By Executing This Agreement, You Are Agreeing to Pay for All Services Received

Financial, Office Policies & Consents

By executing this agreement, you are agreeing to pay for all services received Filing Claims: Please be sure you inform us of any updates or changes to your insurance, so we have your current information. If we do not have current information this will delay payment and possibly cause you to have unexpected expenses. You will be asked to completely fill out a new information profile every year. These profiles expire one year after being signed. Contracted insurance: If we are contracted with your insurance company, we must follow our contract and its requirements. If you have a co-payment, co-insurance and/or deductible, you must pay at the time of service. Non-contracted insurance: Your insurance is a contract between you and your insurance company. We are NOT a party to this contract between you and your insurance company, in most cases. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company who makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. Self-pay patients: All self-pay patients are required to pay at the time the services are rendered. Well Visit vs. Problem-Focused Visit: A visit is considered a “well visit” when a healthy patient is seen to screen for various illnesses or diseases, and is thus considered preventive medicine. If a patient comes in to discuss any suspected illness or disease, this is considered a “problem-focused” visit. We provide services for preventive medicine as well as problem-focused medicine. Some insurance plans cover all office visits no matter what the purpose, other plans will only cover a visit if you have a problem, and some will only cover preventive medicine. Insurance Verification: Our verification staff is dedicated to ensuring your visit is covered by your insurance or advising you otherwise prior to your appointment. In some instances, we might not be able to obtain this information. It is always a good idea for you to check with your insurance carrier to verify your specific benefits so there are no unexpected financial surprises at the time of your visit. Payment for services is ultimately your responsibility. Statements: Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued. It will separately show the previous balance, any new charges to the account, and any payments or credits applied to your account during the month. Returned checks: There is a fee (currently $20.00) for any checks returned by the bank. Past due account: Your account becomes past due 30 days following receipt of your first statement, we will take necessary steps to collect this debt. We have the option to report your account status to any credit reporting agency such as a credit bureau. Waiver of Confidentiality: Please understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if you’re past due status is reported to a credit reporting agency, the fact you received treatment at our office may become a matter of public record. Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent. Appointments: It is our goal to provide services to you in the most comfortable and timely manner as possible. In order to achieve this we must require you to be on time for your appointments. If you must cancel an appointment, we ask you give us 24 hours notice whenever possible. Patients who are 15 or more minutes late may need to be rescheduled. Missed appointments without notification may be charged a $25 fee which will need to be paid prior to next appointment. If you miss three appointments without notifying us before the appointment time you may be dismissed from the practice. In order to ensure accurate records and true identity of all patients you will need to present your Drivers License or Identification Card, Insurance Card and Social Security Number at the time of your appointment. If you are unable to provide this information your appointment may be cancelled or rescheduled. Children: Children are very special to all of us, but for their safety and the courtesy of other patients we must ask you keep your children with you at ALL times while in our office. 1 Financial, Office Policies & Consents

Prescription Refills: If you need a prescription refilled, you will need to contact your pharmacy and request a refill authorization be sent electronically to the office to be processed by the clinical staff and approved by the physician.

Laboratory Test: Unless you instruct us otherwise, your labs will be sent to Clear Point Diagnostic Laboratories. If your insurance requires you use Quest, Lab One, LabCorp or another lab not listed, please be sure to inform the clinical staff at the beginning of your appointment. Remember since we do send all lab specimens to an outside lab we do not charge for the actual test; the lab will bill you separately if your insurance does not cover them. Result Notification: We will make every effort to notify you of results whether they are normal or abnormal. Please allow one week for result notification. Results will also be available thru the patient portal once implemented. If you have not received notification of your results after one week, please call the office. Telephone Calls: We must screen all calls to the Doctor during office hours while patients are being seen. If you have an emergency, explain to the staff the type of emergency you have and a member of our clinical staff will either pick up your call or call you back in a timely manner. Calls deemed “non-emergent” will be handled by the clinical staff in the order received. If it is necessary to leave a message for the Doctor, the call will be returned as soon as possible. Keep in mind, most calls require communication with the Doctor and our medical staff, and are adressed after morning and afternoon clinical hours are completed. Please leave a detailed message, our office operates with a small reliable staff and we use voicemail on a regular basis. Referrals: Occasionally our physicians will need to refer you to another specialist. Our physicians offer recommendations based on their experience with the specialist. The specialist they recommend may or may not be an in-network provider with your insurance carrier. You will need to contact your insurance carrier to determine if that physician is in-network. If they are not you can: 1) choose to see a physician in-network according to your carrier or 2) see the physician we recommend out-of- network. The latter may require you to pay more than customary in-network provider charges. Transferring of Records: You will need to request in writing, and pay a reasonable copying fee if you want to have copies of your records sent to another doctor or organization.

Physician Paperwork: Sometimes insurance companies or other agencies require Physician’s to complete paperwork regarding your healthcare. Examples of such paperwork include FMLA forms, disability forms, and Insurance Company requests for life insurance or other issues. Our office charges the patient $25-$100 for such paperwork depending on the request. This fee must be paid in full in order for the paperwork to be completed.

Assignment of Insurance Benefits : I hereby authorize direct payment of my insurance benefits to McKinney Adult Medicine/Michael J. Parisi, DO. I understand that it is my responsibility to know my insurance benefits and whether or not the services I am to receive are covered benefit. I understand and agree that I will be responsible for any co-pay or balance due that McKinney Adult Medicine/Michael J. Parisi, DO is unable to collect from my insurance carrier for whatever reason.

Consent to Treat: I hereby consent to evaluation, testing, and treatment as directed by my McKinney Adult Medicine physician/Michael J. Parisi, DO or his designee.

Missed Appointment Fee: I understand that I will be responsible for a $25 fee should I “no show” any appointment.

PATIENT NAME: ______DATE OF BIRTH:______

PATIENT SIGNATURE:______DATE:______

2 2. Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This office may use and disclose medical and financial information related to your care that may be necessary now or in the future to facilitate payment by third parties for services rendered by us, or to assist with, aid in, or facilitate the collection of data for purposes of utilization review, quality assurance, or medical outcomes evaluation purposes. Such information may be released to insurance companies, HMO’s and PPO’s, managed care organizations, IPA’s, Medicare/Medicaid, or other governmental or third party payers, or any organizations contracting with any of the above entities to perform such functions. Medical records may be delivered to a primary care physician or any other physician that is directly or indirectly responsible for your medical care or the payment thereof. We may use or disclose your protected health information to send you treatment or healthcare operations communications concerning treatment alternatives or other health-related products or services. We may provide such communications to you in instances where we receive financial remuneration from a third party in connection with such communications. You have the right to opt out of receiving any such compensated communications, and should inform us if you do not wish to receive them. Additionally, if we send such communications, the communications themselves note that we have received compensation for the communication, and will have clear and conspicuous instructions on how you may opt out of receiving such communications in the future. We may use or disclose limited amounts of your protected healthcare information to send you fundraising materials. Any such fundraising materials sent to you will have clear and conspicuous instructions on how you may opt out of receiving such communications in the future. Other than expressly provided herein, any other disclosures of your protected health information will require your specific authorization. Most disclosures of protected health information for which we would receive compensation would require your authorization. Additionally, we would need your specific authorization for most disclosures of your protected health information to the extent it constitutes “psychotherapy notes” or is for marketing purposes. You may request restrictions on certain uses and disclosures. This office is not required to agree to a requested restriction. You have the right to receive confidential communications of your protected health information. You have the right to inspect copy and amend your protected health information. You may also request an accounting of disclosures of your protected health information from this office. As stated above, in most instances we do not have to abide by your request for restrictions on disclosures that are otherwise allowed. However, in certain instances, if you make a request for restrictions on disclosures, we will be obligated to abide by them. Specifically, if you pay for an item or service in full, out of pocket, and request that we do not disclose the information relating to that service to a health plan, we will be obligated to abide by that restriction. You should be aware that such restrictions may have unintended consequences, particularly if other providers need to know that information (such as a pharmacy filing a prescription). It will be your obligation to notify any such other providers of this restriction. Additionally, such a restriction may impact your health plan’s decision to pay for related care that you may not want to pay for out of pocket (and which would not be subject to the restriction). To the extent that this office maintains your protected health information (PHI) in an electronic health record, we agree to account for all disclosures of such PHI upon your request for a period of at least (3) years, prior to such request, as required by HIPAA and HITECH regulations. We are legally obligated to maintain the privacy of your protected healthcare information and to provide you with this Notice of Privacy Practices and to abide by its terms. We reserve the right to change our privacy practices and apply revised privacy practices to protected healthcare information. In certain instances, we may be obligated to notify you (and potentially other parties) if we become aware that your protected healthcare information has been improperly disclosed or otherwise subject to a “breach” as defined in HIPAA. You may register a complaint with this office if you suspect that your privacy rights have been violated. We will investigate the complaint and inform you of the findings. No retaliation will be made against you by this office because you registered a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services. You may speak with the Office manager/Kathy Parisi 972-547-0352 to obtain additional information regarding any questions you may have concerning this Notice or to receive a printed copy of the Notice. This Notice of Privacy Practices is effective as of September 23, 2013.

Patient Signature:______Date:______

3 McKinney Adult Medicine HIPAA Consent 2014

I understand that as part of my healthcare, the physicians of McKinney Adult Medicine (MAM) originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals.

MAM’s Notice of Privacy Practices provides specific information and complete description of how my private health information (PHI) may be used and disclosed. I have been provided a copy or access to the Notice of Privacy Practices and understand that I have the right to review the notice prior to signing this consent. I understand that MAM reserves the right to change the Notice of Privacy Practices. I understand that I have the right to restrict the use and/or disclosure of my PHI for treatment, payment or healthcare operations and that MAM is not required to agree to the restrictions requested. I may revoke this consent at any time in writing except to the extent that MAM has already taken action in reliance of my prior consent. This consent is valid until revoked by me in writing.

We may change our policies and this notice at any time and have those revised policies applied to the entire PHI we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. You can request a paper copy of this notice, or any revised notice, at any time (even if you have allowed us to communicate with you electronically). For more information about this notice or our privacy practices and policies, please contact Kathy Parisi at 972-547-0352.

For the purpose of maintaining and releasing my Private Healthcare Information (PHI), I authorize you to contact ME (patient) for general messages, appointment reminders, test results including labs and x-rays and any necessary detailed medical messages only as indicated below. MAM will not release to any address, phone number or fax number not listed herein. PATIENT AUTHORIZED CONTACT INFORMATION

Patient Name ______

Address______

Cell # ______Home#______Work#______Fax#______

EMAIL ______

NOTE: MAM must obtain your written authorization to use your PHI for any purpose other than treatment or billing. If you want MAM to have access to disclose your PHI to your spouse of any other person during your treatment, please list and sign below

I agree to allow MAM to disclose my (PHI) including date/time of appointments to:

Name: ______Relationship:______Cell#______

I further understand that any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.

I have been provided and have reviewed MAM’s Notice of Privacy Practices September 23, 2013. Signature of Patient or Legal Representative

______Date: ______Print Name of Patient or Legal Representative ______Date: ______

OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: [ ] Individual refused to sign [ ] Communication barrier prohibited obtaining acknowledgement [ ] an emergency prevented us from obtaining acknowledgement [ ] other

Witness: ______Date:______

4 PATIENT INFORMATION: Please use full legal name, no nicknames Last Name: ______First Name: ______Middle Initial _____

Address: ______City: ______State: ______Zip: ______

PHONE/EMAIL: #1 ______#2 ______EMAIL:______

Date of Birth: ______SEX: Male / Female _____ Driver’s Lic # ______SSN#______

Marital Status : Single Married Widowed Separated Divorced Employment Status: Employed Unemployed Retired F/T student

Race: White Black/African American Asian Other ______Ethnicity: Hispanic Non-Hispanic L anguage: English Spanish Other _____

Employer Name: ______Address:______

Emergency Contact Name: ______Phone #: ______Relationship:______

Who may we thank for referring you? ______GUARANTOR INFORMATION

Relationship of Guarantor to Patient: Self______Spouse______Parent ______Other______

Last Name: ______First Name: ______Middle Initial______

Address______City ______State ______Zip ______

PHONE: #1______#2 ______EMAIL______

Date of Birth: ______Male__ __Female_____ SSN:______

Employer Name: ______Address: ______PRIMARY INSURANCE INFORMATION

PRIMARY INSURANCE / INSURANCE COMPANY NAME______

Insured Party: ______DOB ______SSN ______

Relationship to patient ______Employer ______

Member ID ______Group # ______Phone # ______

Effective Date ______Term Date ______Copay ______Deductible ______HRA ______SECONDARY INSURANCE INFORMATION

SECONDARY INSURANCE / INSURANCE COMPANY NAME ______

Insured Party: ______DOB ______SSN ______

Relationship to patient ______Employer ______

Member ID ______Group # ______Phone # ______

Effective Date ______Term Date ______Copay ______Deductible ______HRA ______

I affirm that the above information is accurate.

PATIENT SIGNATURE______DATE______

5 Section A: This section must be completed for all Authorizations (Texas) Patient Name: Birth Date: Social Security No. (optional):

Provider’s Name: Recipient’s Name: Michael J Parisi DO Ph: 972-547-0352 Fax: 972-483-8805 Address 1: Provider’s: 4501 Medical Center Dr. Address 2: Phn: Suite 200 Fax: City: State: Zip: McKinney TX 75069 This authorization will expire on the following: (Fill in the Date or the Event but not both.) Date: Event: Unless a shorter time period is specified, this authorization will expire 180 days after the date it is signed. Purpose of disclosure:

Description of information to be used or disclosed Is this request for psychotherapy notes? Yes, then this is the only item you may request on this authorization. You must submit another authorization for other items below. No, then you may check as many items below as you need.

Description: Date(s): Description: Date(s): Description: Date(s): All PHI in medical record Operative Information Labor/delivery sum. Admission form Cath lab OB nursing assess Dictation reports Special test/therapy Postpartum flow sheet Physician orders Rhythm Strips Itemized bill: Intake/outtake Nursing Information UB-92: Clinical Test Transfer forms Other:

Medication Sheets ER Information Other: I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. ______(Initial) If not applicable, check here.

If this authorization is for disclosure of genetic information, please describe: ______

I understand that: 1. I may refuse to sign this authorization and that it is strictly voluntary. 2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization. 3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices. 4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be redisclosed. 5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it. 6. I get a copy of this form after I sign it. Section B: Is the request of PHI for the purpose of marketing? If yes, the health plan or health care provider must complete Section B, otherwise skip to Section C. Will the recipient receive financial or in-kind compensation in exchange for using or disclosing this information? Yes No If yes, describe:

Section C: Signatures I have read the above and authorize the disclosure of the protected health information as stated.

Signature of Patient/Patient’s Representative: Date:

Print Name of Patient’s Representative: Relationship to Patient:

6 Review of Symptoms

PATIENT NAME: ______DATE:

PHARMACIES / LOCAL: ______LOCATION______

MAIL ORDER :______

Describe the reason for your visit: ______

How did you hear about us? ______

LIST YOUR CURRENT MEDICATIONS & DOSING (INCLUDE VITAMINS, SUPPLEMENTS AND OVER THE COUNTER MEDICATIONS)

Medication Dose Medication Dose 1. 6. 2. 7. 3. 8. 4. 9. 5. 10.

Do you use OXYGEN? YES ( ) NO ( ) Do you use a CPAP or BIPAP device ? YES ( ) NO ( )

When was your last TETNUS shot? ______PNEUMONIA SHOT ? YES ( ) NO ( ) When ______

List any known DRUG & ENVIROMENTAL ALLERGIES and REACTIONS ALLERGY REACTION

Please CIRCLE any of the following that apply to you: Nasal Ear pressure/pain Fever Nausea Depression Urine Congestion incontinence Runny Nose Cough/Productive? Chills Diarrhea Insomnia Blood in Urine Sneezing Shortness of breath Sweats Constipation Memory Loss Burning while urinating Sore throat Wheezing Weight loss/gain Heartburn/Reflux Chest Pain Loss of Consciousness Itchy Eyes Swollen Lymph Fatigue Joint Palpitations Rash/Dry skin Glands Swelling/Pain/Stiffness Headache Dizziness/vertigo Blood in stool Anxiety Urinary Sexual Problems frequency

Do you have any OTHER MEDICAL PROBLEMS NOT listed above? Be Specific . ______

Date of Last PAP SMEAR ? ______Date of Last MAMMOGRAM ? ______Date of last PSA ? ______

OFFICE USE ONLY Height BP Pulse Weight Temp Resp

7 Social/Family/Hospitalization History

PATIENT NAME: ______DATE: ______

SOCIAL HISTORY YES NO Do you Smoke? Cigarettes______Pipe______Cigars______Other______How much per day? ______# of Years? ______Quit? YES NO Year( ) YES NO Do you chew tobacco or dip snuff? How many times per day? ______YES NO Do you drink alcohol? How much? ______How often?______YES NO Do you drink caffeine? How many cups per day? ______SODA____ TEA____ COFFEE_____ YES NO Have you ever used street drugs? What Kind? ______Current Use? YES NO Last Date of Use ______YES NO Do you have tattoos? ______Body Piercings? ______YES NO Do you Work ? Occupation:______YES NO Are you Disabled? Why? Be specific______YES NO Are you Married? Divorced______Separated______Widowed ______Other______

FAMILY HISTORY Condition Mother Father Siblings Children Grandparents Deceased Cause of Death Asthma Cancer/specify Chemical dependency Depression/Mental Illness Diabetes Heart Disease High Blood Pressure Kidney Disease Kidney Stones Osteoarthritis Rheumatoid Arthritis Stroke Tuberculosis

Other Family Medical History: ______

Have you ever been hospitalized? Why? Where? Year Reason for Hospitalization Hospital/Location

Year # of Pregnancies? ______Any Complications?

PATIENT SIGNATURE ______DATE______

8 Health History

PATIENT NAME: ______DATE: ______

Have you ever been diagnosed with any of the following ailments? Please indicate if you currently have, or have ever been treated for the conditions below. What was the year of diagnosis?

DIAGNOSIS

YES _____ Arthritis (Osteoarthritis /Rheumatoid) YES _____ Asthma YES _____ Anxiety YES _____ Blood Clot / Lung YES _____ Blood Clot /Leg YES _____ Blood in Urine YES _____ Blood Transfusion Why? ______YES _____ Blood in Stool YES _____ Cataracts YES _____ Colon Polyp YES _____ Coronary Artery Disease (Heart Disease) YES _____ Congestive Heart Failure YES _____ Blocked Carotid Arteries (Neck) YES _____ COPD/Emphysema YES _____ Dementia YES _____ Depression YES _____ Diabetes Mellitus Insulin? YES or NO YES _____ Diverticulosis/Diverticulitis YES _____ Enlarged Prostate YES _____ Fibromyalgia YES _____ GERD (acid reflux/Heartburn) YES _____ Gout YES _____ Glaucoma YES _____ Hemorrhoids YES _____ Heart Murmur (Mitral Valve Prolapse) YES _____ Hepatitis A B C YES _____ Hepatitis (Unknown Type ) YES _____ High Blood Pressure YES _____ Kidney Stones YES _____ Liver Problems YES _____ Osteoporosis YES _____ Peripheral Vascular Disease YES _____ Stroke YES _____ TIA (mini stroke) YES _____ Thyroid problems High __ Low__ Goiter__ YES _____ Urinary Tract Infections- Recurrent ? YES _____ Tuberculosis YES _____ Ulcer / Stomach ____Duo dental______

CANCER YES _____ Bladder YES _____ Colon YES _____ Breast YES _____ Cervix/Uterus YES _____ Lung YES _____ Melanoma YES _____ Prostate YES _____ Other Site

Other known medical problems – be specific:

PATIENT SIGNATURE: ______DATE ______

9 Diagnostic /Surgical History

PATIENT NAME: ______DATE:______

DIAGNOSTIC HISTORY

Have you had any of the following procedures performed? Please answer YES or NO .If yes, Please indicate what year it was performed, where and results if known. YES NO Stress test Year ______Result______YES NO Heart Catheterization Year ______Result______YES NO Angioplasty Year______Result______YES NO Coronary stent Placement Year ______Result ______YES NO Bronchoscopy Year ______Result ______YES NO Colonoscopy Year ______Result ______YES NO Echocardiogram Year ______Result ______YES NO Colposcopy Year ______Result ______YES NO Pacemaker or Defibrillator Year ______Result ______YES NO Flexible Sigmoidoscopy Year ______Result ______YES NO Upper GI endoscopy Year ______Result ______YES NO Ultrasound of Carotid Arteries (neck)Year ______Result______YES NO Dialysis Year ______Result ______YES NO Bone Density Test Year ______Result ______YES NO CAT SCAN or MRI Year______Result ______

SURGICAL HISTORY ( ) I have NEVER had surgery

YES NO Appendectomy YES NO Endometrial Biopsy YES NO Amputation location ______YES NO Gall Bladder Removed YES NO Aneurism repair YES NO Hernia Location______YES NO Bladder Surgery YES NO Hemorrhoidectomy YES NO Breast Augmentation YES NO Hip Replacement ( R ) ( L ) YES NO Breast Biopsy YES NO Hip Fracture Repair YES NO Mastectomy YES NO Hysterectomy YES NO Back Surgery Type______YES NO Knee Arthroscopy ( R ) ( L ) YES NO Neck Surgery Type______YES NO Knee Replacement ( R ) ( L ) YES NO Carpal Tunnel ( R ) (L ) YES NO Lung Surgery ______YES NO C-Section YES NO Peripheral Vascular YES NO Cataract ( R ) ( L ) YES NO Sinus Surgery YES NO Carotid Artery YES NO Tonsils or Adnoids YES NO Colon Resection YES NO Tubes Tied YES NO Colostomy YES NO Vasectomy YES NO Coronary Bypass #vessels ______YES NO Biopsy of other site ______YES NO D & C

Other Surgeries- Be Specific

PATIENT SIGNATURE ______DATE ______