Kidney Care Physicians, LLC875 Oak St SE Suite #5070 Salem, OR 97301Phone (503) 561-8565 Fax (503) 561-8560

Denis Privalov MDEva Lee MD

Brett Mikeska MD

Lance Dicker MD

Misha Mohindra MD

Andreea Andone MD

Aneet Deo MD

Dear

You have an appointment scheduled withThis appointment will take approximately one hour. We would like to take this opportunity to familiarize you with some of our clinic procedures.

YOUR SCHEDULED APPOINTMENT TIME IS VERY IMPORTANT. PLEASE ARRIVE 20 MINUTES BEFORE YOUR SCHEDULED APPOINTMENT TIME. PLEASE REMEMBER TO ALLOW TIME FOR PARKING AT THE SALEM HOSPITAL.

BRING A LIST OF MEDICATIONS YOU ARE TAKING INCLUDING THE STRENGTH AND DOSAGE. A URINE SPECIMEN WILL BE NEEDED AT YOUR APPOINTMENT TIME, SO PLEASE PLAN ACCORDINGLY.

Co-payments are expected at the time of service and will be collected prior to your appointment with our physician. If you have a managed care insurance that requires a referral or prior authorization from your primary care physician, please contact your primary care physicians to get the referral or prior authorization.

Please complete the enclosed registration forms and return all 5 pages front and back in the self addressed, postage paid envelope as soon as possible. Kidney Care Physicians will bill your primary, secondary, and tertiary insurance plans as a courtesy to you. Please remember to bring a copy of your current insurance card with you. Be aware that the HIPAA act requires us to verify your identity. Please be ready to produce a valid photo ID this would include a state drivers license, state photo ID card, or military photo ID. We will be taking a photo of you to attach to your electronic chart.

IF YOU ARE UNABLE TO KEEP THIS APPOINTMENT PLEASE CONTACT OUR OFFICE 24 HOURS PRIOR TO YOUR APPOINTMENT TIME AS THERE ARE OTHER PATIENTS THAT COULD BE SCHEDULED AT THIS TIME WITH OUR DOCTORS.

If you have any questions regarding our clinic or these procedures, please call our office.

Enclosures: 1. Appointment Card with Date and Time. 2. Patient Demographic Sheet 3. Financial Policy Form 4. Missed Appointment Policy 5. Acknowledgement and Consent Form 6. HIE Consent Form 7. Patient Medication and History Forms 8. Map With Directions To Kidney Care Physicians, LLC 9. Postage Paid Self Addressed Envelope

Patient Name:

Patient Demographic Information Sheet

Last Name: First Name: Middle Int:

Nickname:

Address

City State Zip Code Zip CodeStateCity

Address

Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.

Date of Birth: SSN Number:

Physical Address if Different:Mailing Address/PO Box:

Primary Language: Ethnicity:

Please Check One

Marital StatusPlease Check One

Student Status

Are you a veteran?

Primary Care Physician: Primary Pharmacy:

Other Physicians Participating in Your Care to Send Records to:

Cell Phone: Work Phone:

E-mail Address:

Home Phone:

Please Check Your Preferred Method of Communication:

Emergency Contact Person Contact Phone:Relation:

Sex:

Race:

Please Check One

Confidential Information

Are you currently using tobacco products?

Primary Ins: Secondary Ins:

Please Enter Your Insurance Information Below:

Policy#: Policy#:Group#: Group#:

Decline to Report

Non Hispanic or Latino

Hispanic or Latino

Divorced Legally Separated

Life Partner Married Single Widowed

Please Check One

Full Time Part Time Not A Student

Yes

No

Yes

No

Signature:

Description of Representative's Authority and Patient Name:

-OR-

Print Name:

Date Signed:

Date Signed:

Print Name:

Signature:

Patient Representative

Date of Birth:

I have read and understand the Financial Policy above.

Kidney Care Physicians asks that you read and sign this Financial Policy prior to any treatment. Please let us know if you have any questions.

• We will verify your insurance coverage at every visit. It is the patient's responsibility to supply all current insurance cards at each visit. • All Co-pays are due at the time of the visit. • We will ask you for picture identification for identity verification. • We will take your picture as part of our Red Flag Policy to ensure against identity theft. • If you do not have insurance or cannot provide proof of insurance at the time of your initial visit, a pre-payment of $100.00 will be required before services are provided. • We accept cash, checks, money orders, and most major credit cards. • Payment plans can be arranged with the billing office.

As a courtesy to our patients, we will submit claims to your insurance carrier for you. We will also submit secondary and tertiary claims. Insurance plans vary considerably and we cannot predict or guarantee what part of our services will or will not be covered by your plan. The patient is responsible for knowing the details/rules of his/her health plan(s). I hereby authorize Kidney Care Physicians LLC to release any medical information required in the course of treatment to permit payment directly to them from the insurance carrier. I recognize and accept responsibility for services rendered regardless of insurance coverage. This includes, but is not limited to, Co-Payments, Co-Insurance, Deductible, and Non-Covered Services.

FINANCIAL POLICY

Signature:

Description of Representative's Authority and Patient Name:

-OR-

Print Name:

Date Signed:

Date Signed:

Print Name:

Signature:

Patient Representative

Date of Birth:

MISSED OR LATE APPOINTMENT POLICY

Kidney Care Physicians asks that you read and sign this Missed or Late Appointment Policy prior to treatment in our office. Our policy is to call patients one day prior to the appointment to remind them of the date and time. These calls are a courtesy to our patients and it allows us the opportunity to schedule another patient in that appointment time if you choose to cancel. Missed appointments or arriving late for an appointment prevents other individuals from seeing there provider in a timely manner. Please note that a pattern of missed appointments, last minute cancellations, or being late for the scheduled appointment will result in possible discharge from Kidney Care Physicians. As a courtesy to other patients Kidney Care Physicians asks that you arrive 20 minutes prior to your scheduled appointment time. If you are 15 minutes passed your scheduled appointment your provider may not be able to see you and you will be asked to reschedule the appointment. If you are unable to keep your scheduled appointment, call us 24 hours prior to your scheduled appointment. If we do not receive a call and you miss your appointment there may be a $50.00 fee assessed to your account for that missed appointment. You will be responsible for this payment as your insurance will not pay this fee and it will be due prior to scheduling another appointment. Please call and ask for the Billing Office to settle this payment and schedule a new appointment at your convenience. Kidney Care Physicians gives you the right to appeal any or all charges or fees assessed to your account. If you have any questions or would like to appeal a fee assessed for a missed appointment please call (503) 561-8565 and ask for the office manager.

I have read and understand the Missed or Late Appointment Policy above.

Signature:

Description of Representative's Authority and Patient Name:

-OR-

Print Name:

Date Signed:

Date Signed:

Print Name:

Signature:

Patient Representative

Date of Birth:

ACKNOWLEDGEMENT AND CONSENT

I understand that Kidney Care Physicians LLC (referred to below as KCP) will use and disclose health information about me. I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnosis, treatment, procedures, prescriptions, and similar types of health-related information. I understand and agree that KCP may use and disclose my health information in order to:

• Make decision(s) about and plan for my care and treatment; • Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment; • Determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and • Perform various office; administrative and business functions that support my physician's efforts to provide me with, arrange and be reimbursed for quality cost-effective health care.

I also understand that I have the right to receive and review a written description of how KCP will handle health information about me. This written description is known as a Notice or Privacy Practices and describes the uses and disclosures of health information and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy of the most current version of This Practice's Notice of Privacy Practices in effect can be found in the waiting/reception area or on the company website. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests. By signing below, I agree to and understand the information above:

Signature:

Description of Representative's Authority and Patient Name:

-OR-

Print Name:

Date Signed:

Date Signed:

Print Name:

Signature:

Patient Representative

Date of Birth:

I understand that Kidney Care Physicians LLC (referred to below as KCP) may disclose my Protected Health Information (referred to below as PHI) electronically to or from other covered entities for coordination of patient care. The Health Portability and Accountability Act (HIPAA) states the patient has the right to choose to opt-in or opt-out of the electronic transfer of their PHI. Benefits of (HIE) or Electronic Information Transfer: * Information exchange that is more secure and efficient for patient coordination of care between your primary care, specialists, and medical facilities. * Higher levels of minimum necessary access and file encryption. * An automated and faster response time for information after request is placed. I understand that there is no Oregon Law or HIPAA Law that requires KCP to obtain consent to disclose patient information electronically for treatment, payment, and healthcare operations. I understand that KCP will need a separate form to disclose PHI that involves HIV, Mental Health, Drug and Alcohol Abuse, or Sexually Transmitted Diseases/Infections. I understand that KCP at times many be required by Federal or State law to disclose patient information as stated in the Notice of Privacy Practices. ____ OPT-IN: By opting in your are giving consents for KCP to release your PHI electronically for the above purposes of coordination of care with other covered entities. ____ OPT-OUT: By opting out you are not giving KCP consent to release your PHI electronically for the above purposes of coordination of care with other covered entities even in an emergency but will continue to be released through faxing, phone, or postal services. I understand that by initialing one of the above boxes that KCP will send my PHI in my desired format and that I have the right to change my decision at any time after this form is signed. If I change my decision after signing this form I need to inform KCP in writing or complete the appropriate form with signature and date. I understand that if I change my decision KCP is not responsible for the already sent information prior to the date of the new signed form. If you have any questions regarding the safeguards, manner of transmission, collections of PHI for coordination of care, or other HIE concerns, please contact the HIPAA Official for Kidney Care Physicians at (503) 561-8565. I have read, reviewed, and initialed the appropriate line above and with my signature acknowledge the format in which I would like my PHI sent and received by KCP.

AUTHORIZATION FOR (HIE) OR ELECTRONIC TRANSFER OF PROTECTED HEALTH INFORMATION

Medication and Allergy Information SheetConfidential Information

Please list all of your Allergies to Medications, Food, or the Environment and the reaction(s).

Please list all of your current Medications, Dose, and Directions.

Please list all of your current over the counter Medications, Dose, and Directions.

NSAID (Nonsteroidal Anti-Inflammatory Drug) Usage

Advil Use Never Use

Occasional Use

Daily Use

Amount Per Day

Aleve Use Never Use

Occasional Use

Daily Use

Amount Per Day

Ibuprofen Use Never Use

Occasional Use

Daily Use

Amount Per Day

Motrin Use Never Use

Occasional Use

Daily Use

Amount Per Day

Naproxen Use Never Use

Occasional Use

Daily Use

Amount Per Day

Other NSAID Use Never Use

Occasional Use

Daily Use

Amount Per Day

Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.

Patient Health History SheetConfidential Information

Please check if you have been diagnosed with any of the problems listed below.

Deafness

Other Hearing Problems

Blindness

Cataract

Glaucoma

Other Visual Problems

Lung Disease

Asthma

Emphysema

Chronic Bronchitis

COPD

Tuberculosis

Chronic Cough

Pneumonia

Wheezing

Shortness of Breath

Eyes, Ears, Nose, and Throat LungsHeart Disease

Heart Attack

Congestive Heart Failure

Enlarged Heart

Angina

High Blood Pressure

Irregular Heart Beats

Pacemaker/Defibrillator

Cardiac Catheterization

Angioplasty

Heart

Valvular Disease

Other Heart Disease

Thyroid Disease

Adrenal Disease

Diabetes (Non-Insulin)

Diabetes (Insulin)

Endocrine

Kidney Failure

Ever Been on Dialysis

Kidney Stones

Prostate Problems

Prostate Cancer

Venereal Disease

Kidney and Genital

Other Kidney Disease

Stomach Ulcers

Jaundice

Liver Disease

Hepatitis

Irritable Bowel Syndrome

Gastrointestinal and Stomach

Crohn's Disease

Other Stomach Disorder

Other Bowel Disorder

Stroke

Epilepsy or Seizures

Mental Retardation

Brain Injury

Nerve Injury

Memory Problems

Nervous System

Disc Disease

Blackout/Fainting Spells

Migraine Headache

Skin Disorder

Joint Disease

Arthritis

Osteoarthritis

Muscles and Bones

HIV or AIDS

Other STDS

Other Problems

Please give more detail if you have checked one of the "Other" or "Cancer" boxes. (Example: location and severity)

Ulcerative Colitis

Cancer

Lymphoma

Leukemia

Anemia

Platelet Disorder

Bone Marrow Disorder

Spleen Disorder

Hematology/Oncology

Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.

Please list any previous hospitalizations/procedures and dates.

Patient Health History SheetConfidential Information

Family History Father At What Age? Mother At What

Age? Siblings At What Age? Children At What

Age?

Heart Disease

Hypertension

Stroke

Migraine Headache

High Cholesterol

Seizure

Asthma/COPD

Diabetes

Cancer

Kidney Disease

Congestive Heart Failure

Other

Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.

If you have checked any "other" box(es) please describe here or offer other comments:

Social History

Cigarette Tobacco Use

Never Use

Occasional Use

Regular Use

Packs Per Day

Chewing Tobacco Use

Never Use

Occasional Use

Regular Use

Amount Per Day

Alcohol Use Never Use

Occasional Use

Regular Use

Drinks Per Day

Illicit Drug Use

Never Use

Occasional Use

Regular Use

Route and

Type

Living Status Alone With Spouse With Family Member

With Caregiver

Assisted Living

Care Facilty

Any other comments you might have that apply to your social habits:

Occupation: Employer:Education Level:

Patient Present Health SheetConfidential Information

Are you experiencing any of the following conditions now?

Fever Chills Weight Gain Weight Loss Weakness Night SweatsGeneral

Blurry Cataracts Eye Pain Floaters Black SpotsVision

Sore Throat Ear Pain Nose Bleeds Sinus Problems Hearing LossEars, Nose, Throat

Chest Pain Irregular Heart Beat SwellingCardiac

Swelling Location(s): _______________________________________

Shortness of Breath Cough Pain with Breathing Wheezing Bloody PhlegmRespiratory

Stomach Pain Heart Burn Nausea Vomiting Diarrhea ConstipationGastroenterologic

Appetite Loss Appetite Gain

Urine Urgency Urine Frequency Burning Urination Difficulty with Urination

Erectile Dysfunction

Urinary

Rash Bruising Lesions ItchingSkin

Headache Dizziness Seizures NumbnessNeurologic

Depression Anxiety Insomnia Memory Loss ADHDPsychological

Heat Intolerance Cold Intolerance Hair Loss Energy Up Energy DownEndocrine

History of Falls Back Pain Joint Pain Anemia Weakness Night SweatsMisc

Weakness

Bloody Urine

Bloody Stools Dark or Tarry Stool

Tremors

Please fill out form in black or blue ink. Please fill the form out completely and to the best of your knowledge. Return this form to the front desk at Kidney Care Physicians, LLC.