Shera Qo. 7209 oP. | Assistant Propessor, urmopasdu om yery Spine Surgery, Mount Sinai Hospital Chief of Spine Trauma, Elmhurst Hospital Leni & Peter W. May Department of Orthopaedic Surgery The Mount Sinai Medical Center One Gustave L. Levy Place, Box 1188 New York, NY 10029-6574 ‘Tel: Fae: Name: Date: DOB: Referring Physician: Primary Care Physician: Location of pain (circle ail that apply): Neck Pain Upper Extremity Pain Mid Back Pain Low Back Pain Lower Extremity Pain Dominant Hand (clrcie one): Right Left Review of Systems (Please check all items you fee! are applicable to you]: ___ Recent Infection ___ Fever or chills __ Weight Loss __ Difficulty Hearing __. Arm numbness __ Leg numbness __ Genital numbness __ Cough ___ Bowel incontinence __ Change !n appetite ___ Bladder incontinence © __ Shortness of breath __. Fatigue _ Headaches __ Poor Sleep .... Muscle weakness __. Swollen glands __ Sore throat __ Eye pain __ Severe nighttime paln __Sinusttis _. Cod hands/feet ___ Hoarse voice _. Cough blood __ Anemia _. Bronchitis __ Leg swelling __ Loss of vision _.. Pneumonia __ Palpitations ___ Asthma _— Ringing in ears _— Murmur ___ Double vision — Chest pain _ Sputum _ Ulcer ___ Indigestion __ Blood in stoo! __ Umited motion __ Constipation ; .. Paln on urination ___ Blood In urine __. Muscle aches __ Difflcuit urination —Kidney stones __~ Swollen joints __ Thyroid problem _. Kidney Infection _.. Red joints nn GOUT _. Painful intercourse Arthritis — Dry mouth __ Iitteriness __ Rash __ Ory. eyes _.. Cold Intolerance __ Vulvar pain , ___ Nausea _ Excess sweating ___ Painful periods __ Prostate enlargement __ Abdominal paln EFTA00283637

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O 0Dr.Cho New Patient Registration Form O Or, Lichtblau OD Dr. Colvin Department of Orthopaedics O Or. Markinson OU Or. Flatow Mount Sinai School of Medicine 0 Or. Parsons O Dr. Forsh 1 Or. Qureshi O Dr. Gladstone OQ ODr. Weinfeld O ODr. Hausman O Or. Wittig O) Or. Hecht Patient Intormation wic NF Legal Last Name: Address: Apt. # First Name: City, State, and Zip: Middle Initial Home Telephone: Cell: Social Security Number: E-mail Address: Date of Birth: ss / / Employer Name: Employer Address: Age: City, State, Zip: Sex: Male Female Employer Telephone: Marital Status: Student/Employment Status: Occupation: Rel to Guarantor: Emergency Contact: Guarantor Name: Relationship: Guarantor SSN: Telephone Number: Guarantor DOB: Guarantor Address: Guarantor Telephone: Guarantor Employer's Name: Guarantor Employer's Address: Guarantor Employer's Telephone: Additional Patient Information Condition that brings you here: Date of Onset: If accident, where and how did it occur? Were you referred by a physician? YES NO. If yes, name of physician requesting this consultation: Address of Physician: Phone: EFTA00283638

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Dec. 11. 2013 3:06PM No.7 V Insurance Information Primary Secondary Insurance Co. Name: insurance Co, Address: Insurance Co. Telephone: Policy Number: Group Number: Name of Insured: Insured's Date of Birth: Relationship of Insured: Effective Date: Hh Expiration Date: PERMANENT INSURANCE SIGNATURE | request that payment of authorized Medical Benefits be made either to me or on my behalf to the Department of Orthopaedics ~ Faculty Practice Associates for any service furnished to me by my physician. | authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. Photostat of this authorization shall be considered as effective and valid as the original. | acknowledge that | am financially responsible for charges not covered by my insurance carrier due to the physician's non-participating/ out-of-network status with my insurance carrier and /or due to a lack of referral or prior authorization required for today’s services should one not be present at the time of service, | acknowledge that | am financially responsible for any deductible, coinsurance, and/or co-payment deemed my responsibility by my insurance carrier as well as any non-covered charges. a Print Patient's Name a Patient's (Or Guardian's) Signature Date EFTA00283639

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Dec. 11. 2013 3:07PM No. 7288 P. 4 O Dr. Allen 0 Dr. Hecht Oj Dr. Cho New Patient Registration Form 0 Dr. Iofin 0 Dr. Colvin Department of Orthopaedics 0 Dr. Lichtblau O Dr Flatow Mount Sinai School of Medicine © Dr. Parsons Q Dr. Forsh 5 East 98" Street, 9 Floor 0 Dr. Qureshi 0 Dr. Gladstone 0 Dr. Weinfeld O Dr. Hausman C1 Dr. Wittig Additional Patient Information 2.0] Condition that brings you here: Date of Onset: If accident, where and how did it occur: Did a physician refer you? Yes No If yes, name of physician requesting this consultation: Address of referring Physician: Telephone Number : Permanent Insurance Signature I request that payment of authorized Medical Benefits be made either to me or on my behalf to the Department of Orthopaedics — Faculty Practice Associates for any service furnished to me by my physician. I authorize any holder of medical information about me to be released to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services, Photostat of this authorization shall be considered as effective and valid as the original. I acknowledge that I am financially responsible for charges not covered by my insurance carrier due to the physician’s non-participating/ out-of-network status with my insurance carrier and /or due to a lack of referral or prior authorization required for today’s services should one not be present at the time of service. I acknowledge that I am financially responsible for any deductible, coinsurance, and/or co- payment deemed my responsibility by my insurance carrier as well as any non-covered charges. Print Patient’s Name Patient’s (Or Guardian’s) Signature Date Giforms: New patient registration form.2 Billing 2012 EFTA00283640

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The Mount Sinai 8 Hospital of Queens ‘A Desdainn of The Mow disse Matta MOUNT SINAL SCHOOL OF NEGICINE Mies North Shore Silicim Medical Group ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (NOPP) By signing below, I acknowledge that I have been provided a copy of this Notice of Privacy Practices and have therefore been advised of how health information about me may be used and disclosed by the hospitals and the facilities listed at the beginning of this notice, and how I may obtain access to and control this information Patient Name Signature of Patient or Personal Representative Print Name of Patient or Personal Representative Date Description of Personal Representative’s Authority I was not able to obtain the patient’s acknowledgement of receipt of the NOPP upon registration because: O The patient refused to sign despite good faith efforts Oo The patient was unaccompanied and not alert and oriented Oo The patient was unaccompanied and needed emergency care 0 Other, ( explain} Employee Signature: Print Name: Date: Employee Title: O = Acknowledgement subsequently obtained, (see above). MR-205 (Rev 5/04)} EFTA00283641

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— e mn Lo uo ~~ o —t mo co o° < 1 11¢ IVLUUTLL Oldl Hospital # North Shore of Queens Medical Group ‘A Division of The Mount Sinai Hospital MOUNT SINAL SCHOOL OF MEDICINE CONSENT FOR COMMUNICATION VIA E-MAIL (Provider~Patient) I, , hereby consent to have my physician, ’ communicate with me or members of his staff, where appropriate or other physicians, nurse practitioners and pharmacists via e-mail regarding the following aspects of my medical care and treatment: [test results, prescriptions, appointments, billing, etc.]. I understand that e-mail is not a confidential method of communication. I further understand that there is a risk that e-mail communications between my physician and me or members of my physician's office staff, or between my physician and other physicians, nurse practitioners and pharmacists regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any e-mail communications between my physician and me or members of his office staff, or between my physician and other physicians, nurse practitioners or pharmacists regarding my medical care and treatment will be printed out and made a part of my medical record. I understand that in an urgent or emergent situation I should call my provider or go to the Emergency Room and not rely on e-mail. Signature: Date: Mes MR-240 (9/03) (orthopaedics) EFTA00283642

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i) rs mm uo a] o = ad mm <° oo ~ The Mount Sinai 7 fount scope MM North Shore jinai_ of Queens elm Medical Group A = Divtsinn of The Mace Ss age SCHOOL OF MEDICINE MOUNT SINAI USE OF INFORMATION AUTHORIZATION Dear Patient, Like other major academic medical centers, Mount Sinai depends greatly upon the generosity of our patients to help us provide the finest in patient care, educate the next generation of physicians, and promote research and discovery of new treatments and cures. Federal law now requires hospitals to obtain your written authorization prior to informing you of marketing or philanthropic initiatives that support the work of your doctors. Your authorization below permits Mount Sinai doctors, development officers, trustees, and other staff to learn the name(s) of your health care provider(s) for the purpose of contacting you about marketing or philanthropic efforts that may be of interest to you. No other information about you or your medical treatment will be disclosed - that is strictly between you and your doctor. Maintaining patient confidentiality and ensuring your right to privacy has always been, and will always be, a priority at Mount Sinai. We hope you will take a moment to read this authorization and sign below. If you have any questions, please call the Compliance Officer in the Mount Sinai Development Office at (212) 659-1570. Thank you, ] authorize that the Mount Sinai Hospital and Mount Sinai School of Medicine (“Mount Sinai”) may disclose the name of my health care provider(s) to Mount Sinai development officers, and other staff, volunteers, and consultants and contractors assisting in fund-raising efforts, for the purpose of contacting me about Mount Sinai: 3 Marketing G Pund-raising opportunities. | understand that this authorization will expire five (5) years from the date of my signature below. I also understand that my health care treatment at Mount Sinai wall not be affected in any way by my refusal or failure to sign this form. J further understand that this authorized information will not be released to any third party vendors for any purpose other than that expressed above. I may revoke this authorization at any time by writing to the Mount Sinai Development Office, One Gustave L. Levy Place, Box 1049, New York, New York 10029-6574, By signing below, I acknowledge that I have read and accept all of the above. x. a, Signature of Patient Print Name of Patient Date or Personal Representative/Guardian or Personal Representative /Guardian Address of Patient If Applicable, Description of Authority of Personal Representative/ Guardian The patient or personal representative/ guardian may request a copy of this form. MR-212 (REV 4/06) OFFICE USE ONLY EFTA00283643

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Dec. | ‘The Mount Sinai Hospital One Gastave L. Lavy Place, Boot 1188 New York, N¥ 10029-6574 ‘Tels (212) 241-6144 () ractu Dear Mr./Ms. You insurance company requires that we report our services to them using a coding system * known as CPT (Current Procedural Terminology). The CPT codes used to describe the sorvices we did for you are found in the “Surgery” section of the CPT workbook. This does not mean ws are implying that you had an operation. This is merely the way the CPT book Is organized for ease of use by both insurance cornpanies and physicians. According to CPT guidelines, fracture care may be reported to the insurance company as a “packaged” service. This means that at the time of Initial care, a claim Is generated that includes thé following work/sérvice: 1. The application of the first cast or splint 2. 90 days of normal, Uncomplicated, follow-up care The services that are not included in the fee associated with the fracture are billed separately: 4. X-rays (initial and all foliow-up) : 2. All casting supplles (Including those used in the first cast or splints) 3, Replacement cast application for medical necessity - 4, Evaluation and management of any additional problems or injuries 5. Treatment 9f complications, return to operating room There will bs a separate charge for these and any appropriate copayments, deductibles, or coinsurances may apply. ‘Note: Cast replacements that are not for medical necessity may be denied by your insurance company and may be bliled to you, the patient or guarantor of service. , if you have any questions, please do not hesitate to contact the billing office at 212-241-6980, EFTA00283644