Bring your insurance card(s) and a picture identification card to your appointment.

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1 Your appointment is on / / at :. Thank you for choosing Midwest Ear Specialists (a member of the BJC Medical Group) as your healthcare partner. We value communication, beginning with the new patient registration process; the information in this packet will help you prepare for your first visit to our office. Your packet contains directions to our office and general information about our office policies and procedures. Included below is a list of information you need to bring with you to the appointment. Bring your insurance card(s) and a picture identification card to your appointment. Bring a copy of your medication list to your appointment. You should request this from all treating physicians that you currently go to for health care. Bring payment for your copayment or coinsurance, as required by your insurance carrier. If you are not prepared to pay your copayment, you will need to reschedule your appointment. Please plan to arrive at the office at least 30 minutes prior to your scheduled appointment time. This will allow ample time to complete the registration process. You will be asked to read and sign the following notifications: Included in This Packet: Patient Information Form Patient Demographic Form Patient Medical History Form CHC/HIE Participation Form Authorization for Disclosure of Health Information At Your Visit: HIPAA Notice Financial Statement of Patient Responsibility Review of Systems Complete and bring the included forms. During your visit, we will ask you to describe your current symptoms. Again, we thank you for choosing our practice and we look forward to working with you to achieve your healthcare goals We encourage you to call the office if you have any questions about the information contained in this packet. Sincerely, The Doctors and Staff of Midwest Ear Specialists

2 OFFICE POLICIES & GENERAL PRACTICE INFORMATION Office Hours: Monday through Friday 8:30am - 4:15pm Appointments If you arrive more than 10 minutes late for your appointment, we may ask you to reschedule. 24-hour advance notice is required to cancel your appointment. Your doctor may ask you to find an alternate source of medical care if you repeatedly fail to keep your scheduled appointments. Medical Records When you need a copy of your current records, we must have a signed, HIPAA-compliant authorization. You can drop-off, mail, or fax the authorization form to us. We use a professional service to manage our medical records requests and, according to Missouri law, they may charge a fee for copying medical records. Please allow at least 14 days from the receipt of the signed authorization to receive your records. Medication Refills Rx We accept refill requests during regular office hours. We will fill refill requests or contact you about your request between the hours of 8:30am and 4:30pm. Please ask your pharmacy to fax your request to Please allow hours to process your request. After Hours Care If you have a non-life-threatening medical problem after office hours, you may contact one of our doctors through the exchange

3 Financial Expectations We have contracts with over 100 different insurance plans. As a result, it is your responsibility to know your insurance coverage for office visits, procedures, physicals, and labs. Accepted methods of payment are cash, check or credit card. Appointments Failure to arrive in time for your appointment may result in the need to reschedule your appointment. 24-hour advance notice is required to cancel your appointment. Patient who fail to show up or cancellations received less than 2 hours prior to a scheduled office appointment may be charged a fee of $25. Copays are due at the time of service or you may be asked to reschedule. Under-insured or No Health Insurance (1) Non-Procedural Office Visits: Pay a deposit of $50 prior to service. (2) Procedural Visits: Pay $75 prior to service. (3) Patients who are deemed self-pay according to the BJCMG s Self Pay Policy will receive a 25% discount off billed charges. This discount will be credited toward the remaining account balance but does not modify the amount of the above defined deposit. We will file claims for all services provided by our doctors with our contracted insurance plans, including Medicare under the Medicare plan guidelines. All non-covered, unpaid balances will remain the responsibility of the patient. Outstanding Account Balance If outstanding balance is greater than $250 you will need to contact the Central Business Office (CBO) to setup monthly payment arrangements ( ). BJC Medical Group offers several financial assistance plans. If you need additional information about financial assistance, please call the Central Business Office at (314) or (800) Cosmetic Services If requesting a medically unnecessary cosmetic service not covered by insurance, patient will pay 100% of estimated professional charges one week prior to scheduled appointment. Completion of Forms: (1) No Charge: FMLA forms for patient s own condition, Medication assistance forms, work excuse letters, health insurance and physical forms. (2) $25 Fee: FMLA forms for the patient s spouse/parent/caregiver, disability forms unless completed during patient visit, income protection forms, and all other forms not listed.

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5 Patient Demographic Form Name: Date of Birth: / / How did you hear about us? Referral From a Friend Practice Website Other: In accordance with the American Recovery and Reinvestment Act of 2009, Midwest Ear Specialists is required to ask for the following information from our patients. Address: Cell Phone Number: - - Primary Dental Provider: Race (please select one): Language (please select one): Ethnicity (please select one): African American/Black Albanian Hispanic or Latino American Indian/Alaskan Native American Sign Language Not Hispanic or Latino Asian Arabic Unknown/Not Reported Caucasian/White Bosnian Hispanic/Latino Bulgarian Multiracial Central Khmer Not Provided Chinese Other Unknown English French German Haitian: Haitian Creole Hebrew Hindi Italian Japanese Korean Nepali Polish Portuguese Russian Somali Spanish; Castilian Swahili Thai Urdu Vietnamese

6 Date: / / Patient Name: Primary Care Doctor: Pharmacy Number: DOB: / / Referred by: List reason(s) for visit and duration of problem: Medical History Allergies to Medications: Current Medications: (Prescription and Over the Counter) 1. Dosage 2. Dosage 3. Dosage 4. Dosage 5. Dosage 6. Dosage Check any illness or condition you have had: Diabetes High Blood Pressure Heart Attack Heart Stents or Surgery Cancer: Emphysema/COPD Stroke/TIA Easy Bleeding Serious Reaction to Anesthesia Depression/Anxiety Allergies (seasonal/year round) Other: Past Surgical History Please list all prior surgeries with the approximate year in which the surgery took place: No past surgical history Surgery: Surgery: Surgery: Surgery: Year: Year: Year: Year: Social History What is your current marital status? Married Single Divorced Widowed Other Do you drink alcohol? Do you drink caffeine? Do you use tobacco? If quit, date quit: / / Yes Yes Yes No No No Formerly Formerly Formerly What is your current smoking status? Every day smoker Some day smoker Former smoker Never smoked Family History Please tell us about your family s medical history: No relevant family history Mother Age: Health Problems: Father Age: Health Problems: Brother / Sister (please circle) Age: Health Problems: Brother / Sister (please circle) Age: Health Problems:

7 Consent for Sharing of Information via Health Information Exchanges (HIE) ( HIE Consent ) General Consent I understand and agree that my health information may be stored in or exchanged through one or more electronic health information exchanges through which health care professionals and facilities and others involved in my care may view and obtain my information. I also understand and agree that, once my health information is exchanged in that way, it may be added into other treating providers medical records, and may be aggregated with the health information of others and used or disclosed to conduct data analysis, or for any other lawful purpose. Consent for Release of Sensitive Information I understand and agree that my health care providers may store or exchange through one or more health information exchanges health information related to any of the following: mental health or developmental disability treatment, alcohol or drug abuse treatment program services, HIV/AIDS testing or other communicable diseases, head trauma and brain injuries, genetic testing/counseling, sexual assault or artificial insemination (any or all of which are Sensitive Information. ). I specifically consent to the disclosure or receipt of such Sensitive Information for the purposes described above in the Consent for Sharing Information via Health Information Exchanges. I may have the right to inspect and copy any of my mental health or developmental disability information that will be shared. Duration of HIE Consent I understand that this HIE Consent applies to information generated prior to the date of this HIE Consent or during any subsequent time while this Consent is in effect. This HIE Consent is effective on the date of my signature (or the signature of my authorized representative below). The Consent for Release of Sensitive Information expires with respect to information about mental health and developmental disability services 25 years after the signature date on this HIE Consent. I may revoke this HIE Consent in writing, at any time; provided, however, that such revocation will not apply to any uses or sharing of my health information that occurred prior to the date the written revocation was received. Patient Signature Date Print Name of Patient Date of Birth If person other than patient has signed above, indicate relationship to patient: Name: Relationship to Patient:

8 Due to the federal privacy regulations, we cannot leave messages with protected health information on home answering machines or with family members without written permission. I give Midwest Ear Specialists permission to leave detailed messages: On my home answering machine / voic # On my work answering machine / voic # On my cell phone # With persons listed (name and relationship to patient) Signature Date I do not want any medical information released except to myself. Signature Date

9 MISSOURI BAPTIST MEDICAL CENTER 3009 NORTH BALLAS ROAD, BUILDING C, SUITE 380 SAINT LOUIS, MO (314) FROM ILLINOIS (ALTERNATE ROUTE TO AVOID I-40[64]) DEPENDING ON YOUR STARTING POINT, TAKE I-255 (N OR S) TO I-270 AND THEN FOLLOW THE INSTRUCTIONS BELOW. FROM I-270 GET ON I-40 (64) EAST. GET OFF AT THE BALLAS ROAD EXIT. GO RIGHT AT THE LIGHT ONTO BALLAS ROAD. TURN RIGHT INTO MISSOURI BAPTIST MEDICAL CENTER. THEN TAKE OUR FIRST RIGHT AND FOLLOW SIGNS TO PROFESSIONAL BUILDING C. FROM I-40 (64) WESTBOUND (NOT COMING FROM I-270) GET OFF AT THE BALLAS ROAD EXIT AND GO LEFT. TURN RIGHT INTO MISSOURI BAPTIST MEDICAL CENTER. THEN YOU RE YOUR FIRST RIGHT AND FOLLOW SIGNS TO PROFESSIONAL BUILDING C. FROM I-40 (64) EASTBOUND. GET OFF AT THE BALLAS ROAD EXIT AND GO RIGHT. TURN RIGHT INTO THE MISSOURI BAPTIST MEDICAL CENTER. THEN TAKE YOUR FIRST RIGHT AND FOLLOW SIGNS TO PROFESSIONAL BUILDING C. BUILDING C OFFERS VALET PARKING OR THERE IS A PARKING GARAGE DIRECTLY UNDER BUILDING C.

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