l:00 pm for lunch. Any issues requiring pain medication after hours or on the weekend will likely need to be seen in the Emergency Room for treatment.

Hillcountry Arthritis Center

2110 Scenic Drive Georgetown, Texas 78626 512.948.7611 888.524.4073 Fax

Dr. D. Rahmani, FACR, FACP Dr. Rahmani. is contracted with several of the local insurance carriers which require appropriate referrals. OBTAININGTHIS REFERAL IS THE PATIENT'S RESPONSIBILITY. If seen without the necessary authorization and eligibility, you are responsible for any charges incurred. PLEASE PRINT AND FILL OUT COMPLETELY Patient Information Name Mailing Address Home Phone Social Security # Marital Status: Married Widowed Divorced Work Information Occupation Employer Address Employer Phone # Preferred Pharmacy Pharmacy Name Insurance Information

IF YOUR INSURANCE IS THROUGH YOUR SPOUSES EMPLOYER PLEASE LIST THEIR INFORMATION BELOW. Insurance card(s) will be photocopied, but the following information must be completed.

Birthdate City Cell Phone State Drivers License # Name of Spouse Zip Gender: Male/Female

Employer City State Zip

Location

Phone#

Primary Insurance Insurance Name Policy # Policy Holder Name Do you have any other insurance? Yes/No Secondary Insurance Insurance Name Policy # Policy Holder Name Referring Doctor

Insurance Address Group # Relationship to Patient Employer

Insurance Address Group # Relationship to Patient Primary Care Physician Employer

Assignment and release: I hereby authorize Hillcountry Arthritis Center to release medical information required in the course of my examination or treatment to any physician(s) treating me and for insurance claim purposes. I authorize payment of medical benefits to Hillcountry Arthritis Center for services rendered. I understand that I am responsible for all charges not covered by my medical insurance. In addition, I am responsible for any deductible, co-payments, and co-insurance amounts. Should my insurance decline to pay for services rendered, even after obtaining a referral authorization number. I will agree to be financially responsible and pay for charges incurred. I further understand that should my account be turned over to collections, I am responsible for all fees accrued by collection agencies, court costs, or attorney fees.This may be released by fax. Signature Date

Patient History Form

Name:

LAST FIRST MI

Age:

Occupation

Gender: Male Female Marital Status: Never Married Referring Physician:

RHEUMATOLOGIC (ARTHRITIS) HISTORY

Married

Divorced

Separated

Widowed

At any time have you or a family member had rheumatological problems?

MEDICATION ALLERGIES: SOCIAL HISTORY

Do you smoke? Yes No Past

Please shade all the locationsns of your pain on the body figures.

Example:

Do you drink alcohol? Yes No Number per week_______

Previous Surgeries (Please list the type):

_____________________________________________________

PAST MEDICAL HISTORY

List all prior medical problems or conditions for which you are taking medication for:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

SYSTEMS REVIEW

Musculoskeletal Morning stiffness How long? ________Minutes _______Hours Joint pain Muscle weakness Muscle tenderness Joint swelling List joints affected in the last 6 mos.

Cardiovascular Pain in chest Irregular heart beat High blood pressure Heart murmurs

Respiratory Shortness of breath Swollen legs or feet Cough Coughing of blood Wheezing (asthma)

Integumentary (skin and/or breast) Easy bruising Redness Rash Hives Sun sensitive (sun allergy) Tightness Nodules/bumps Hair loss Color changes of hands or feet in the cold

Constitutional Recent weight gain amount____________ Recent weight loss amount____________ Fatigue Weakness Fever Eyes Pain Redness Loss of vision Double or blurred vision Dryness

Gastrointestinal Nausea Vomiting of blood or coffee ground material Stomach pain Jaundice Increasing constipation Persistent diarrhea Blood in stools Black stools Heartburn

Neurological System Headaches Dizziness Fainting Muscle spasm Loss of consciousness Sensitivity or pain of hands and/or feet Memory loss Night sweats

Ears--Nose--Mouth--Throat Ringing in ears Loss of hearing Nosebleeds Bleeding gums Sores in mouth Loss of taste Dryness of mouth Hoarseness Difficulty in swallowing

Genitourinary Difficult urination Pain or burning on urination Blood in urine Cloudy, smoky urine Pus in urine

Psychiatric Excessive worries Anxiety Easily losing temper Depression Agitation Difficulty falling asleep Difficulty staying asleep

Endocrine Excessive thirst Hematologic/Lymphatic Swollen glands Tender glands Anemia Bleeding tendency Transfusion/when_____ Allergic/Immunologic Frequent sneezing Increased suscepibility to infection

Patient's Name

Date

Physician's Initials

Hillcountry Arthritis Center

2110 Scenic Drive Georgetown, Texas 78626 512.948.7611 888.524.4073 Fax

Billing Policy of Hillcountry Arthritis Center

Dear Patient: Unfortunately we no longer accept monthly payment plans for billed services. If payments need to be made, we do accept Visa, Discover, and MasterCard. All payments will be due in full at the time of your visit. If these arrangements can't be fulfilled then please reschedule. All bills will be due within ninety days of your statement otherwise we will turn over the statement to a collection agency (West Central Texas Collection Bureau). Please note that by law, a fee of up to, but not to exceed, 40% (forty) may be added to any account that becomes delinquent and thus is turned over to a collection agency. This fee can be assessed by the above-named creditor, and may be added to any patient's account, per the creditor's approval. If you have questions about your bill please call our billing agency Medorizon at 1-888-419-8176. Sincerely, Hillcountry Arthritis Center Signature____________________ Date______________________

2110 Scenic Drive Georgetown, Texas 78626 512.948.7611 888.524.4073 Fax

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby give my consent for Hillcountry Arthritis Center to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Hillcountry Arthritis Center's Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior of signing this consent. Hillcountry Arthritis Center reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Officer Darush Rahmani, D.O. at Hillcountry Arthritis Center, 2110 Scenic Drive, Georgetown, TX 78626. With this consent, Hillcountry Arthritis Center may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent, Hillcountry Arthritis Center may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. With this consent, Hillcountry Arthritis Center may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Hillcountry Arthritis Center restrict how it uses or discloses my PHI to carry out PHI. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Hillcountry Arthritis Center's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Hillcountry Arthritis Center may decline to provide treatment to me. Signature of Parent or Legal Guardian Patient's Name Print Name of Parent or Legal Guardian Date

2110 Scenic Drive Georgetown, Texas 78626 512.948.7611 888.524.4073 Fax

FAMILY/FRIEND RELEASE FORM

I UNDERSTAND THAT IF I CHOOSE TO BRING A FAMILY MEMBER OR FRIEND INTO THE EXAMINATION ROOM WITH ME, THAT MY PERSONAL INFORMATION WILL BE DISCUSSED IN FRONT OF THOSE PEOPLE. FURTHERMORE I UNDERSTAND THAT IF I ASK DR. RAHMANI ANY MEDICAL QUESTIONS OUTSIDE OF THE EXAMINATION ROOM IT MAY BE POSSIBLE THAT OTHER PATIENTS AND STAFF WILL HEAR PRIVATE INFORMATION ABOUT ME. SIGNATURE_____________________________ DATE______________________________

2110 Scenic Drive Georgetown, Texas 78626 512.948.7611 888.524.4073 Fax

Our Financial Policy: Dr. Rahmani and his staff are very concerned about the cost of your healthcare and want to address some issues related to the cost of medical services in our office. Considerable care has been taken in setting our fees. We want to assure you that the charges accurately reflect the complexity of care rendered and the skill and expertise required for your care. Medicare: We are a participating provider for Medicare. Patients are responsible for 20% of the amount that Medicare allows. If you have a supplemental insurance, we will submit a claim for you. Medicaid: We are a Medicaid provider. Please present current Medicaid eligibility sheet to our front desk staff at each visit for verification of Medicaid benefits. HMO and PPO Members: If you are a member of an HMO or PPO in which we participate, you are responsible to see that we have a current referral on file if your insurance carrier requires one. If we do not have this referral at the time of your visit, your insurance company may hold you responsible for all charges. You may also be sent back to see your Primary Care Physician prior to being treated to obtain a current referral. If you are not sure that Dr. Rahmani is a provider for your PPO, please look in your PPO directory or call your insurance carrier for clarification. Co-pays, co-insurance and deductibles are due at time of service, so please be prepared to pay at the time of your appointment. Our front office staff will advise you of these amounts when you check in. We accept cash, checks, debit cards, Visa and MasterCard. Inability to pay your portion may result in your appointment having to be rescheduled. We charge a $25 fee on all returned checks. Please inform our front office staff of any changes in your name, address, phone number, employment or insurance information as soon as possible. This will help us properly bill your insurance for the services you receive. Dr. Rahmani may refer you to another physician or setting outside this clinic (such as laboratory) for additional services. We will assist you to the best of our ability with this referral process for outside services. However, insurance companies do not notify us regarding whether follow up visits outside our clinic have been approved for payment. Therefore, you must be sure that your insurance company has authorized any follow up visits or referrals Dr. Rahmani has ordered.

Signing this notice means that you have reviewed and understood the above policies. Print_____________________________________ Date___________________________

Signature__________________________________

Patient Name

DOB

In general, the HIPPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's home. Hillcountry Arthritis Center will make a reasonable attempt to communicate with patient according to the patient's request indicated below.

Hillcountry Arthritis Center

2110 Scenic Drive Georgetown, Texas 78626 512.948.7611 888.524.4073 Fax

IMPORTANT! Patient Information LAST NAME ADDRESS CITY

Items in BOLD are required to process your claims. Failure to provide this information could lead to the denial of benefits. FIRST NAME GENDER MaleFemale STATE ZIP CELL PHONE STUDENT: NoPart TimeFull Time DATE OF BIRTH MI

SOCIAL SECURITY # HOME PHONE

WORK RELATED?:Yes No IF YES, DATE OF INJURY? *If work related, the following information MUST be completed to process your claim. EMPLOYED:Full TimePart Time NoRetired EMPLOYER ADDRESS CITY POSITION Primary Insurance Information INS. COMPANY INS. CLAIMS ADDRESS MEMBER ID # GROUP NAME TYPE OF PLAN:HMOPPOPOS NAME OF INSURED INSURED'S ADDRESS RELATIONSHIP TO INSURED Secondary Insurance Information (If Applicable) INS. COMPANY INS. CLAIMS ADDRESS MEMBER ID # NAME OF INSURED IN CASE OF EMERGENCY NOTIFY: EFFECTIVE DATE RELATIONSHIP TO INSURED PHONE INS. PHONE NUMBER EFFECTIVE DATE GROUP ID # Other REFERRAL NECESSARY?YesNo INSURED'S DOB INS. PHONE NUMBER STATE ZIP WORK PHONE DRIVERS LICENSE #

I understand that I am responsible for all charges incurred by me and all charges not allowed by my insurance company. I authorize release of any medical information necessary to process my claims. I authorize payment of any assigned benefits to: DarushRahmani, D.O. * Hill Country Center * 2110 Scenic Dr. * Georgetown, TX 78626 Signature Date For Office Staff Only REFERRING PHYSICIAN UPIN # DIAGNOSIS WC FILE #

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