Phone:770-277-9222Fax:770-817-0186

725WaltherRoad,Bldg.200,SuiteBLawrenceville,GA30046

www.atlantaareaortho.com

HealthInsurancePortability&AccountabilityAct(HIPAA)

PatientName:_________________________________________ D.O.B:_______________________Phone:____________________________________Ihaveagreedtoletcertainindividualstoparticipateindiscussionsanddecisionsrelatedtomymedicalcare.Therefore,IherebygivepermissiontothephysiciansofAtlantaAreaOrthopedic&Imaging,LLCandtheirstafftodisclosemypersonalmedicalinformationtothefollowingindividual(s):Name:_____________________________________________Relationshiptopatient_________________________Name:_____________________________________________Relationshiptopatient_________________________Name:_____________________________________________Relationshiptopatient_________________________ConditionsforDisclosure(Checktheitem(s)thatapply):O Thepracticemaydisclosemypersonalhealthinformationtotheindividual(s)aboveONLYinmypresence.O Thepracticemaydisclosemymedicalinformationtotheindividual(s)aboveindiscussionswhileinmypresence

andwhenIamnotphysicallypresent,includingdisclosuresbytelephone,facsimile,e-mailorregularmail.O OtherconditionsofDisclosure_________________________________________________________________O ThepracticemaynotdisclosemymedicalorpersonalhealthinformationtoanyoneinmypresenceorwhenI

amnotphysicallypresent.

Iunderstandthatthisconsentmayberevokedbymeatanytimebywrittennoticetothepractice.IunderstandthatacopyoftheHealthInsurancePortability&AccountabilityAct(HIPAA)isavailabletomeuponmyrequest.

PatientSignature:_________________________________________ Date:___________________

WitnessSignature:_________________________________________ Date:___________________

PatientInformationSheet

Phone:770-277-9222Fax:770-817-0186

725WaltherRoad,Bldg.200,SuiteBLawrenceville,GA30046

www.atlantaareaortho.com

Patient Name: ____________________________________________ _______ SS#________________________________ Last First MI Mailing Address________________________________________________________ Email _______________________________________ City/State_____________________________________________________________ Zip_________________________________________ Home Phone #___________________________________________ Alternate Phone #___________________________________________ Physical Address ___________________________________________________________________________________________________ City/State_____________________________________________________________ Zip_________________________________________ Date of Birth_____________________________ Male________ Female_______ Minor_______ Single_______ Married_________ Policy Holder’s Name: __________________________________________________SS#_________________________________________ Address______________________________________________________________ Phone #_____________________________________ Relationship to patient: Self_______ Parent_______ Spouse_______ Guardian_______ Date of Birth_____________________________ Employed by ______________________________________________ Occupation______________________________________________ Business Address______________________________________________________ Phone #______________________________________ City/State_____________________________________________________________ Zip_________________________________________ Pharmacy Name _______________________________ Location ______________ Phone # _____________________________________ Hospital Preference (Please confirm that your insurance is in network.) ________________________________________________________ Lab Preference (Please confirm that your insurance is in network.) ___________________________________________________________

In Case of an EMERGENCY whom should we contact? Name _______________________________________________ Relationship _______________ Phone #__________________________________________ Referring Physician __________________________________ Primary Care Physician______________________________________________________

I authorize payment directly to the physician of benefits due for services rendered. I understand that I am financially responsible for charges not covered by the agreement. I authorize the physician and supplier to release any information required to process my insurance claims. I understand that if I am self-pay, payment is expected at time services are rendered. I understand that delinquent accounts are turned over to a collection agency and I acknowledge responsibility. I give this practice permission to electronically verify my insurance and prescription benefits, download my Rx history and communicate with me via email. _____________________________________________________ ___________________________________________________ Patient Signature Date Guarantor Signature Date

PATIENT MEDICAL HISTORY

LAWRENCEVILLE

770-277-9222 AtlantaAreaOrtho.com

725 Walther Road, Bldg. 200, Suite B Lawrenceville, GA 30046

LAWRENCEVILLE

770-277-9222 AtlantaAreaOrtho.com

725 Walther Road, Bldg. 200, Suite B Lawrenceville, GA 30046

770-277-9222 AtlantaAreaOrtho.com