If Yes, please list those problems.

Instride Greensboro Podiatry Date: _________________ Name: ______________________________________ Date of Birth: ____________ Age: ______ Gender: ________ Mailing address:____________________________________________________________________________________ City, State: _____________________________________________________________ Zip: ___________________ Home Phone: ____________________ Cell Phone: ________________________ Work Phone:_____________________ Email address: _____________________________________________________ Contact by: phone / email / text / letter Preferred Language: ___________________ Race: ___________________ Ethnicity: _________________________ Marital Status: Single / Married / Divorced / Separated / Widowed SS#: _____________________________ Employed by: _________________________________________ Occupation: ________________________________ Emergency Contact: _______________________________________________ Phone: __________________________ Insured party’s Name: __________________________________________________________ Self / Spouse / Parent Insured party’s SS#: _____________________________ Insured party’s DOB: ________________________________ Family Doctor: ____________________________________________ Date of Last Visit: _______________________ Whom may we thank for referring you to our office: ______________________________________________________ What is your main foot problem today? Do you have any other foot problems that need attention? When did your main problem begin? ___________________________________________________________________ Locate the area of the problem: _______________________________________________________________________ Is the pain: ! Burning ! Throbbing ! Sharp ! Dull ! Aching ! Other_________________ What causes the problem or makes it worse? _____________________________________________________________ Was it caused by an injury? ! No ! Yes If Yes: please explain: ______________________________________________________________________________ What’s your: Shoe Size: ____________ Height: ______ ft. ______ in. Weight: _________lbs. Name and location of your preferred pharmacy: ___________________________________________________________ Allergies: List all allergies and reactions (includes medication, environmental, and food) ! None Are you allergic to: Adhesive: ! No ! Yes Latex: ! No ! Yes

Yes

No

Patient Name: ___________________________________________________

Page 2

Have you ever been treated for any of the following ! None Condition No Yes If Yes, please provide date and other details: Diabetes Duration: Avg. blood sugars: Arthritis (any type) List: Cancer Type: Heart disease High blood pressure High Cholesterol Liver problems Peripheral Neuropathy Reflux disease or GI disorder Stroke or Neurological disorder Thyroid problems Vascular disease to legs Arterial? Venous? Other List ALL MEDICATIONS you currently take (include vitamins or herbal medication): ! None List ALL SURGERIES you have had: ! None Surgery Date Have you ever had a problem with anesthesia? ! No ! Yes If Yes: ! Headache after a spinal ! Nausea & vomiting ! Malignant hyperthermia ! Other: ______________________________________________________________ Has any blood relative ever had a problem with anesthesia? ! No ! Yes If Yes: please describe: ___________________________________________ Are you currently a tobacco user? ! Yes ! No ! Used to – Quit date: _______________ __________________ If Yes: Type: cigarettes / cigars / pipe / chewing tobacco # of packs per day: __________ # of years: _______ Do you drink alcohol? ! Yes ! No ! Used to – Quit date: _________________________ If Yes: Type: beer / wine / liquor _______ drinks per day / week / month / year Have you used drugs such as LSD, marijuana, methamphetamines, cocaine or heroin in the past 2 years? ! No ! Yes If yes: please describe: ____________________________________________________________________________ Women Only: Are you, or do you have reason to think that you might be pregnant? ! No ! Yes Is there a Family History of any of these disorders? ! None

Patient Name: ___________________________________________________

Page 3

Do you experience any of the following (check all that apply): General: ! Fatigue ! Weight change ! Chills ! Fever ! Sweats ! MRSA ! HIV/AIDS Skin: ! Rash ! Itching ! Sores ! Hives ! Moles Head & Neck: ! Headache ! Pain ! Stiffness ! Trauma Eyes: ! Glasses ! Pain ! Infection ! Glaucoma Ears: ! Hearing difficulties ! Infection ! Pain ! Tinnitus ! Vertigo Nose: ! Discharge ! Blood ! Pain ! Allergic Rhinitis Mouth: ! Pain ! Sore ! Dentures ! Swallowing ! Dry Respiratory: ! Cough ! Sputum ! Pain ! Asthma ! TB ! Wheezing ! COPD ! Pneumonia Cardiac: ! Angina ! Murmur ! Palpitation ! Myocardial Infarct ! Hypertension ! Heart Disease ! Arrhythmia Vascular: ! Pain in calf when walking ! Phlebitis ! Ulcers in legs ! Varicose Veins Abdomen: ! Reflux disease ! History of stomach ulcers and/or bleeding ! Diarrhea ! Constipation ! Hernia ! Jaundice ! Hepatitis ! Cholecystitis Renal / Urinary: ! Kidney stones ! Kidney Disease ! Dialysis ! Blood in urine ! Frequency ! Stones

! Incontinence Hematologic: ! Anemia ! Bruising ! Bleeding or clotting disorders Endocrine: ! Thyroid Disease ! Diabetes Musculoskeletal: ! Pain ! Stiffness ! Weakness ! Swelling ! Backache ! Cramps ! Gout ! Osteoporosis Nervous: ! Syncope ! Seizures ! Dizziness ! CVA ! Memory Problems Emotional: ! Anxiety ! Insomnia ! Depression ! Hallucinations Do you take antibiotics before routine dental cleanings and/or procedures? ! No ! Yes

Condition No Yes If Yes: list family members Allergies Arthritis (any) Cancer Diabetes Epilepsy Gout Heart Attack Hypertension Kidney disease Mental Illness Migraines Spinal disorder Tuberculosis Other

DIVISION PODIATRIST

Robert van Brederode, William Broyles, Thomas Verla

Ankle & Foot Center of Charlotte (Resigned from group 7/1/2017) Scott Basinger

Brunswick Foot & Ankle Surgery, PA Joseph Kibler

Capital Foot and Ankle Centers Eldon Peters (eff: 10/1/2018)

Carmel Foot Specialists (Resigned from group 1/1/20)Barbara Kaiser, Richard Lind, Richard Miller, Kevin Molan, Tori Simmons‐Lewis

Carolina Foot & Ankle Health Center Millicent Brown

Carolina Foot Care Associates, PLLC Ashma Davidson, Terry Donovan (ret 1/1/18), William O’Neill

Carolina Podiatry Group Brandon Percival, Julie Percival, William Harris, Katlin Jackson (eff:7/1/19), Robert Ezewuiro (eff:8/15/19)

Central Carolina Foot & Ankle Associates Melissa Hill, Gary Liao, Alan Sotelo

Chapel Hill Foot & Ankle Associates, P.A. Jane Andersen, Alan Bocko, Katherine Williams

Charlotte Foot & Ankle Specialists, PLLC (resigned from group 8/1/2017) Kristine Strauss

Coastal Carolina Foot & Ankle Thomas Hagan, Tyler Hagan

Coastal Carolina Foot & Ankle Associates Jeffrey Pupp(ret. 12/31/2019), Kevin Bachman (eff: 1/1/2019), Derek Pantiel

Comprehensive Foot & Ankle Center, P.A. Zack Nellas

Crystal Coast Podiatry Thomas Bobrowski

Family Foot & Ankle Center, P.A. Patrick Dougherty, Doug Smith

Family Foot Care Kevin McDonald, Neil Younce (eff: 10/1/2019), Erin Younce (eff: 12/19/2019)

Foot & Ankle Center of Durham Eric Simmons

Foot & Ankle of the Carolinas, PLLC Eric Ward, Blaise Woeste

Gaston Foot & Ankle Associates, P.A. (Resigned from Group 12/1/19) David Kirlin, Ryan Meredith, Wagner Santiago, Randell Contento

Greensboro Podiatry Associates, P.A.Martha Ajlouny, N’Tuma Jah (resigned 12/21/17),Jonathan Simpson (eff: 1/1/18) term 5/10/18

Hendersonville Podiatry Russ Barone(ret. 2/2/18), Pam Stover

James Mazur, D.P.M., P.A. James Mazur, Erin Younce (eff: 12/19/2019)

Kinston Podiatry Dale Delaney

Matthews Foot Care Brian Killian, Kevin Killian, David Ellenbogen(termed 10/23/19), Wesley Jackson (eff:  7/1/19)

Mt. Airy Foot & Ankle Center, PLLC Jim Shipley, David Collard, Walter Falardeau, Thurmond Siceloff termed

10/23/2018) , Jeffrey Hunter (eff: 7/1/19)

Myers Podiatric Clinic William Myers

Piedmont Foot & Ankle Clinic (Terming from Group 2/1/20) Rick Hauser, Rob Lenfestey (ret.), Jason Nolan, Joel Kelly, Elizabeth BassDaughtry, Jacob Panici, Brian Futrell (eff:3/1/18)

Piedmont Podiatry AssociatesSubodh Choudhary, Nicholas Canoutas, Cassandra Pike, Sarah Fitzgerald

Queen City Foot & Ankle Specialists, P.C. Roxanne Burgess, Alison Garten(termed 11/6/19), Wesley Jackson (eff: 7/1/19)

Raleigh Foot & Ankle (Resigned from Group 1/1/2018) Alan Boehm, Robert Hatcher, Jordan Meyers, Kirk Woelffer

Roberson Foot Care, PC Ainsley Rusevlyan (eff: 2/1/2019)

Ryan Foot & Ankle Clinic David Garchar, Jeff Glaser, Michael Ryan, Scott Whitman, Matthew Borns, Bradley Lind (eff:7/23/19)

Salem Foot Care Scott Matthews

Summit Podiatry Derek Pantiel, Kevin Bachman

Upstate Foot Care Hans Blaakman

Wake Foot & Ankle Center Mike Hodos, Jim Judge

Wilson Podiatry Associates, PA Kendall Blackwell

Welcome to our New PatientsOur practice is a division of the InStride Foot & Ankle Specialists, PLLC. We have divisions across North and South Carolina, and we operate under one tax ID number. As such, if you have seen any of the following physicians in the past three years, we need to know so that we will not file a new patient code for your visit today. Since the insurance carriers look at us as one large practice, if you have been seen at any of the following divisions, you will not be considered a new patient in our practice. Visits prior to 2017 do not need to be disclosed.Please review the names of the divisions and podiatrists below and indicate if you have been seen at any of these divisions by

putting a √ on the line to the left of the practice name. Thank you for disclosing this information to us – it will allow us to be in compliance withnationally mandated correct coding initiatives.

I attest that I have been seen in the above indicated division of the InStride since 01/01/2017.

I attest that to my best recollection, I have not been seen by any of the above divisions/physicians since 01/01/2017.

Signature of patient: Date:

Alta Ridge Foot Specialists (Resigned from Group 1/1/20)

Patient Financial Policy We are dedicated to providing the best possible care and service to you and regard your complete understanding our financial policies as an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor.

!! As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office.

!! Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, cash or check.

!! Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your

insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment.

!! We have made prior arrangements with insurers and other health plans to accept an assignment of benefits. We will

bill those plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible at the time of service

!! If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send

the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service.

!! All health plans are not the same and do not cover the same services. In the event your health plan determines a

service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.

!! You must inform the office of all-insurance changes and authorization referral requirements. In the event the office

is not informed, you will be responsible for any charges denied.

!! For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility.

!! There are certain elective surgical procedures that we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due prior to the surgery.

!! We require patients to furnish a Credit Card on File with our office. See attached documents for further details.

!! Past due accounts are subject to collection proceedings. All fees including, but not limited to collection fees,

attorney fees and court fees shall become your responsibility in addition to the balance due this office.

!! There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee.

!! There is a $20.00 fee for each completion of disability (FMLA) paperwork. There is a $10.00 fee for printed copies of medical records OR digital copies of x-ray studies.

!! Sales of miscellaneous supply items are final. Returns may be accepted for defective items only.

Signature of Patient/Responsible Party:________________________________________________________

Printed Name: Date:

Witness: Date:

Printed Name:

Patient initials to indicate copy received. Rev. 01/18

NOTICE OF PRIVACY PRACTICES

1. Instride Greensboro Podiatry may use and disclose protected health information for treatment, payment, and healthcare operations. Examples of these include, but are not limited to, requested preschool or sports physicals, foster care homes, home health agencies, and/or referral to other providers for treatment. Payment examples include, but are not limited to, insurance companies for claims including coordination of benefits with other insurers, and/or collection agencies. Healthcare operations include, but are not limited to, internal quality control and assurance, including auditing of records.

2. Instride Greensboro Podiatry is permitted or required to use or disclose protected health information without the individual’s written consent or authorization in certain circumstances. Two examples of such are for public health requirements or court orders.

3. Instride Greensboro Podiatry will not use or disclose PHI for marketing purposes and/or disclosures constituting a sale of PHI without the individual’s Authorization.

4. Instride Greensboro Podiatry will not sell or make any other use or disclosure of a patient’s protected health information without the patient’s written authorization. Such authorization may be revoked at any time. Revocation must be requested in writing.

5. Instride Greensboro Podiatry will abide by the terms of this notice currently in effect at the time of the disclosure. 6. Instride Greensboro Podiatry, reserves the right to change the terms of its notice and to make new notice provisions effective

for all protected health information that it maintains. Instride Greensboro Podiatry will provide each patient with a copy of any revisions of its Notice of Information Practices at the time of the patient’s next visit, or at the patient’s last known address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at the office of Instride Greensboro Podiatry.

7. Any patient, guardian or personal representative has the right to object to the use of their health information for directory purposes.

8. Any patient, guardian or personal representative has the right to inspect and obtain copies of the patient’s medical record. The records will be provided within 30 days of the request, and a reasonable charge may be assessed for any copies after the first request in a 12-month period. If Instride Greensboro Podiatry is unable to act within the required period, Instride Greensboro Podiatry may provide the patient with written notice of the reason for delay and expected date of completion of the request. This extension of time will not exceed 30 days.

9. Any patient, guardian or personal representative has the right to request amendments be made to the patient’s medical record. 10. Any patient, guardian or personal representative has the right to request a 6-year accounting of all disclosures of the patient’s

medical record. The history will be provided within 30 days of the request, and a reasonable charge may be assessed for any copies after the first request in a 12-month period. If Instride Greensboro Podiatry is unable to act within the required period, Instride Greensboro Podiatry may provide the patient with written notice of the reason for delay and the expected date of completion of the request. This extension of time will not exceed 30 days.

11. Any patient, guardian or personal representative has the right to request restrictions as to how the patient’s health information may be used or disclosed to carry out treatment, payment, or healthcare operations. Instride Greensboro Podiatry is not required to agree to the restrictions requested, but if Instride Greensboro Podiatry does agree, Instride Greensboro Podiatry, must abide by those restrictions.

12. Any patient, guardian or personal representative has the right to restrict disclosure of certain Personal Health Information to a health plan for payment or health care operation purposes, but not for treatment purposes, for items or services that have been paid in full and out-of-pocket.

13. Any affected patient will be notified by the Instride Greensboro Podiatry Security Officer following a breach of unsecured Personal Health Information of the affected patient. The Practice has permission to contact me via e-mail.

14. Any person/patient may file a complaint to Instride Greensboro Podiatry and to the U.S. Secretary of Health and Human Services if the patient believes his or her privacy rights have been violated. To file a complaint with the Practice, please contact the Privacy Officer at Instride Greensboro Podiatry, 530 North Elam Ave, Greensboro, NC 27403; telephone (336) 299-0271. All complaints will be addressed, and the results will be reported to the Privacy Officer.

15. It is the policy of Instride Greensboro Podiatry that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.

Effective Date:___________________________ Name of Patient:__________________________________________________________________________ Signature of Patient or Legal Guardian:_______________________________________________________ Date:_______________