WELCOME! Thank You for choosing American Health Network for your Primary Care Physician. We are excited to partner with you in your healthcare needs.

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Carmel Watts
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1 Sarab Alfata, MD Kimberly R. Mauller, MD Whitney Crider, PA-C M. Saber Bahrami, MD Caleb R. Overpeck, MD Claudia Fenoglio, NP Jonathan D. Condit, DO Mark A. Reedy, MD Rita Liming, NP Michelle R. Cropper, DO Steve L. Rousseau, MD Kelsey Moore, NP Steven A. Farmer, MD William E. Sowers, MD Travis Newman, NP Gregory K. Gahl, MD Erin E. Vinson, DO Marjorie Wiseman, NP Jonathan J. Gries, MD SPECIALISTS: Joseph J. Van Valer, MD Andrew Kapsalis, DPM, AACFAS Dear New Patient, WELCOME! Thank You for choosing American Health Network for your Primary Care Physician. We are excited to partner with you in your healthcare needs. American Health Network is a comprehensive facility that enables us to provide multiple services under one roof. We also provide OB care and are able to facilitate applicants for presumptive Medicaid eligibility. For more information on this, please call Lisa Holloway at For additional information on our providers, visit Please complete the enclosed New Patient Packet. Please indicate if you have an urgent need. Your request will be processed as soon as possible. You may , mail, fax, or drop off your packet to any check-in desk. The is andrea_pruitt@ahni.com. The phone and fax number is Our New Patient Coordinator is here to assist you. Our office hours are: Monday Friday 8:00 am 5:00 pm. Urgent care clinic hours on Saturday are 9:00 am 12:00 pm. There is a provider on-call 24 hours a day, 7 days a week for emergencies. At your first appointment, please be sure to bring your photo ID and insurance cards. Please also bring your prescription bottles including any vitamins or over the counter medications you may be taking. We ask you to arrive 15 minutes prior to your appointment time. We look forward to seeing you! Sincerely, Providers and Staff at American Health Network. family medicine and specialty care services [Type here] 3631 N. Morrison Rd, Muncie, IN S Co Rd 800 W., Daleville, IN P

2 New Patient Request and Information Form Date Submitted: Check all that apply to you: I have an urgent need (Please explain: ) I would like seen within the next 30 days I do not have a physician preference I prefer the Muncie Location I prefer the Daleville Location I prefer a male or female physician (Circle One) I am assigned to the following provider by my insurance plan: Provider Insurance I am currently pregnant or need an appointment to confirm pregnancy. If yes, when was your last menstrual period? Do you need prenatal vitamins? I would like the same physician as my immediate family member or close friend Family/Friend Name Physician Name: Please list any family members who are current American Health Network patients and their physician: Who was your last physician? When were you last seen? Why are you transferring care? Where was your last provider located: PATIENT INFORMATION Patient Name: (Last, First, MI ) Sex: Date of Birth: SSN: Address: City/State/Zip: Home Phone: Work Phone: Cell Phone: Address: Emergency Contact/Relationship: Would you like to be able to the office? Contact Phone: Employer or Student: RESPONSIBLE PARTY INFORMATION (IF DIFFERENT FROM ABOVE) Name: Sex: Date of Birth: SSN: Address: City/State/Zip: Home Phone: Work Phone: Cell Phone: Relationship to Patient: Employeer: PRIMARY INSURANCE Name of Insurance Company: Policy Number: Group Number: Name of Insured: Date of Birth: Relationship: SECONDARY INSURANCE Name of Insurance Company: Policy Number: Group Number: Name of Insured: Date of Birth: Relationship:

3 HEALTH HISTORY QUESTIONNAIRE FOR OFFICE USE ONLY: Date/Time Appointment Scheduled: with Patient Name: Date of Birth: Date: All questions contained in this document are strictly confidential and will become part of your medical record. Medical Conditions: 1) 5) 2) 6) 3) 7) 4) 8) Current Medications (attached additional information if necessary): Name: Strength: Directions: 1) 2) 3) 4) 5) 6) 7) 8) Current Pharmacy: Location: Are you allergic to any medication? Yes No If yes, please list. Medication Name: Reaction you had: 1) 2) 3) 4) 5) Past Surgeries and Dates: 1) 5) 2) 6) 3) 7) 4) 8)

4 HEALTH HISTORY QUESTIONNAIRE Patient Name: Date of Birth: Date: All questions contained in this document are strictly confidential and will become part of your medical record. Family History: Do any of your family members have the following?: Asthma Who: High blood pressure Who: Cancer Who: Mental Illness Who: Diabetes Who: Stroke Who: Heart Disease Who: Thyroid problems Who: Any other family conditions not listed above: Social History: Are you: Married Single Widowed Divorced Partnered Do you smoke? Yes No If yes, how much? How many years? What age did you start smoking? Are you interested in quitting? Yes No Do you drink alcohol? Yes No If yes, how much? How often? What kind? Are you interested in quitting? Yes No Do you drink caffeine? Yes No Type: Coffee Soda Tea Chocolate Do you use a service pet? Yes No If yes, please state the reason: Do you need an interpreter? Yes No If yes, please state the reason: *AHN does provide interpreters at no charge to you! Please contact the office 48 hours prior to your appointment* Immunization History *Have you had a tetanus booster within the past 10 years? Yes No If yes, when? *Have you had a pneumonia vaccine? Yes No If yes, when? *Have you had a shingles vaccine? Yes No If yes, when?

5 Page 1 of 1 American Health Network 215 Patient/Guardian Authorizations to Disclose Protected Health Information to Others Patient Name: DOB: Today s Date: Primary Care Provider & Location: To the patient: American Health Network will attempt to follow your instructions to the extent the healthcare provider believes such disclosure will not interfere with your treatment. This form will be used at all AHN locations. Please note that AHN does not need specific authorization to disclose information for treatment, operations or payment purposes consistent with its Notice of Privacy Practices. Authorization by: Patient Legal Guardian (name): American Health Network may disclose all of my Protected Health Information* (including that about alcohol/substance abuse, human immunodeficiency virus (HIV) and/or AIDS, or information related to psychiatric treatment or counseling, and related to communicable disease, unless I limit below) to: Name Relationship Contact info (phone/address) NextMD Access Y/N * Limitation - The following Information may NOT be disclosed to any of the above: Duration/Expiration: ONLY the most recent signed DISCLOSURE AUTHORIZATION will be honored. This Authorization will stay in effect during my treatment at AHN unless it is revoked/revised by me in writing. I agree that AHN is not responsible for information that might be re-disclosed by those persons who I have authorized to receive information. Patient/Guardian Signature: Date: Provide copy to the patient at his/her request. Reviewed: 02/13/2018 Last Board Approval: 12/16/2015; 02/20/2018 Privacy Form# 215: Indiana &Ohio

6 Sarab Alfata, MD Kimberly R. Mauller, MD Whitney Crider, PA-C M. Saber Bahrami, MD Caleb R. Overpeck, MD Claudia Fenoglio, NP Jonathan D. Condit, DO Mark A. Reedy, MD Rita Liming, NP Michelle R. Cropper, DO Steve L. Rousseau, MD Kelsey Moore, NP Steven A. Farmer, MD William E. Sowers, MD Travis Newman, NP Gregory K. Gahl, MD Erin E. Vinson, DO Marjorie Wiseman, NP Jonathan J. Gries, MD SPECIALISTS: Joseph J. Van Valer, MD CANCELLATION AND MISSED APPOINTMENT AGREEMENT We strive to render excellent medical care to you and the rest of our patients. Your care is of our utmost importance. In an attempt to be consistent with this, we have an Appointment Cancellation Agreement that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient. We understand that circumstances may not make it possible for you to keep your appointments. As a courtesy to you, we make an outreach call to confirm your scheduled appointment. Appointments can be confirmed or canceled by calling our office at or communicating with us via NextMD at If you are not currently registered for NextMD, please ask your provider or one of our American Health Network staff members for details. We require that you give our office 24 hours notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. If 3 appointments are missed, you may be asked to find another primary care physician for your medical needs and a fee of $50.00 may be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility. If you have any questions, please do not hesitate to contact us at Patient, Parent or Agent (must be 18 years of age or older) Date Print Patient Name Patient s Date of Birth family medicine and specialty care services 3631 North Morrison Road, Muncie, IN P S Co Rd 800 W, Daleville, IN 47334

204a Authorization to Release Medical Records from NON- AHN facility to AHN RECORDS TO BE RELEASED FROM: (This form can be used if another healthcare provider requires written pateint authorization

7 204a Authorization to Release Medical Records from NON- AHN facility to AHN RECORDS TO BE RELEASED FROM: (This form can be used if another healthcare provider requires written pateint authorization to obtain patient records needed by AHN) AUTHORIZATION TO RELEASE MEDICAL RECORDS Name of HealthCare Provider: Address: I hereby request and authorize the above named Healthcare Provider to release records to: American Health Network ( AHN ) located at: At my request, or for the purpose of:. The records of: Patient Name Address Print: Last First Middle/Maiden Street City State Zip Telephone Date of Birth Social Security No. Please release the following information (check those that apply): Provider notes Special Diagnostic test results Lab reports Billing records X-ray reports Chemical/Alcohol Treatment records ALL Medical Records Other (specify) Unless I HAVE LIMITED BELOW, I understand that this also pertains to records regarding testing and treatment for alcohol/substance abuse, human immunodeficiency virus (HIV) and/or AIDS, and for psychiatric treatment or counseling or communicable disease. Limitations: Confine to summary information from records regarding treatment for following condition or injury: On or about (date(s)) 1. Other: I UNDERSTAND (1) I MAY REVOKE THIS AUTHORIZATION AT ANY TIME, EXCEPT TO THE EXTENT THAT ACTION HAS BEEN TAKEN BASED UPON IT, AS DESCRIBED IN THE PROVIDER S PRIVACY NOTICE. (2) THAT THIS AUTHORIZATION WILL EXPIRE IN 60 DAYS FROM THE DATE SIGNED, UNLESS I SPECIFY OTHERWISE. (3) THAT THE RECIPIENT OF THESE RECORDS MAY FURTHER DISCLOSE INFORMATION BECAUSE OF THIS AUTHORIZATION AND THEN IT MAY NO LONGER BE PROTECTED BY THE FEDERAL PRIVACY REGULATIONS, AND THAT THE PROVIDER WOULD NOT BE RESPONSIBLE FOR THIS ACTION, and (4) I AM ENTITLED TO ASK FOR A COPY OF THIS DOCUMENT. Date Expiration (if none, at 60 days): 204a February 17, 2010 Latest Board Approval: 02/12/2010 Signature If patient Signature (Parent/Guardian/Legal Representative, if patient unable to sign- Relationship) Common

Comprehensive Healthcare It s all right here OFFICE PROCEDURES Breast Aspirations Child/Adolescent and Adult Immunizations Colonoscopy Colposcopy Ear Wax Removal EKG Endometrial Biopsy Hemorrhoid

8 Comprehensive Healthcare It s all right here OFFICE PROCEDURES Breast Aspirations Child/Adolescent and Adult Immunizations Colonoscopy Colposcopy Ear Wax Removal EKG Endometrial Biopsy Hemorrhoid Banding Holter Monitor IRIS Retinal Exams IUD Placement Joint Injection King-of-Hearts/Event Recording Laceration Repairs Nasopharyngoscopy Nexplanon (implantable contraception option) Overnight Pulse Oximetry Pap Smears Skin Lesion Removal Spirometry Upper Endoscopy (EGD) Vasectomy-No Scalpel Wart Treatment DISEASE MANAGEMENT Asthma/COPD Clinic Coag (Coumadin) Clinic DIETICIAN SERVICES Diabetic Clinic Gestational Diabetes Eating Disorders Weight Management Hyperlipidemia Hypertension Continuous Glucose Monitoring IMAGING SERVICES ONSITE Bone Density Scanning Breast Biopsy CT Echocardiogram General X-Ray Mammography (Screening & Diagnostic) MRI Ultrasound (Abdominal, Breast, OB, Pelvic, Thyroid) Nuclear Gallbladder DISIDA, Thyroid, Total Body, Extremity General Nuclear Testing Nuclear Stress Test (Cardiolyte) PHYSICAL THERAPY Physical Therapy Rehabilitation Services LAB TESTING Lab Testing & Cultures PHARMACY Access to Care Pharmacy and Out Patient Infusion Services SLEEP DISORDERS Obstructive Sleep Apnea (OSA) Clinic Sleep Center SPECIALTY SERVICES Audiology (Hearing Aid Fitting, Hearing Testing) Cardiology Neurology (EEG, EMG) Podiatry) Research (various ongoing clinical research studies)

Sage Medical Center New Patient Forms

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