MEDICAL HISTORY FORM

Our practice is committed to providing the best treatment and care possible for our patients.

Disclaimer

Welcome to our office and thank you for choosing Great Lakes Orthopedics & Sports Medicine, P.C. as your health care provider.We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment. Although we make every effort to obtain accurate Information from your insurance carrier, verification of benefits is not a guarantee that an insurance carrier will pay a medical claim. The insurance carrier makes the final determination based upon the specific plan negotiated by the Insured or Insured's employer. Consequently, the patient or guarantor remains ultimately responsible for the charges incurred during each visit. Additionally patients are responsible for providing correct and factual information regarding their injury, the event related to the injury and the date of occurrence.

Patient Responsibilities

It is the responslbility of the patlent to call and cancel scheduled appointments 24 hours prior to the appointment. If appointments are not cancelled at least 24 hours prior to the scheduled appointment, Great Lakes Orthopedics & Sports Medicine, P.C, reserves the right to charge for the no-show. We require a copy of your current insurance card. Without your insurance card, your account will be considered a 'self-pay' account and subject to the rules identified below, You, the patient or guarantor, are responsible for knowing the requirements of your insurance plan including which laboratories, radiology,, imaging sites and hospitals are authorized for treatment. Our staff will offer assistance, but we are not responsible for knowing or interpreting the benefits or your policy.

You may need to have an authorization or a referral completed by you Primary Care Physician(PCP) prior to seeing our physicians or recelving Physical Therapy, (particularly if your plan is an HMO, POS, or EPO). If we have not received the authorization or referral prior to your arrival, your visit will be rescheduled. If you Insurance policy requires a copayment, you must pay your copay at the time of service. We reserve the right to reschedule your appointment until your copay obligations are met. You are responsible for the payment for all services rendered by Great Lakes Orthopedics & Sports Medicine, P.C., even if your insurance determines that a service is 'not covered'. We try to inform patients when services may not be covered; however, it is the patient's responsibility to understand his/her policy and it's limitatlons.

Patient Patients who are minors (less than 18 years of age): must have a parent or legal guardlan accomp;any them to every visit. The accompanying adult is responsible for payment of the account. The responsibility for payment of services rendered to minor children whose parents are divorced rests solely with the parent seeking treatment for the child, regardless of judgements defined your divorce decree, For unaccompanied minors, non-emergency treatment will be denied. A mlnor, anyone under the age of 18 years and non-emancipated, must be accompanled by an adult 18 years or older to authorize treatment prior to recelving health care services. (IC16-18-2-5. P.L. 1993, Sec. 1.)

Work place injuries

The patient is responsible for notifying Great Lakes Orthopedics & Sports Medicine, P.C. prior to your appointment if your injury occurred at work. Our worker's compensation coordinator will secure the proper authorization for treatment, Insurer information, claim number, date of injury,. employer and adjuster and/or attorney information. Your visit with our practice must be authorized before you are seen. Providing correct and necessary information to our coordinator while setting up your appointment will accelerate the process.

Auto Policy

Great Lakes Orthopedics & Sports Medicine, P.C. will submit clalms to an accident insurance carrier(auto or personal) on behalf of a patlent, however, the patient remains laible for the full amount charged for services rendered by Great Lakes Orthopedics & Sports Medicine, P.C, and It is the patient's respónsibility to ensure all claims are paid in a timely manner, whether by his/her insurance carrier or him/her individually. We do not make payment arrangements or bill an insurance company suggested by your attorney. Our relationship is only with you, the patient.

If you are involved in an automobile accident and have filed a claim, you must provide us with the claim number and billing information for us to file a claim for you. If you DO NOT have a claim nubmer, we will bill your private health insurance, if applicable, or you will be treated as a selfpay account. Please remember that you,as the individual receiving medical treatment, are ultimately responsible for ensuring that all services rendered by Great Lakes Orthopedics & Sports Medicine, P.C. are paid in full, even if you were not responsible for causing the accident.

Self-Pay Accounts

Self-Pay accounts shall exist in the following instances:

• A Patient has no Insurance
• There is no insurance card on file
• Services provided are not covered by insurance

Payment for self-pay accounts is required in full at time of service. We offer to our patients a program call Care Credit which allows you to pay in installments to a credit car company, if you do not qualify for Care Credit you can pay through our practice monitored payment plan. Our billing staff can assist you with these arrangements.

Any changes in coverage must be reported to our office immedlately for proper processing. As a courtesy to our patlents, Great Lakes Orthopedics & Sports Medicine, P.C, willtake 'asslgnment for billing and collecting from our participating (In network) and non-participating (out of network) health plans. Any outstanding balances from these plans are the responsibility of the patient

Credits: GLO will issue a refund only if there are no outstanding Insurance or patient balances and no future appointments scheduled.

I have read the Financial Policy. I understand that I am responsible for all charges not paid by my insurance company. An account is considered past due 45 days after the balance becomes the patient's responsibility unless other arrangements have been made. Unpald accounts beyond 90 days are considered delinquent and may be forwarded to our collection agency. In the event that an account is forwarded to our collection agency, I understand that I will also be responsible for any costs of collection services, including reasonable attorney fees.

We accept payment by cash, money order, cashier check, personal check or an accepted credit card (Discover, MasterCard, VISA and American Express). There will be a $35.00 surcharge for all checks returned for nonsufficient funds, which shall be paid to Great Lakes Orthopedics & Sports Medicine, P.C. by either cash or accepted credit cards.

HB 1273 Notice: (1) An out-of-network provider may be called upon to render health care items or services during the course of treatment. (2) An out-of-network provider described in (1) is not bound by the payment provisions that apply to health care items or services rendered by a network provider under the patient's health care plan. (3) The patient may contact their Insurance before recelving health care items or services rendered by an out-of-network provider described in (1): to obtain a list of network providers that may render the health care items or services: and for additional assistance.

For your convenience, our billing office is available Monday through Thursday 8 am to 4:30 pm and Friday 8 am to 3 pm. The phone number is (219)365-0220. Our knowledgeable staff will be happy to address any question or concerns you may have regarding your account.

ASSIGNMENT AND RELEASE:

• I certify that the insurance information that I have provided is accurate, complete and current and that no other coverage or insurance exists.
• I assign my right to receive payment of authorized benefits to Great Lakes Orthopedics & Sports Medicine, P.C.(GLOSM) and request that payment of authorized benefits be made directly to them.
• If my health Insurance Plan will not direct payment to GLOSM, I agree to forward to GLOSM all health insurance payments which I receive for the services rendered by GLOSM and its health care providers.
• I authorize GLOSM or any holder of medical information about me or the patient listed above to release to my Health Insurance Plan such information needed to determine these benefitsor the benefits payable for related services.

I FURTHER ACKNOWLEDGE AND AGREE:

• I am responsible for all charges for services provided to the patient listed above which are not covered by my Health Insurance Plan or for which I am directly responsible for payment.
• This financial form with assignment of benefits applies to and extends to subsequent visits and appointments at GLOSM. I certify that I have read and understand the above statements, that all of my questions have been answered to my satisfaction, that I agree with statement above.
• I authorize GLOSM to download my medication history and to use SureScripts. Great Lakes Orthopedics & Sports Medicine, P.C. complies with the applicable Federal civil rights laws and does not discriminate on the base of race, color, national origin, age, disability or sex,

The health insurance portability and accountability act (HIPAA) has established a foundation of federal protection for personal health information. HIPAA avoids unnecessary barriers to the delivery of quality health care while prohibiting disclosure of protected health information unless authorized by patients.

In order to comply with HIPAA and protect your personal health information, Great Lakes Orthopedics & Sports Medicine, P.C. requests that you list all individuals (family and friends) to whom we may discuss or release information regarding your current health, Information will not be released to individuals not listed below.

We may use and disclose your health information to your insurance company or a third party payer for the purpose of payment. We may use and disclose your health information to your physictan or another healthcare provider to be
sure those parties have all the information necessary to diagnose and treat you.

I agree to allow Great Lakes Orthopedics & Sports Medicine, P.C. to utilize my personal health information as needed and release my informatton as needed to the individuals listed below. I understand that information will not be released to any individuals not listed.

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.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic Information, that my identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosure of Protected Health Information

Your protected health Information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physiclan's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate,or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to, to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee revlew activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that Interact with patients at our offlce, In addition, we may use a sign-in sheet at
the registration desk where you will be asked to sign you name and indicate your physiclan. We may also call you by name in the walting room when your physician is ready to provide care to you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health Issues as required by law, Communicable Disease: Health: Abuse or Neglect Food and Drug Administration requirement: Legal Proceedings: law Enforcement: Coroner, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers' Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosure to you and when required by the Secretary of the Department of Health and Human Services to Investigate or determine our compllance with the requirement of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be made With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke' this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken actlon in rellance on the use or disclosure Indicated in the authorization.

Your Rights:
Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, you may not Inspect or copy the following records, psychotherapy notes, Information compiled in reasonable anticipation of, or use in, civil criminal, or administrative actlon or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restrictlon of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment or healthcare operations, You may also request that any part of your protected health information not be disclose to family members or friends who may be involved in your care or for notification purposes as
described in this Notice of Privacy Practices. Your request must state the specific restrictions requested and to who you want the restriction to apply.

Your physician is not requlred to agree to a restriction that you may request. If a physiclan belleves it is in your best interest to permit use and disclosure of your protected health Information, your protected heath informatlon will not be restricted. You then have the right to select another Healthcare Professional.

You have the right to request to receive confidentlal communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively l.e. electronically.

You may have the right to have your physician amend your protected health Information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health Information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You have the right to object or withdraw as provided in this notice.

Complaints:

You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retallate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individual with, this notice of our legal duties and privacy practices with respect to protected health Information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you received this Notice of our Privacy Practices: