William W. Truslow, MD PLLC Practice of Rheumatology 409 Parkway Drive, Suite A Office Hours: 9 AM-5 PM (M-Th)/closed on Friday Greensboro, NC 27401 www.williamwtruslowmd.com Telephone #: (336) 379-7597 Fax #: (336) 379-9197 Referring Physician: ____________________________ PATIENT NAME: ___________________________________________________________ APPOINTMENT DATE: _____________________________________________________ PLEASE ARRIVE AT: _______________ FOR YOUR _______________________ APPT. Dr. Truslow is dedicated to providing you with the best possible medical care. Dr. Truslow is a rheumatologist, which is a specialist that treats patients with various forms of arthritis. If you have any questions prior to your appointment, please do not hesitate to contact our office. Please complete the enclosed forms and bring them with you for your appointment. Our office has agreements with the following Insurance companies: AARP Complete, Advantra Medicare, Aetna, Blue Cross Blue Shield, Cigna, Coventry National Network, First Health, Humana, Medicare (including most replacement plans), Medcost, Multiplan, PHCS, Unicare, United Healthcare, UMR, Wellcare, and Wellpath. OUR OFFICE DOES NOT FILE WORKER’S COMPENSATION CLAIMS. Please be prepared to present a valid photo ID and current insurance card in order to be seen & file insurance: otherwise your appointment will be rescheduled. FOOD AND DRINKS ARE NOT PERMITTED IN THIS OFFICE. *Please bring a written list of any medications that you are currently taking and the bottles for those medications, as well as any medical information provided by your referring physician. *Please refrain from wearing any strong perfumes, lotion, colognes, or smoking prior to coming in our office. Many of our patients have adverse reactions to these odors. *As a courtesy, we ask that you notify our office at least 24 hours in advance if you are unable to keep your appointment. Thank you for your consideration of other patients and the Doctor. New patient appointments that are not kept will not be rescheduled. Please call and reschedule if the appointment date and time will not work for you. DIRECTIONS: Our office is located off of Wendover Avenue, and is close to Moses Cone

Hospital. Turn onto Cridland (right if you are eastbound, left if you are westbound) beside the Marathon gas station. Then take the immediate right to continue on Cridland. Our office is the third building on the left, and can be entered from the left side of the building. The Latham Park Tennis Facilities are located across the street from our building.

OFFICE POLICIES AND PROCEDURES

Please read the following information and keep it for future reference regarding our office policies and procedures. INSURANCE PLANS AND MANAGED CARE: Please contact your insurance company to verify that Dr. Truslow is a participating physician in their network if you are unsure that we will accept your insurance plan. This telephone number, in most cases is printed on your insurance card. We will file your insurance claim if we participate with your insurance plan. It is the patient’s responsibility to obtain a referral from your primary care physician if required by your HMO or POS to see a specialist. Medicare and Supplements: We do accept assignment from Medicare. You are required to pay your deductible that has not been met and any co-pay/co-insurance at the time services are rendered. The 2015 Medicare deductible is $147.00. Most Supplemental plans are crossed over automatically after Medicare has processed the claim. Payment: Payment of applicable copays and/or coinsurances & deductibles will be expected at the time of service.. We will be glad to reschedule your appointment if necessary. If you have a private/group insurance plan that we do not participate with, full payment is due at the time of service. We will provide you with a document that you can use to file your own insurance claim with your insurance carrier. In the event that we filed and your insurance carrier determines that a service that you received is not a covered service, you will be responsible for the full payment. If your insurance carrier pays only a percentage of your bill leaving a balance on your account, you will receive a bill from our office which will be payable upon receipt. We accept cash, check, money order, Discover, Visa and MasterCard. Credit & debit cards are accepted. Prescription Refills: Dr. Truslow provides enough medication on his prescriptions to last until the patient’s next return appointment. Please bring all of your current medications with you to each visit to our office. Prescriptions written by Dr. Truslow become the patient’s responsibility to get filled by a pharmacy. Please inform Dr. Truslow during your office visit if you are using a mail order pharmacy with special requirements. This will eliminate extra work and phone calls for our office. Please do not contact our office requesting refills for prescriptions that Dr. Truslow did not prescribe. Contact the doctor’s office that wrote your prescription because we cannot refill something that Dr. Truslow did not prescribe. We do not refill prescriptions after hours or during the weekend. Please have your pharmacy contact us directly for refill requests. We submit all prescriptions electronically to both local and mail order pharmacies. EMERGENCIES: Dr. Truslow can be contacted at his office during normal business hours; however, in the event that an emergency occurs during the hours that the office is closed, please call your primary care physician. If you don’t have a PCP, please go to an urgent care near you. Call 911 if you are having a life-threatening emergency. Hospital admissions are performed by a hospital based “Hospitalist” group, and Dr. Truslow will be available for consultative services. If your problem is not an emergency, please contact our office during normal office hours. Please call 336-378-8620 to leave any none emergency message with our answering service. MISSED APPOINTMENTS: Patients that miss 3 appointments with less than a 24 hour notice will be dismissed from our practice. A fee of $10.00 will be charged for all missed appointments. If you have any questions, please contact someone in our business office. Our normal business hours are: 9:00 AM to 5:00 PM Monday- Thursday. Our office is closed on Friday. Our office telephone number is (336) 379- 7597. I have read and agree to accept the terms of the office policy of Dr. William Truslow: Signature of patient: __________________________________ Date: ___________________________

PATIENT INFORMATION

DATE____________ Patient_______________________________________________________________Age____ Birth date_________ Sex M / F Last First Middle Address______________________________________________________________________________________________

Number Street City State Zip Code

Home Phone _________________________________________Work Phone_______________________________________

Social Security #_____________________________________ Cellular Phone_____________________________________

Marital Status: Single( ) Married( ) Widowed( ) Divorced( ) Other ( ) Race:_____________________ Occupation__________________________________Employer_________________________________________________ Spouse’s Name___________________________________________________________________ Birth Date____________ Last First Middle Initial Spouse’s Employer_______________________________________________ Social Security#________________________ Emergency Contact____________________________________ ph#_______________ Relationship___________________ Person Responsible For Bill ___________________________________________Relationship to Patient________________ Referred By___________________________________ Primary Physician________________________________________ Does you insurance (HMO/ POS) require an authorization from your primary care physician to see a specialist? Y / N Referring Physician’s Address_________________________________________________ Phone____________________ Primary Insurance Secondary Insurance Name___________________________________________ Name____________________________________________ Address_________________________________________ Address__________________________________________ Policy Holder_____________________________________ Policy Holder_______________________________________ Policy #__________________________________________ Policy #__________________________________________ Group #__________________________________________ Group #__________________________________________ Please indicate how you plan to pay your bill before leaving the office? CASH ( ) CHECK ( ) CREDIT CARD ( ) Do you have Medicare? YES ( ) NO ( ) Is Medicare your PRIMARY insurance? YES ( ) NO ( ) Do you have additional insurance other than Medicare? YES ( ) NO ( )

WILLIAM W. TRUSLOW, M.D. 409- A Parkway Drive Greensboro, NC 27401

(336) 379-7597 phone (336) 379-9197 fax

AUTHORIZATION TO RELEASE MEDICAL INFORMATION: The undersigned authorizes the release of all or parts of the patient’s medical records by telephone or writing to applicable professional review organizations, or a person or corporation, which is or may be liable under a contract with William W. Truslow, MD or to the patient, authorized family member, or employer of the patient or insurance company. Patient authorizes access to pharmacy history records when medications are prescribed. GUARANTEE OF PAYMENT: For medical services rendered to the above named patient including telephone consults and missed appointment fees, the undersigned guarantees payment to Dr. William W. Truslow, MD. ASSIGNMENT OF INSURANCE BENEFITS: I hereby assign all of my right, title and interest in and to any insurance benefits, and direct payment to Dr. William W. Truslow, MD of insurance benefits, including Major Medical or any other insurance payable to or on behalf of the undersigned by virtue of services rendered by Dr. William W. Truslow, MD. Signature of Patient______________________________________________________________ Date__________________

This authorization/ release shall remain valid until rescinded at another date.

NAME___________________________________________________________AGE__________________ DATE___________________ WHAT ARE YOUR SYMPTOMS?__________________________________________________________________________________ HISTORY OF ILLNESS – MUST ANSWER ALL THE FOLLOWING QUESTIONS WHERE IS YOUR PROBLEM?__________________________________________________________________________ WAS THIS AN ACCIDENT?_________________________________DATE OF ACCIDENT________________________ HOW LONG HAVE YOU HAD THIS PROBLEM?__________________________________________________________ HOW SEVERE IS YOUR PROBLEM?____________________________________________________________________

HOSPITALIZATION OR SURGERY

DATE REASON DR. DATE REASON DR.

MEDICINES: List ALL current medicines, even over the counter. This is very important. Show number of milligrams and how often you take the medicine. 1.______________________________ 5.______________________________ 9._________________________________ 2.______________________________ 6.______________________________ 10.________________________________ 3.______________________________ 7.______________________________ 11.________________________________ 4.______________________________ 8.______________________________ 12.________________________________ (attach a list if there is not enough space to list all) DRUG ALLERGIES Please list drug name and type of reaction: 1.________________________________________________ 3._________________________________________________ 2.________________________________________________ 4._________________________________________________ HABITS: SMOKING: YES ( ) NO ( ) Packs per day ___________ How many years ______________ ALCOHOL: YES( ) NO( ) Type ________________ Amount_____________ CAFFEINATED DRINKS (Cups per day): _____________________________________ WOMEN ONLY: Number of pregnancies________ Miscarriages?_________ Last menstrual period______________ Planning pregnancy?________________ Last bone density test_________________ FAMILY HISTORY: Father: Living ( ) Deceased ( ) Age at death______________ Cause of death____________________________________ Mother: Living ( ) Deceased ( ) Age at death______________ Cause of death____________________________________ Brothers: Number living______________ Number deceased_________________ Sisters: Number living______________ Number deceased_________________ Number of Children: _____________________ Is there a family history of ARTHRITIS? Relatives________________________ Type of Arthritis_______________________ Cancer____________________________________ Diabetes________________________________ Stroke____________________________________ High blood pressure/Heart disease__________________________________ WEIGHT: Current:_______________________ Weight one year ago:________________________ HEIGHT: _______________________________

FOR OFFICE USE ONLY: BP: ____________ HT: ______feet ______inches Pulse: __________ BMI: ___________ LB: __________ Initials: ________

For Physician Use

AM Stiffness Joint Swelling F,S,C Anorexia, insomnia, fatigue, weight loss, depression Rash Psoriasis Photosensitivity Oral Ulcers Alopecia Pleurisy HA, migraine, vision Raynaud’s Myalgia and weakness Dysphagia, diarrhea, const, HB, melena, BRB Conjunctivitis Urethritis, hematuria Heel or Achilles tendon Back pain Tick exposure Tryptophan Miscarriage, menses

William W. Truslow, M.D. 409-A Parkway Drive

Greensboro, NC 27401

PATIENT CONSENT Patient Name: ____________________________________________ Date of Birth: ______________

By signing this consent you are giving the providers and office staff permission to use and

disclose your health information. Your health information will be used and disclosed to provide your care and treatment, to bill and collect payment for the services provided, and to perform necessary routine office operations.

You have been provided with a copy of our “Notice of Privacy Practices” that contains a complete description of the uses and disclosures covered under this consent. You have been given time to review the “Notice of Privacy Practices” and we have encouraged you to read it and ask any questions that you may have prior to signing this consent.

Our office reserves the right to change the privacy practices as stated in the “Notice of Privacy Practices.” You will be given a copy of the revised notice with your first office visit following any change.

You have the right to request that we restrict how your health information is used or disclosed. We are not required to agree to your requested restriction, but if we do agree to the restriction, we will honor the restriction.

You have the right to revoke this consent except to the extent that we have already taken action covered under the consent. If you choose to revoke this consent, you must do so in writing. This consent will remain in effect until revoked. _______ I give permission for Dr. Truslow or his staff to leave a message on a home/work/cell answering device. Please list the preferred number on which you would like for us to leave the message. Please specify if there are any restrictions. I give permission for Dr. Truslow or his staff to leave messages with my spouse, family member, or friend, etc…regarding my personal information. Please specify the name(s), relationship, and telephone number(s) of the individuals you wish to authorize. Sign and Date below

Relationship if Not Patient _____________