The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION

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1 The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Daytime Phone Number: Date of Birth: / / Age: How did you hear about Dr. Krause? Referring Doctor: Primary Care Physician: Address: Phone # Chief Complaint: Date of Accident/Onset: / / Which side is your problem on? Right Left Please describe the recent events that brought on this orthopaedic problem: How long has it been a problem? How often do you have pain? What makes it worse? What makes it better? Have you had prior treatment for this injury? Yes No When? ByWhom? What Treatment? Neck Shoulder area Elbow Forearm Wrist Hand Hip Thigh Knee area Calf area Ankle Foot Neck Shoulder area Elbow Forearm Wrist Hand Hip Thigh Knee area Calf area Ankle Foot

2 HEALTH HISTORY Height Weight Shoe Size Do you have diabetes? Yes No Do you have fibromyalgia? Yes No Do you have rheumatoid arthritis? Yes No Do you have gout? Yes No Do you have any heart problems? Yes No Do you have any lung problems? Yes No Have you ever had a heart attack? Yes No Do you have stomach ulcers? Yes No Do you have high blood pressure? Yes No Do you have or have you had hepatitis? Yes No Do you have depression? Yes No Do you have a mental illness? Yes No Do you have any bleeding disorders? Yes No Do you have any kidney trouble? Yes No Do you have seizures? Yes No Do you have cancer? Yes No Have you ever had a stroke? Yes No Do you have anemia? Yes No If you are a woman, are you pregnant? Yes No Have you ever had a blood transfusion? Yes No Do you have HIV/AIDs? Yes No Have you ever had a blood clot in your legs or lungs? Yes No Explain all yes answers and list any other medical problems: PAST SURGICAL HISTORY: (List all surgeries you have had) TYPE OF SURGERY DATE (or approx. date) WHERE NAME OF SURGEON / / / / / / / / MEDICATIONS: (List all medications you are currently taking, including vitamins, OTC meds, herbal medications) MEDICATION STRENGTH/FREQUENCY CONDITION ALLERGIES: Are you allergic to Latex? Yes No Have you ever had a reaction to aspirin or a non-steroidal anti-inflammatory type medication?(i.e. Motrin, Ibuprofen) Yes No If yes, what was the name of the medication and what happened? Have you ever had an allergic reaction to a medication? MEDICATION Yes No If yes, please list: REACTION

3 FAMILY MEDICAL HISTORY: Do any of your relatives (immediate family, aunts, uncles, grandparents) have any of the following medical problems? Diabetes Yes No Stroke Yes No Rheumatoid arthritis Yes No Bleeding Disorders Yes No Lupus/Gout Yes No Cancer Yes No Heart problems Yes No Lung problems Yes No Anesthetic Reactions Yes No Any other medical problems Yes No Please explain all yes answers: Occupation Employer Hours Do you smoke? Yes No Cigarettes / Cigars / Other Quit? Yr How many packs per day? How many total years have you smoked? Do you use chew tobacco? Yes No Do you consume alcohol? Yes No How much/often? List any activities that you participate in on a regular basis outside of work (sports, gardening, weight lifting, musical instruments, etc.) Are you here for a work-related injury? Yes No If yes, please complete page 3 Do you have an attorney regarding this injury? Yes No If yes, who? Do you regularly attend religious services? Yes No How important is religion/spiritual issues in your life? Very Moderately Somewhat Not important Patient Expectations Please check the box the most appropriately describes your current expectations for treatment. Definitely non-surgical Probably non-surgical Not sure Either surgical or non-surgical Probably surgical Definitely surgical Please check off which factors most influence your decision to seek treatment. (Check all that apply) Pain the limits daily activities/work Pain that limits sporting activities Pain that limits shoewear I am unhappy with the appearance Concerns about long term damage to the bones/joint/ligaments Friends/family recommended I seek treatment Directed by workman s comp or an attorney

4 Review of Systems General Musculoskeletal Cardiopulmonary Normal Normal Normal Neurological Endocrine Normal Normal GastroIntestinal HEENT Skin Normal Normal Normal Psychiatric GenitoUrinary OB/GYN Normal Normal Normal Signature: Date: / /

5 COMPLETE THIS SECTION ONLY IF YOU ARE HERE FOR A WORK-RELATED PROBLEM Your answers to these questions are very important. Please take the time to be as accurate and as specific as possible. WORK HISTORY: What is your current occupation? What company do you currently work for? When did you first start working for this company? If you are no longer working for this company, when did you last work for this company? Are you currently working your regular job? Yes No If so, are you on light duty? Yes No If you are on light duty, what are your work restrictions? What was your occupation when you developed the problem that you are being seen for? What company were you working for when you developed this problem? How many hours a day do you (or did you) work? How many hours a week do you (or did you) work? Have you have prior injuries or treatment for the same joint/extremity that you are being seen for? If so, when? Describe your job in detail (the job you were working when you developed your problem): What percentage of your day is standing? What percentage of your day is sitting? How much walking is required? Do you climb, work on ladders, or work at heights? How much do you lift? How Frequently? Additional Comments: Do you have a second job? Yes No If yes, please describe what you do and list how many hours per day and week you work there: PAST WORK HISTORY: Please list the type of work you did before you worked for the company you were working for when you developed this problem: Where did you work? How long did you work there? (from when to when) What did you do? Additional Comments: Signature: Date: / /

6 John O. Krause, M.D. Board Certified Orthopedic Surgeon Lower Extremity Surgery Foot & Ankle Surgery Things to know before your visit with John O. Krause, M.D. Bring prior films with the report (x-rays, MRI, CT Scan or Bone Scan). Not bringing the films/report may delay your treatment until they can be obtained. Please bring your insurance card (s), proper identification, a referral form from your Primary Care Physician if required by your insurance and your co-pay. Your co-pay will be collected before each visit. PLEASE ARRIVE 30 minutes PRIOR TO APPOINTMENT TIME. This insures that you will have ample time to complete required paperwork. Please be aware that if you arrive late for a scheduled appointment, out of consideration for the patients who arrive on time, you will be worked into the schedule. This means, that you will be seen, but you might have a long wait. If additional test/procedures are needed, we encourage patients to have them done at our facility. (This also will depend on your insurance). Our staff will set up the appointments and check with insurances. Dress Appropriately. For problems regarding the lower extremity, it is frequently easier to wear shorts or loose fitting pants. If you do not do so, they will be provided for you. Please make sure you have a current list of all your medications & drug allergies, as well as your insurance card when you check in for your appointment. Please inform the staff if you have an allergy to latex. Write down questions for the Doctor in advance. Having this ahead of time prevents missing any questions that you might have. Dr. Krause and his staff strive to meet the individual needs of each patient. Unfortunately, we are unable to predict when a patient will have an accident and require an emergency appointment or surgery. This may cause Dr. Krause to run behind schedule. If this is the case, you will be offered the opportunity to reschedule your appointment. Dr. Krause and his staff appreciate your cooperation and patience. Please call in advance if you have specific questions about the appointment ( ) N. Outer Forty Rd. Suite 200 Chesterfield, MO FAX:

7 Welcome To Our Practice Dr. Krause and his staff, a.k.a. Team Mobility, would like to welcome you to our practice. Mobility Matters! Mobility is the one thing that allows you to participate in all activities of daily life. My practice is geared toward helping each patient to meet their mobility goals, whether they are an elite athlete, a child playing their first soccer game, a new parent taking a walk with their baby, or an older adult walking their dog. In my orthopedic practice, I treat a variety of orthopedic conditions that affect a patient s mobility, from bunions and hammertoes to ankle fractures, to patellar tendonitis, to arthritis of the hip. Along with my staff, Team Mobility, my goal is to restore pain-free mobility to all of our patients, regardless of your level of activity Team Mobility is a division of The Orthopedic Center of St. Louis. The Orthopedic Center of St. Louis consists of ten highly specialized physicians working in the same office. Each physician has a team dedicated to their individual practice; however, each team may not necessarily have the same policies or hours. Nevertheless, they all have the same goal which is state of the art, world class patient care delivered in a friendly, respectful, prompt setting. Team Mobility consists of the following staff: John O. Krause, M.D. Debra Guy, MA Trish O'Laughlin, FNP Tanya Smullin, MA Deborah Channel, Billing Specialist Patti Fires, Workers Compensation Coordinator We strive to treat our patients with compassion and flexibility in an effort to make the process of returning you to activities as convenient as possible. Most of the feedback we get is that we are very user friendly. Dr. Krause s biggest referral source is former patients; this is something we are very proud of and hope to continue. We welcome any feedback from you either verbally or in writing (letter or ). Office Hours: Our office is open Monday through Friday from 8:00 am to 5:00 pm. Dr. Krause sees patients all day on Monday, Wednesday, and on Friday. Dr. Krause performs surgery Tuesdays and Thursdays at the following facilities: St. Louis Spine and Orthopedic Center o (Town & Country in Charter Commons just north of Hwy 141 & Clayton) St. Louis Surgery Center (Creve Coeur at Olive and Craig Rd.)

8 Missouri Baptist Medical Center (SW Corner of I-64 and I-270) After hours answering service is available for emergencies that number is: We have an office that is checked daily please feel free to utilize this option as well. Appointments: Appointments can be made or changed through our office, We would appreciate a telephone call or if you are going to be running late or if you have to cancel appointments. Unfortunately, we have had patients who no-show repetitively for appointments that we had to stop making appointments for them and refer them to another practice. Dr. Krause does his best to stay on time for patient appointments. However, we are an orthopedic practice that sees emergency patients. This may have unforeseen delays. We will try to keep you updated on whether Dr. Krause is running on time. You are welcome to reschedule your appointment if Dr. Krause is running late and you cannot wait due to other responsibilities. Dr. Krause encourages his patients to bring reading materials/work to do while waiting. We have wireless internet access available in our waiting room and you will have computer access to the internet while waiting in each exam room. X-rays/Imaging: Dr. Krause requires x-rays to be obtained on most of his new patients. Please bring all previously taken X-rays/MRI/CT films to your appointment. If you are bringing x- rays from an outside facility, please have the images put on a CD if possible, and include the written report. You may be required to have new x-rays taken at your office visit. If an MRI or CT is required to diagnose your condition, our office normally schedules these at Imaging Partners of Missouri, MRI partners of Chesterfield, or CT Partners of Chesterfield. These facilities are located on the main level of our building. These facilities have high resolution MRI scanner. This allows x-ray images to be delivered to Dr. Krause electronically. In addition, the radiologist will call Dr. Krause with verbal, same day results. We will attempt to schedule your MRI/CT & follow up appointments so that you can get your test then come to our office to review the results with Dr. Krause. As always, you have freedom of choice as you select your provider, as long as you use a closed scanner with high resolution. Narcotic Policy: Dr. Krause has a very strict policy regarding narcotics. It is his policy that patients will receive prescription narcotics only when they are in the immediate post-operative period or have an acute traumatic injury. You should only require narcotics for a limited period of time. Every effort will be made to switch you over to a non-narcotic pain medication as soon as your pain level permits. If you require long term narcotic use or narcotic use for chronic, non-traumatic conditions, you will be referred to your primary care provider or a pain management physician for pain management. If you are prescribed a narcotic pain medication you must: 1. Only use one pharmacy for these prescriptions. If you feel you have good reason and must change pharmacies, you must notify us in advance. 2. Only receive your narcotic pain medicine from one physician.

9 3. It is your responsibility to call your pharmacy for refill requests in a timely manner. Dr. Krause is not in the office every day. Therefore, if you require a refill on your prescriptions by a certain day, please make sure your pharmacy faxes a request before noon. Refill requests will not be addressed on weekends, after hours, or after 12pm on Friday. We regret that we cannot make exceptions to this. 4. We ask you to inform us of your present medications. Please tell us of any new medications that you have received from other physicians at each appointment. YOU MUST USE YOUR MEDICINE AS DIRECTED. EARLY REFILLS WILL NOT BE HONORED FOR ANY REASON. DO NOT LOSE YOUR PRESCRIPTION(S). DO NOT LET OTHERS USE MEDICATIONS FOR ANY REASON. Any violation of the above may be addressed by referring you to a pain medicine specialist or discontinuing your narcotic medicine. Medical Records/Disability Forms: If you need your patient information for any reason contacting our office at Please ask for the medical records department. This department is also responsible for filling out all disability and FMLA paperwork. Most insurance plans to NOT cover this service so there may be additional charges. Billing Issues: We are happy to bill your medical insurance for you. Please understand that our billing service is offered as a courtesy to you. It does not obligate us to wait indefinitely for payment by your carrier. Co-payments and any prior balance, including co-insurance and/or deductible are required to be paid before every visit and we reserve the right to reschedule your appointment if you are not prepared to pay your account balance. Prior to elective surgery, we will check with your insurance company to determine if authorization is required. It is your responsibility to also contact your insurance company to determine your coverage, check any pre-existing condition clauses, and your financial responsibility. You will be required to pay your portion of your financial responsibility prior to your elective surgery. Dr. Krause reserves the right to cancel surgery if your financial obligation has not been met. If you have any billing questions please contact Tricia Downing, billing specialist at ext. 227 Litigated/Work Comp Issues: Our office cannot legally bill your private insurance if there is pending litigation of if there is a workman s compensation claim. It is the responsibility of the patient/guarantor to disclose potential/impending litigation or potential workman s compensation filing. Failure to do so constitutes insurance fraud with associated legal consequences. Please ask Dr. Krause or the staff if you have specific questions. Workers Compensation Patients: Dr. Krause is very experienced in workman s compensation injuries and laws pertaining to work comp. He will help you to get you back to your activities and to work as quickly as possible. After your examination, Dr Krause will advise you of your work restrictions due to your injury or condition. Our office is aware that the work restrictions may not necessarily be an option at your place of employment. Nevertheless we still must list the restrictions on your work status statement and your employer will advise as to

10 whether or not they can accommodate you. Please keep in mind that worker s comp patients are not allowed to change or reschedule their own appointments without authorization from the case manager/adjuster. Therefore, all changes must go through their workers compensation case manager/adjuster. We thank you for the trust you have placed in us. We hope you find our practice to be friendly and professional and that it meets your expectations for your given orthopedic condition.

11 The Orthopedic Center of St. Louis NOTICE OF PRIVACY PRACTICES Effective Date: May 1, 2013 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. We are required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice, which describes the health information privacy practices of our medical group, its medical staff and affiliated health care providers who jointly perform health care services with our medical group, including physicians and physician groups who provide services at our facilities. A copy of our current notice will always be posted at all registration and/or admission points. You will also be able to obtain your own copies by accessing our website at or calling the Privacy Officer at If you have any questions about this notice or would like further information, please contact the above referenced individuals. WHAT HEALTH INFORMATION IS PROTECTED We are committed to protecting the privacy of information we gather about you while providing health-related services. Some examples of protected health information include information indicating that you are a patient of our medical group or receiving health-related services from our facilities, information about your health condition, genetic information, or information about your health care benefits under an insurance plan, each when combined with identifying information, such as your name, address, social security number or phone number. REQUIREMENT FOR WRITTEN AUTHORIZATION Generally, we will obtain your written authorization before using your health information or sharing it with others outside of our medical group. There are certain situations where we must obtain your written authorization before using your health information or sharing it, including: Marketing. We may not disclose any of your health information for marketing purposes if our medical group will receive direct or indirect financial remuneration not reasonably related to our medical group s cost of making the communication. Sale of Protected Health Information. We will not sell your protected health information to third parties. The sale of protected health information, however, does not include a disclosure for public health purposes, for research purposes where our medical group will only receive remuneration for our costs to prepare and transmit the health information, for treatment and payment purposes, for the sale, transfer, merger or consolidation of all or part of our medical group, for a business associate or its subcontractor to perform health care functions on our medical group s behalf, or for other purposes as required and permitted by law. If you provide us with written authorization, you may revoke that written authorization at any time, except to the extent that we have already relied upon it. To revoke a written authorization, please write to the Privacy Officer at our medical group. You may also initiate the transfer of your records to another person by completing a written authorization form. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN AUTHORIZATION There are some situations when we do not need your written authorization before using your health information or sharing it with others, including: 1. Treatment, Payment and Health Care Operations. Treatment. We may share your health information with doctors or nurses at the medical group who are involved in taking care of you, and they may in turn use that information to diagnose or treat you. A doctor in our medical group may share your health information with another doctor to determine how to diagnose or treat you. Your doctor may also share your health information with another doctor to whom you have been referred for further health care. Payment. We may use your health information or share it with others so that we may obtain payment for your health care services. For example, we may share information about you with your health insurance company in order to obtain reimbursement after we have treated you. In some cases, we may share information about you with your health insurance company to determine whether it will cover your treatment. Health Care Operations. We may use your health information or share it with others in order to conduct our business operations. For example, we may use your health information to evaluate the performance of our staff in caring for you, or to educate our staff on how to improve the care they provide for you. 2. Appointment Reminders, Treatment Alternatives, Benefits and Services. In the course of providing treatment to

12 you, we may use your health information to contact you with a reminder that you have an appointment for treatment, services or refills or in order to recommend possible treatment alternatives or health-related benefits and services that may be of interest to you. 3. Business Associates. We may disclose your health information to contractors, agents and other business associates who need the information in order to assist us with obtaining payment or carrying out our business operations. For example, we may share your health information with a billing company that helps us to obtain payment from your insurance company, or we may share your health information with an accounting firm or law firm that provides professional advice to us. If we do disclose your health information to a business associate, we will have a written contract to ensure that our business associate also protects the privacy of your health information. If our business associate discloses your health information to a subcontractor or vendor, the business associate will have a written contract to ensure that the subcontractor or vendor also protects the privacy of the information. 4. Friends and Family Designated to be Involved In Your Care. If you do not object, we may share your health information with a family member, relative, or close personal friend who is involved in your care or payment for your care, including following your death. 5. Proof of Immunization. We may disclose proof a child s immunization to a school, about a child who is a student or prospective student of the school, as required by State or other law, if a parent, guardian, other person acting in loco parentis, or an emancipated minor, authorizes us to do so, but we do not need written authorization. 6. Emergencies or Public Need. Emergencies or As Required By Law. We may use or disclose your health information if you need emergency treatment or if we are required by law to treat you. We may use or disclose your health information if we are required by law to do so, and we will notify you of these uses and disclosures if notice is required by law. Public Health Activities. We may disclose your health information to authorized public health officials (or a foreign government agency collaborating with such officials) so they may carry out their public health activities under law, such as controlling disease or public health hazards. We may also disclose your health information to a person who may have been exposed to a communicable disease or be at risk for contracting or spreading the disease if permitted by law. We may disclose a out their military mission. child s proof of immunization to a school, if required by State or other law, if we obtain and document the agreement for disclosure from the parent, guardian, person acting in loco parentis, an emancipated minor or an adult. And finally, we may release some health information about you to your employer if your employer hires us to provide you with a physical exam and we discover that you have a work related injury or disease that your employer must know about in order to comply with employment laws. Victims Of Abuse, Neglect Or Domestic Violence. We may release your health information to a public health authority authorized to receive reports of abuse, neglect or domestic violence. Health Oversight Activities. We may release your health information to government agencies authorized to conduct audits, investigations, and inspections of our facilities. These government agencies monitor the operation of the health care system, government benefit programs such as Medicare and Medicaid, and compliance with government regulatory programs and civil rights laws. Lawsuits And Disputes. We may disclose your health information if we are ordered to do so by a court or administrative tribunal that is handling a lawsuit or other dispute. We may also disclose your information in response to a subpoena, discovery request, or other lawful request by someone else involved in the dispute, but only if required judicial or other approval or necessary authorization is obtained. Law Enforcement. We may disclose your health information to law enforcement officials for certain reasons, such as complying with court orders, assisting in the identification of fugitives or the location of missing persons, if we suspect that your death resulted from a crime, or if necessary, to report a crime that occurred on our property or off-site in a medical emergency. To Avert A Serious And Imminent Threat To Health Or Safety. We may use your health information or share it with others when necessary to prevent a serious and imminent threat to your health or safety, or the health or safety of another person or the public. In such cases, we will only share your information with someone able to help prevent the threat. We may also disclose your health information to law enforcement officers if you tell us that you participated in a violent crime that may have caused serious physical harm to another person (unless you admitted that fact while in counseling), or if we determine that you escaped from lawful custody (such as a prison or mental health institution). National Security And Intelligence Activities Or Protective Services. We may disclose your health information to authorized federal officials who are conducting national security and intelligence activities or providing protective services to the President or other important officials. Military And Veterans. If you are in the Armed Forces, we may disclose health information about you to appropriate military command authorities for activities they deem necessary to carry We may also release health information about foreign military personnel to the appropriate foreign military authority. Inmates And Correctional Institutions. If you are an inmate or you are detained by a law enforcement officer, we may disclose your health information to the prison officers or law enforcement officers if necessary to provide you with health care, or to maintain safety, security and good order at the place where you are confined. This includes sharing information that is necessary

13 to protect the health and safety of other inmates or persons involved in supervising or transporting inmates. Workers Compensation. We may disclose your health information for workers compensation or similar programs that provide benefits for work-related injuries. Coroners, Medical Examiners And Funeral Directors. In the event of your death, we may disclose your health information to a coroner or medical examiner. We may also release this information to funeral directors as necessary to carry out their duties. Organ And Tissue Donation. In the event of your death or impending death, we may disclose your health information to organizations that procure or store organs, eyes or other tissues so that these organizations may investigate whether donation or transplantation is possible under applicable laws. 7. Completely De-identified Or Partially De-identified Information. We may use and disclose your health information if we have removed any information that has the potential to identify you so that the health information is completely deidentified. We may also use and disclose partially deidentified health information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified health information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address, or license number). 8. Incidental Disclosures. While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur during or as an unavoidable result of our otherwise permissible uses or disclosures of your health information. For example, during the course of a treatment session, other patients in the treatment area may see, or overhear discussion of, your health information. 9. Fundraising. We may use or disclose your demographic information, including, name, address, other contact information, age, gender, and date of birth, dates of health service information, department of service information, treating physician, outcome information, and health insurance status for fundraising purposes. With each fundraising communication made to you, you will have the opportunity to opt-out of receiving any further fundraising communications. We will also provide you with an opportunity to opt back in to receive such communications if you should choose to do so. 10. Changes to this Notice. We reserve the right to change this notice at any time and to make the revised or changed notice effective in the future. We will notify you of any changes. YOUR RIGHTS TO ACCESS AND CONTROL YOUR HEALTH INFORMATION You have the following rights to access and control your health information: Right To Inspect And Copy Records. You have the right to inspect and obtain a copy of any of your health information that may be used to make decisions about you and your treatment for as long as we maintain this information in our records, including medical and billing records. To inspect or obtain a copy of your health information, please submit your request in writing to the Privacy Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies we use to fulfill your request. If you would like an electronic copy of your health information, we will provide you a copy in electronic form and format as requested as long as we can readily produce such information in the form requested. Otherwise, we will cooperate with you to provide a readable electronic form and format as agreed. 2. Right To Amend Records. If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is kept in our records by writing to us. Your request should include the reasons why you think we should make the amendment. If we deny part or all of your request, we will provide a written notice that explains our reasons for doing so. You will have the right to have certain information related to your requested amendment included in your records. 3. Right To An Accounting Of Disclosures. You have a right to request an accounting of disclosures, which is a list with information about how we have shared your health information with others. To obtain a request form for an accounting of disclosures, please write to the Privacy Officer. You have a right to receive one list every 12-month period for free. However, we may charge you for the cost of providing any additional lists in that same 12-month period. 4. Right to Receive Notification of a Breach. You have the right to be notified if there is a probable compromise of your unsecured protected health information if the breach poses a significant risk of identity theft, financial, reputational or other harm to you within sixty (60) days of the discovery of the breach. The notice will include a description of what happened, including the date, the type of information involved in the breach, steps you should take to protect yourself from potential harm, a brief description of the investigation into the breach, mitigation of harm to you and protection against further breaches and contact procedures to answer your questions. 5. Right To Request Restrictions. You have the right to request that we further restrict the way we use and disclose your health information to treat your condition, collect payment for that treatment, run our normal business operations or disclose information about you to family or friends involved in your care. You also have the right to request that your health information not be disclosed to a health plan if you have paid for the services in full, and the disclosure is not otherwise required by law. The request for restriction will only be applicable to that particular service. You will have to request a restriction for each service thereafter. To request restrictions, please write to the Privacy Officer. We are not required to agree to your request for a restriction, and in some cases the restriction you request may not be permitted under law. However, if we do agree, we will be bound by our agreement unless the information is needed to

14 provide you with emergency treatment or comply with the law. Once we have agreed to a restriction, you have the right to revoke the restriction at any time. Under some circumstances, we will also have the right to revoke the restriction as long as we notify you before doing so. 6. Right To Request Confidential Communications. You have the right to request that we contact you about your medical matters in a more confidential way, such as calling you at work instead of at home, by notifying the registration associate who is assisting you. We will not ask you the reason for your request, and we will try to accommodate all reasonable requests. 7. Right To Have Someone Act On Your Behalf. You have the right to name a personal representative who may act on your behalf to control the privacy of your health information. Parents and guardians will generally have the right to control the privacy of health information about minors unless the minors are permitted by law to act on their own behalf. 8. Right To Obtain A Copy Of Notices. If you are receiving this notice electronically, you have the right to a paper copy of this notice. We may change our privacy practices from time to time. If we do, we will revise this notice and post any revised notice in our registration area and on our website 9. Right To File A Complaint. If you believe your privacy rights have been violated, you may file a complaint with us by calling the Privacy Officer at , or with the Secretary of the Department of Health and Human Services. The hospital will not withhold treatment or take action against you for filing a complaint. 10. Use and Disclosures Where Special Protections May Apply. Some kinds of information, such as HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information, are considered so sensitive that state or federal laws provide special protections for them. Therefore, some parts of this general Notice of Privacy Practices may not apply to these types of information. If you have questions or concerns about the ways these types of information may be used or disclosed, please speak with your health care provider

15 THE ORTHOPEDIC CENTER OF ST. LOUIS ACKNOWLEDGMENT AND CONSENT 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 medical group listed at the beginning of this notice, and how I may obtain access to and control of this information. I also acknowledge and understand that I may request copies of separate notices explaining special privacy protections that apply to HIV-related information, alcohol and substance abuse treatment information, mental health information, and genetic information from my Health Care Provider. Finally, by signing below, I consent to the use and disclosure of my health information to treat me and arrange for my medical care, to seek and receive payment for services given to me, and for the business operations of the medical group, its staff, and its business associates. Signature of Patient or Personal Representative Print Name of Patient or Personal Representative Date Description of Personal Representative s Authority

16 David M. Brown, M.D. Donald A. degrange, M.D. Matthew F. Gornet, M.D. Lyndon B. Gross, M.D., Ph. D. John O. Krause, M.D. Paul S. Lux, M.D. Mark D. Miller, M.D. George A. Paletta Jr., M.D. Mitchell B. Rotman, M.D. Luke S. Choi, M.D. Nathan A. Mall, M.D. Consent to Release Information I,, authorize The Orthopedic Center of St. Louis staff to discuss my medical treatment and any billing issues with the following people: (Please list any family members, friends, or legal counsel with whom we are allowed to discuss your treatment or billing issues.) Relation: Relation: Relation: Relation: Patient Signature: (Parent or Guardian Signature if a minor) Date: Patient Signature (2 nd Annual): Date: N. Outer Forty Rd Suite 200 Chesterfield, MO (314) Fax (314)

17 Dear Friends and Patients, Thank you for choosing The Orthopedic Center of St. Louis. The Orthopedic Center of St. Louis constantly strives to provide the highest quality comprehensive care for you and your family. We have organized this building to include providers that complement our services so that you can get the care you need in one convenient location. This includes: 10 Fellowship Trained Orthopedic/Plastic & Reconstructive Surgeons with subspecialty training in specific areas. Digital x-rays and electronic medical records in our state of the art facility High resolution digital MRI and MR Arthrograms on the first floor at Imaging Partners of Missouri CT Partners & MRI Partners of Chesterfield provides state of the art CT & MRI scanning on the first floor Electrodiagnostic testing on the third floor at the Neurological & Electrodiagnostic Institute ProRehab on the third floor provides physical therapy and custom splinting, often the same day as your appointment at The Orthopedic Center of St. Louis Medical Equipment (DME) is available on-site through our office and the Corner Pharmacy delivers medications to each of the following surgical facilities and some of our Surgeons dispense medications in-house to save you a trip to the drugstore. Pain & Rehabilitation Specialists of St. Louis specializes in interventional pain management and non-operative spine treatment If surgery is required, Timberlake Surgery Center is located on the 1 st floor. The St. Louis Spine and Orthopedic Surgery Center and Advanced Surgery Center are located nearby and provide additional locations for outpatient surgeries, spine patients, and patients who require an overnight stay. These facilities are staffed with experienced nurses and staffs that work closely with our physicians to provide the highest quality specialized care in an efficient and personalized fashion. Financial Disclosure Some of the individual physicians at The Orthopedic Center of St. Louis have ownership in some of the surgical and imaging facilities listed above as permitted by both state and federal law. You have complete freedom of choice as you select your providers and facilities. Our physicians and staff are happy to provide you with the names of other service providers and will help coordinate your appointments with your provider of choice. For more information, visit our website We appreciate the opportunity to serve you and your family. Signed: Date: Printed Name: TOC: Revised 6/28/2012

18 John O. Krause, M.D. Board Certified Orthopedic Surgeon Lower Extremity Surgery Foot & Ankle Surgery Patient Financial Policy Welcome to our practice and thank you for choosing us as your health care provider. Our staff is dedicated to providing the best possible care and service to you. We regard your complete understanding of your financial responsibilities an essential element of your care. In order to reduce confusion and misunderstanding between our patients and our practice, Dr. Krause has adopted the following financial policy. You will be required to sign a financial responsibility and authorization for treatment form. If you have any questions regarding this policy, please discuss them with our billing specialist, Tricia Downing. Tricia can be reached at , ext General Payment Policies: Patients are required to present a current insurance card at every visit; without an insurance card you may be required to pay the estimated amount for the visit at the time of service. It is the patient s responsibility to update the office when their insurance information changes. We accept cash, check, Visa, Mastercard, Discover & American Express Co-payments and account balances are due at the time of service. Patients without co-payment at the time of service will be required to reschedule the appointment. There will be a $25.00 fee assessed for all checks returned as Non-Sufficient Funds (NSF) Payment of your financial responsibility is due upon the receipt of our bill. Accounts become past due after thirty (30) days. Your account payment history is considered when an urgent/overbook appointment is requested. Insurance Billing Information: Your insurance policy is a contract between you and your insurance company. We will, however, do a courtesy billing on your behalf. If your insurance company has not paid your account in full within ninety (90) days, the balance may be automatically transferred to your responsibility for payment upon receipt of statement. All insurance payments that are made directly to you must be endorsed and paid to this office. It is your responsibility to contact your insurance in the event of non-payment or discounted payments. You will be responsible to pay any charges associated with care received that your insurance determines is NOT a covered benefit. You must be aware of your own insurance benefits. When in doubt contact your insurance company directly for clarification. Many private insurance companies, in an effort to set physician fees, restrict payment indicating that fees are over their Usual and Customary fees for this area. Our fees are comparable to that of other offices providing the same quality and level of care in our area. We will not allow insurance companies to set an arbitrary fee for our services, based upon their willingness to pay. Medicare: We accept Medicare assignment. As a Medicare patient you are responsible for your deductible and for the difference between the approved charge and the amount Medicare pays. If you have supplemental insurance we will bill it for you. Any remaining balance will be billed to you. Non-Participating Insurance Plans or Out of Network : As a service to our patients, we will bill as a nonparticipating claim. All outstanding balances are the responsibility of the patient. I understand if I elect to be treated by any physician who does not participate in my insurance plan, I am directly responsible for my N. Outer Forty Rd. Suite 200 Chesterfield, MO FAX:

19 payments, and may not be reimbursed by insurance. It is the patient s responsibility to determine if the Dr. Krause is in network with their insurance plan. Referrals: If your plan requires a referral from your primary care physician, it is YOUR responsibility to obtain prior to your appointment and to have it with you at the time of the appointment. If your insurance requires a referral and you do not have your referral, you will have to reschedule your appointment Self-Pay Patients: Self-Pay patients and patients who present without proof of insurance are required to pay $300 on the day of their visit. The payment will be applied to the charges for the visit. Your account may have a credit or balance due after the office visit. Patients with a credit may choose to have the balance refunded or applied to the next visit. Any subsequent visit charges will be due at time of service. If you cannot pay in full, you will need to set up a payment plan with our billing specialist, Tricia Downing. Financial Hardship Policy: Dr. Krause realizes that there may be circumstances when a patient has a financial hardship and is unable to pay for their Orthopedic Care. Please contact Tricia Downing, billing specialist at , ext. 227 to obtain the Financial Hardship paperwork. Minor Child Policy: The legal guardian who accompanies the minor patient to the first appointment will be the responsible party for payment of any guarantor portion of fees that are to be paid to John O. Krause, M.D., LLC. Outstanding Balances: If you have any outstanding self-pay or insurance designated outstanding balances for co-pays, deductibles and coinsurance, and you have been billed more than once without payment, you will be required to pay your balance at your appointment. Chronic non-payment of bills you are directly responsible for can constitute severance from the Practice. Delinquent Accounts: Delinquent accounts may be assigned to a collection agency. All collection costs will be added to your outstanding balance. We cannot be involved in negotiating payment for divorce orders for medical bills. Whichever parent brings the minor child in for treatment will be responsible for payment of the bill regardless of your divorce decree (see minor policy) Third Party Insurance Forms (Disability, FMLA, etc), X-Rays and Medical Records: There is a charge for completing any form that is not directly related to reimbursement of medical services. There are also charges for copying, sending medical records, depending on the circumstances. Our Practice charges $25 per FMLA form and for any third party form not related to reimbursement. For compliance purposes, the patient information portion of the form must be completed and signed prior to acceptance, along with payment. Form services must be paid in full prior to completion. I have read the Financial Policies of John O. Krause, M.D. and agree to comply with the Financial Polices. In addition, John O. Krause, M.D. has my permission to provide medical documentation in order to obtain reimbursement. Patient Name (Print Please) Date Patient (or Representative Guardian Parent) Signature Date

20 PATIENTLEGALNAME EMERGENCYCONTACT RESPONSIBLEPARTY PRIMARYINSURANCE SECONDARYINSURANCE Weaskthisquestiontoinsureproperhandlingofyourclaim AUTHORIZATIONANDASSIGNMENT: SIGNED

21 John O. Krause, M.D. Board Certified Orthopedic Surgeon Lower Extremity Surgery Foot & Ankle Surgery Important Financial Information Regarding our Practice The Orthopedic Center of St. Louis strives to provide the highest quality, comprehensive care for your orthopedic problems under one roof in a convenient, personalized setting. So that we may quickly and accurately diagnose injuries, we have arranged for state of the art diagnostic equipment to be located in the same building as our Center. This includes digital x-rays on the 2 nd floor, a high resolution MRI scanner and CT scanner at Imaging Partners of Missouri and CT Partners of Chesterfield on the 1 st floor, and electrodiagnostic testing at NEI on the 3 rd floor. To facilitate instituting treatment programs in an efficient, timely manner, the Timberlake Surgery Center is located on the 1 st floor to provide outpatient surgical services. This state of the art facility is staffed with experienced nurses and staff that work closely with our physicians to provide the highest quality specialized care in an efficient, personalized fashion. The St. Louis Spine and Orthopedic Surgery Center is located nearby and provides care for spine patients and orthopedic patients that may require an overnight stay. The SSM Pharmacy will deliver post operative medications to families and loved ones in the waiting room at the surgery center so that after surgery, there is no need to stop and wait at the pharmacy to get prescriptions filled. Physical Therapy services are available at ProRehab on the 3 rd floor to institute therapy or have custom splints made the same day as your visit to TOC, if necessary. Dr. Krause and his partners at TOC have an ownership interest in some of these facilities. You have complete freedom of choice as you as you select your providers. Dr. Krause will be happy to provide you with the names of other service providers if you would prefer, and his office will coordinate setting up appointments with a provider of your choice. We appreciate the opportunity to serve you N. Outer Forty Rd. Suite 200 Chesterfield, MO FAX: