PAT IENT INFORMAT ION

Susan Biegel M.D. Date: Referred by:

Name •Mr. nMrs. DMS.

First Middle Last

Age Date of Birth SSN

Marital Status • Single • Married • Divorced • Separated • Widow • Widower

Home Address

Phone Numbers Home Cell* Work

Email Address May we contac t you t h r ough you r emai l to con f i rm appo i n tmen t s and a ler t you of updates? • YeS • NO

*May we contac t you by t ex t i ng you r cell phone? • YeS • NO

Spouse's Name DOB First Middle Last

Emergency Contacts 1. Name Phone Number

2. Name Phone Number

EMPLOYMENT INFORMAT ION

Patient Employed By

Occupation Work Number

Address

Spouse Employed By

Occupation

Address

Work Number

INFORMAT ION FOR YOUR P H Y S I C I A N

Name . DOB Age . Place of Birth Race/National i ty of Parents Religion Education Age on complet ion Occupation For how long? Where and when have you l ived or t rave led outs ide the U.S. and Canada?

Living Age or Age a t death Present hea l th o r cause of dea th

Father • Yes • No Mother • Yes • No Spouse • Yes • No Present marr iage length Previous marr iage length Brothers # Living Health

# Dead Cause of death Sisters # Living Health

# Dead Cause of death Chi ldren # Living Health

# Dead Cause of death Please circle illnesses which have occurred in any of your blood relat ives.

Diabetes Bleeding Tendency Kidney Disease Tuberculos is Heart Disease Stroke High Blood Pressure Nervous Il lness Al lergy Cancer

Please circle illnesses or condit ions you have had. Diabetes Glaucoma Heart Trouble Syphi l is Vein Trouble Cancer Asthma Jaundice Gonorrhea Bleeding Tendency Tuberculosis Pneumonia Kidney Disease Rheumatic Fever Nervous Disorder

Please list other il lnesses not requir ing operat ion for which you were hospita l ized.

Have you had serious injur ies, broken bones, etc.? I f yes, please l ist.

Have you had al lergy or sens i t iv i ty to medic ines or o ther substances? I f yes, please describe.

Do you use tobacco now? In the past? Amoun t For how long? Do you use alcoholic beverages? Type Amoun t For how long? Please check the diseases against which you have been immun ized .

• Smal lpox • Tetanus • Typhoid • Polio • Inf luenza • Other Please list previous operat ions, g iv ing dates, hospital where per fo rmed, and the name of the surgeon.

Please list previous x-ray therapy or s imi lar t r ea tmen t .

Medications

Menstrual History: last period Periods are • Regular • I r regu la r # of Pregnancies # of Miscarriages

Have you take Cort isone-type drugs? Oral Contraceptives? Have you received a blood transfusion? Date Your we ight dressed How long have you been th is weight? Please wr i te the main reason you came to the off ice

Provider's S ignature Date

REVIEW OF SYSTEMS Susan Biegel MD

Date

Patient's Name DOB_

General Nose Respiratory

• Yes • No Weight loss or gain • Yes • No Stuffness • Yes • No Snoring

• Yes • No Fatigue/ tiredness • Yes • No Discharge • Yes • No Cough

• Yes • No Weakness (yellow/ green/ clear) • Yes • No Sputum

• Yes • No Trouble sleeping • Yes • No Itching (yellow/ green/ clear)

D Y e s D No Night sweats • Yes • No Hay fever • Yes • No Coughing up blood

• Yes • No Nosebleeds • Yes • No Shortness of breath

Skin • Yes • No Sinus pain • Yes • No Wheezing

• Yes • No Rashes • Yes • No Sneezing • Yes Q No Painful breathing

• Yes • No Lumps • Yes • No Trouble breathing after

• Yes • No Bruising easily Throat exertion

• Yes • No Itching/ pruritis • Yes • No Bleeding • Yes • No Stop breathing while

• Yes • No Dryness • Yes • No Dentures sleeping (apnea)

• Yes • No Color changes • Yes • No Sore tongue

• Yes • No Losing hair • Yes • No Hoarseness Cardiac

• YesD No Brittle nails • Yes • No Thrush • Yes • No Chest pain or discomfort

• Yes • No Moles • Yes • No Non-healing sores (stabbing/sharp/ pressure)

• Yes • No Acne • Yes • No Need to clear throat • Yes • No Tightness

• Yes D No Lesions frequently • Yes • No Palpitations

(heart pounding)

Head Ear • Yes • No Shortness of breath with

• Yes • No Headache • Yes • No Decrease hearing activity (dyspnea)

• Yes • No Head injury • Yes • No Ringing in ears • Yes • No Difficulty breathing lying

• Yes • No Neck pain • Yes • No Earache down (orthopnea)

• Yes • No Facial pain • Yes • No Drainage • Yes • No Swelling of ankles

• Yes • No Spinning of room o Yes • No Sudden awakening from

Eyes sleep with shortness of breath

• Yes • No Vision loss/ changes Neck (paroxysmal nocturnal dyspnea)

• YesD No Glasses or contacts • Yes • No Lumps

• Yes • No Pain • Yes • No Swollen glands

• Yes • No Redness • Yes • No Pain

• Yes • No Blurry or double vision • Yes • No Stiffnes

O Yes • No Flashing lights P L E A S E O Yes • No Specks Breasts

• Yes • No Glaucoma • Yes • No Lumps F L I P @WE§t • Yes • No Cataracts • Yes • No Pain

• Yes • No Dry eyes O Yes • No Discharge

• Yes • No Itchy eyes (clear/ bloody/ milky/ green)

• Yes • No Watery eyes • Yes • No Rash •4 • Yes • No Watery eyes • Yes • No Rash

• • Yes • No Last eye exam • Yes • No

• Yes • No

Self-exams

Breast feeding

REVIEW OF SYSTEMS Susan Biegel MD

Date

Patient's Name DOB_

Gastrointestinal

a Yes • No Swallowing difficulties

(dysphagia)

Heartburn

Change in appetite

Nausea

Change in bowel habits

Rectal bleeding

(hematochizia)

• YesD No Constipation

Diarrhea

Yellow eyes or skin

Black stool (melena)

Abdominal pain

Vomiting

Laxative use

Antacid use

History of hepatitis

• Yes • No

• Yes D No

D Yes • No

• Yes • No

• Yes • No

• Yes • No

• Yes • No

• Yes • No

• Yes • No

• Yes • No

• Yes • No

• Yes • No

D Yes • No

Urinary

• Yes •

• Yes •

• YesD

• YesD

No Frequency

No Urgency

No Burning or pain (dysuria)

No Blood in urine

(hematuria)

• Yes • No Incontinence (leaking

when sneezing)

• Y e s n N o Change in urinary

strength (weak urine stream)

• YesD No Nighttime frequency

(nocturia)

• YesD No Loss of libido

• YesD No Erectile dysfunction

Musculoskeletal

• Yes Q No Muscle or joint pain

• Yes • No Stiffness

• Yes • No Back pain

• Yes • No Redness of joints

• Yes • No Swelling of joints

• Yes • No Trauma

• YesD No Nocturnal leg cramps

Neurologic

• Yes • No

• Yes • No

• Yes • No

• Yes • No

• Yes O No

• Yes • No

• Yes • No

• Yes • No

• Yes • No

D Yes • No

• Yes • No

Dizziness

Fainting

Seizures

Weakness

Numbness

Tingling

Tremor

Memory loss (dementia)

Unstable gait (utaxia)

Falls

Behavioral changes

Hematologic

• Y e soNo Ease of bruising

• Y e snNo Ease of bleeding

Endocrine

• Yes • No Heat or cold intolerance

• Yes • No Sweating

• Y e s n N o Frequent urination

• Yes • No Thirst/ dry mouth

• YesD No Change in appetite

• Y e snNo Weight gain or loss

P L E A S E F L I P O V E R

Vascular

• Yes O No Calf pain with walking

• YesD No Leg cramping

• YesD No Ulceration of leg

• Yes • No History of blood clots in

legs

• YesD No Discolation of skin in legs

• Yes • No Varicose veins (DVT)

Psychiatric

• Yes • No Nervousness/ Irritability

• Y e s oNo Stress/Anxiety

• Yes • No Depression

Doctor's Signature

Name

S u s a n B iegel MD

DOB

• 1 in 3 A m e r i c a n s have und i agnosed s l e ep d i so rde r s . • Ove r 4 0 mi l l ion A m e r i c a n s a r e chron i ca l l y ill w i th v a r i o u s s l eep d i s o rde r s . • 4 0 % of A m e r i c a n s repor t di f f iculty e i the r fa l l ing a s l e e p or s t ay i ng a s l e ep . • I t is e s t ima t ed tha t 9 0 % of t he popu lat ion of obs t ruc t i ve s l e ep a p n e a h a s

not been d i agnosed .

Please check the box only if you answer "yes" to the quest ions. Points

Ha\/p vnu hppn t*nlrl fh^f \/nii t̂~nn hrprithinn whilp V O I I ' T P I l u v c y u u u c c i i L v j i v j L I I C J L y U U O L W \J U I c CJ L I I I I I y vv M n c y u u i c.

^Ippninn ? • Yes 8

Have vou ever fallen asleeo or nodded off while drivina? 1 1 V - - y W C I L—. V L^ 1 1 L_.l 1 1 v _ | | V_J 1 \—. \—. l__4 V_/ 1 I I V_4 V,< I I w ¥ 1 I I I V | 1 V 1 1 1 -—4 •

• Yes 6 Do you awaken suddenly with shortness of breath, gasping or wi th your heart racing?

• Yes 6

Do you feel excessively sleepy during the day? • Yes 4 Has anyone ever told you that you snore whi le you're sleeping?

• Yes 4

Have you had a weight gain and found it diff icult to lose? • Yes 2 Have you taken medicat ion for or been diagnosed wi th high blood pressure?

• Yes 2

Do you kick or j e r k your legs while sleeping? • Yes 3 Do you feel burn ing, t ingl ing or crawling sensations in your legs when you wake up?

• Yes 3

Do you wake up wi th headaches dur ing the night or in the morning?

• Yes 3

Do you have trouble fall ing asleep? • Yes 4 Do you have trouble staying asleep once you fall asleep? • Yes 4 Add the points together when you answered "yes".

Score & Risk Factor

Patient Consent I hereby consent to the d isc losure of m y responses to th is Sleep Apnea Quest ionna i re fo r the purpose of ass ist ing in the d iagnos is and t r e a t m e n t of a potent ia l sleep d isorder . I unders tand tha t as pa r t of the t r e a t m e n t , p a y m e n t or hea l th care opera t i ons , it may become necessary t o disclose m y pro tec ted hea l th i n f o rma t i on t o ano the r en t i t y , and I consent such disc loser fo r these pe rm i t t ed uses, inc lud ing, bu t not l im i ted to , d isc losers via fax. I fu l ly unde r s tand and accept the t e r m s of th i s consent .

Signature Date

Your doc to r is screen ing for sleep apnea w i th the above ques t ionna i re and may r e c ommend you fo r a sleep s tudy . I f you are r e c omme4nded fo r a sleep s tudy by you r doctor , t he Institue of Sleep and Wellness wi l l con tac t you to

schedule you r sleep s tudy and ver i f y you r insurance.

This ques t ionna i re was deve loped based upon publ ished art ic les by the Amer i can Academy of Sleep Medic ine (A.A.S.M.).

B I L L I N G P O L I C I E S AND P R O C E D U R E S

1. Appointments not cancelled 48 hours prior to your scheduled t ime wil l be charged $50 per appo intment.

2. We provide courtesy billing for patients wi th accurate insurance bill ing informat ion including copy of insurance cards, claims address and claim fo rm if required. I f this informat ion is not given at the t ime of service, it will be the patient's responsibi l ity to pay for the services rendered.

3. I f you have a change in insurance, it is your responsibi l i ty to alert our office of this change. I f you fail to do this before services are rendered, it will be your responsibi l ity to pay for the services.

4. I t is your responsibi l ity to understand your insurance policy and its benefits. Make sure you understand how it works in regard to co-pays, deductibles and co-insurance. P l ease m a k e su r e you know w h a t j s and w h a t is not cove red .

5. Insurance companies do not always pay the ent ire bil l. I t is to be understood that any balance after payment by the insurance company will be billed to you and should be paid prompt ly or an a r rangement made.

6. Your insurance is a contract between you, your employer and the insurance company.

7. Not all services are covered benefits in all contracts. Some insurance companies arbi trar i ly select certain services they will not cover. In the event the insurance does not cover the payment for services, they are the patient's responsibi l i ty.

8. I t is your responsibi l ity to check wi th your insurance company if pr ior author izat ion is required.

9. HMO PATIENTS: I t is your responsibi l ity to make sure tha t : a. Your policy is effective for the IPA you have selected and the PCP

you have chosen is correct on your card. b. Your co-pay is paid at the t ime of service, if you have a co-pay. c. I f you have services done and we are not the PCP l isted, you may

be liable for the bil l. 10. We do accept ass ignment of benefits f rom Medicare. As a courtesy we

will bill your secondary insurance. Any balance not covered will be the patient's responsibi l i ty.

1 1 . CASH PATIENTS: There may be charges in addit ion to your initial off ice visit charge for procedures and surgeries.

12. All co-pays and deductibles are payable at the t ime of service. 13. All accounts are due and payable wi th in 60 days f rom the date of

service unless arrangements have been made.

Signature of Patient/Responsible Party Date

I N S U R A N C E INFORMAT ION & E L I G I B I L I T Y GUARANTEE

Patient's Name DOB

Subscriber's Name DOB

Contract Name (i.e. Blue Cross...)

Medical Group (if HMO) (i.e. Regal, IEHP...)

Policy Number Group Number

I understand that if the above is not t rue , or if I am ineligible under the

te rms of my health plan and/or employer 's group's Medical and Hospital

Subscriber Agreement, I am financial ly responsible for all charges for

services rendered. Addit ional ly, assuming my el igibi l i ty for benefits is not

established as set for th above, I agree to pay for all services wi th in 60 days

of receiving a bill f r om this office.

Signature Date

Print Name DOB

Susan Biegel M.D. Inc. 1113 Alta Ave. Suite 220

Upland, CA 91786 Tel. (909) 985-1908 Fax (909) 963-1800

Dear Patient,

This is our office policy: if you do not keep your appointments, with the doctors or other providers, or cal and give a 48-hour notice of cancellation, you wil l be charged a $ 5 0 fee per every m issed appointment .

Thank you for your courtesy.

Signature Date

Print Name DOB

/

P H Y S I C I A N - P A T I E N T A R B I T R A T I O N AGREEMENT

Art ic le 1: Ag r eemen t to A rb i t r a te : I t is unders tood t h a t any d i spu te as to medica l ma lprac t i ce , t h a t is as to whe t he r any medica l services rendered under th is cont rac t were unnecessary or unauthor i zed or were imprope r l y , neg l igent ly o r i n compe ten t l y rendered , wil l be de t e rm ined by submiss ion to a rb i t r a t i on as p rov ided by Cal i fornia law, and not by a lawsu i t o r resor t t o cour t process except as Cal i fornia law prov ides fo r jud i c ia l rev iew of a rb i t ra t i on proceed ings . Both part ies to th is cont rac t , by en te r ing into it, are g iv ing up the i r cons t i tu t i ona l r i gh t t o have any such d ispute dec ided in a cou r t of law before a j u r y , and instead are accept ing the use of a r b i t r a t i on .

Art ic le 2: All Cla ims Must Be A rb i t r a t ed : I t is t he in ten t ion of the part ies t ha t th i s ag r eemen t shal l cover all c la ims o r cont rovers ies whe the r in t o r t , con t rac t or o the rw i se , and shall b ind all part ies whose c la ims m a y ar ise ou t of o r in any way re la ted t o t r e a t m e n t o r services p rov ided or not p rov ided by the below ident i f ied phys i c ian , med ica l g r oup or assoc iat ion, the i r par tners , associates, associat ions, corpora t ions , par tnersh ips , emp loyees , agents , cl inics, and/o r p rov iders (he re ina f t e r co l lect ive ly re fe r red to as "Physic ian") t o a pa t ien t , inc lud ing any spouse o r heirs of t he pa t i en t and any ch i ld ren, whe the r born or unbo rn , at the t ime of the occur rence g iv ing rise to any c la im. In the case of any p regnan t mo the r , t he t e r m " pa t i e n t " here in shall mean bo th the m o t h e r and the mothe r ' s expec ted chi ld or ch i ld ren .

Filing by the Physician of any act ion in any cou r t by the physic ian t o col lect any fee f r o m the pa t i en t shall no t wa ive the r i gh t to compe l a rb i t r a t i on of any ma lprac t i ce c la im. However , fo l lowing the asser t ion of any c la im aga ins t Physician, any fee d i spute , whe the r or not the sub jec t o f any ex i s t ing cou r t ac t ion , shal l also be reso lved by a rb i t r a t i on .

Ar t i c le 3: Procedures and Appl icable Law: A demand for a rb i t ra t i on mus t be c ommun i c a t ed in w r i t i n g by U.S. ma i l , postage prepa id , to all par t ies , descr ib ing the c la im aga inst Physic ian, the a m o u n t o f damages sought , and the names , addresses and te lephone numbe r s of the pat ient , and ( i f appl icab le) h is/her a t t o r ney . The part ies shall t he rea f t e r select a neut ra l a r b i t r a t o r who was prev ious ly a Cal i fornia super ior cou r t j u d g e , t o pres ide ove r the ma t t e r . Both part ies shal l have the abso lute r i gh t t o a rb i t r a te separate ly the issues of l iabi l i ty and damages upon w r i t t en request to the a rb i t r a to r . Pat ient shall pursue h is/her c la ims w i th reasonable d i l igence, and the a rb i t r a t i on shall be gove rned pursuan t t o Code of Civil Procedure §§ 1280-1295 and Federal A rb i t r a t i on (9 U.S.C. §§ 1-4). The par t ies shall bear t he i r own costs, fees and expenses, a long w i th a pro rata share of t h e neut ra l a rb i t ra to r ' s fees and expenses.

Art ic le 4: Retroact ive Effect: The pa t i en t in tends th is ag r eemen t t o cover all services rendered by Physician not on ly a f te r t h e da te it is s igned ( inc lud ing , but not l im i ted to , emergency t r e a t m e n t ) , bu t also be fore it was s igned as we l l .

Art ic le 5: Revocat ion: This ag reemen t may be revoked by w r i t t en not ice de l ivered t o Physician w i th i n 30 days of s ignature and if no t revoked wil l gove rn all medica l services rece ived by the pat ien t .

Art ic le 6: Severab i l i ty Provis ion: In the event any prov i s ion(s) of th is Ag r eemen t is dec lared vo id and/o r unenforceab le , such prov i s ion(s ) shal l be deemed severed t h e r e f r om and the r ema i nde r of the Ag r eemen t enforced in accordance w i th Cal i fornia law.

I unders tand t h a t I have the r i gh t to receive a copy of the ag reemen t . By my s i gna tu re below, I acknow ledge t h a t I have rece ived a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

By: Susan Biegel M.D

By

By:

By:

By:

S igna tu re of Physician Date By

Print Name of T rans la to r Date By

S igna tu re of T rans la to r Date By:

Print Name of Pat ient Date

S igna tu re of Pat ient Date

Print Name of Representat ive & Date Relat ionship w i t h Pat ient

S igna tu re of Pat ient 's Representat ive Date

HIPAA NOT ICE OF P R I V A C Y P R A C T I C E S

Susan Biegel M.D. 1113 Alta Ave. Ste. 220

Upland, CA 91786 Tel (909) 985-1908 Fax (909) 963-1800

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 Not ice of Privacy Practices descr ibes how we may use and disclose you r p ro tec ted hea l th i n f o rma t i on (PHI) t o ca r ry ou t t r e a tmen t , p a y m e n t of hea l th care operat ions (TPO) and fo r o the r purposes t ha t a re p e r m i t t e d or requ i red by law. I t also descr ibes you r r i gh t to access and cont ro l you r p ro tec ted hea l th i n f o rma t i on . "Protected Health I n f o r m a t i o n " is i n f o rmat i on about you , inc luding demograph i c i n f o rmat i on , t h a t may ident i fy you and t h a t re lates t o you r past, present or f u t u r e physica l or menta l hea l th o r cond i t ion and re la ted hea l th care serv ices.

U s e s a n d D i s c l o s u r e of P r o t e c t e d H e a l t h I n f o r m a t i o n Your p ro tec ted hea l th i n f o rma t i on may be used and disclosed by you r phys ic ian, ou r of f ice staf f and o the rs outs ide of ou r of f ice t ha t a re invo lved in you r care and t r e a t m e n t fo r the purpose of p rov id ing hea l th care services t o y ou , to pay you r hea l th care bil ls, to suppor t the opera t ion of t he physic ian's pract ice, and any o the r use requ i red by law.

T r ea tmen t : We wi l l use and disclose you r p ro tec ted hea l th i n f o rma t i on t o prov ide , coord ina te , or manage you r heal th care and any re lated services. This includes the coord inat ion or managemen t of you r hea l th care w i th a th i rd pa r t y . For examp le , we wou ld disclose you r pro tec ted heal th i n f o rma t i on , as necessary, to a h o m e hea l th agency t ha t prov ides care fo r you . For examp le , you r p ro tec ted hea l th i n f o rma t i on may be p rov ided t o a phys ic ian t o w h o m you have been re fe r red t o ensure t ha t the phys ic ian has the necessary i n f o rma t i on t o d iagnose or t r ea t y ou .

Payment: Your p ro tec ted heal th i n f o rma t i on wil l be used, as needed, to obta in p a y m e n t fo r y ou r hea l th care serv ices. For examp l e , ob ta in ing approva l fo r a hospi ta l stay may requ i re t ha t you r re levant p ro tec ted hea l th i n f o rma t i on be disclosed to the hea l th plan to ob ta in approva l fo r the hospi ta l admiss ion .

Health Operat ions: We may use or disclose, as-needed, y ou r p ro tec ted hea l th i n f o rma t i on in o rde r t o suppo r t the business act iv i t ies of you r physic ian's pract ice. These act iv i t ies inc lude, but are not l im i ted t o , qua l i t y assessment act iv i t ies , emp loyee rev iew act iv i t ies , t ra in ing of medica l s tudents , l icensing, and conduc t ing or a r rang ing for o t he r business act iv i t ies . For examp le , we may disclose you r p ro tec ted heal th i n f o rma t i on t o medica l s tuden ts t h a t see pat ients a t ou r of f ice. I n add i t i on , we may use a s ign-in sheet a t the reg i s t ra t ion desk whe re you wi l l be asked t o sign you r name and indicate you r phys ic ian. We may also call you by name in the wa i t i ng r o o m when you r phys ic ian is ready t o see you . We may use or disclose you r p ro tec ted heal th i n f o rma t i on , as necessary, to contac t you to r em ind you of you r appo i n tmen t .

We may use or disclose you r p ro tec ted hea l th i n f o rma t i on in fo l l ow ing s i tuat ions w i t h ou t y o u r au tho r i z a t i on . These s i tuat ions inc lude: as Required by Law, Public Health issues as requ i red by law, Commun i cab l e Diseases: Hea l th Overs ight : Abuse or Neglect: Food and Drug Admin i s t r a t i on r equ i r emen t s : Legal Proceedings: Law En fo rcement : Coroners: Funeral D i rectors , and Organ Donat ion: Research: Cr imina l Ac t iv i ty : Mi l i tary Ac t i v i ty and Nat ional Secur i ty : Worker ' s Compensa t i on: I nma t e s : Required Uses and Disclosures: Under the law, we m u s t make disc losers t o you and when requ i red by the Secretary of t he Depa r tmen t of Health and Human Services t o inves t iga te o r d e t e rm i ne our compl iance w i th the r equ i r emen t s of Sect ion 164 .500 .

O the r pe rm i t t ed and requ i red uses and disc losures wil l be made only w i th you r consent , au tho r i za t i on or oppo r t un i t y to ob jec t unless requ i red by law.

You may revoke th is au thor i za t i on , at any t ime , in w r i t i n g , except to the ex t en t t h a t y ou r phys ic ian or the physic ian's pract ice has t aken an act ion in re l iance on the use o r d isc losure ind icated in the au tho r i z a t i on .

HIPAA NOT ICE OF P R I V A C Y P R A C T I C E S

Susan Biegel M.D. 1113 Alta Ave. Ste. 220

Upland, CA 91786 Tel (909) 985-1908 Fax (909) 963-1800

Y o u r R i g h t s The fo l l ow ing is a s t a t emen t of y ou r r ights w i th respect to you r p ro tec ted hea l th p lan .

You have the r i gh t t o request a res t r i c t ion of you r p ro tec ted hea l th i n f o rma t i on . This means you may ask us not t o use or disclose any pa r t of you r p ro tec ted hea l th i n f o rmat i on fo r the purpose of t r e a tmen t , p a y m e n t or hea l th care opera t ions . You may also request t h a t any pa r t of you r p ro tec ted heal th i n f o rma t i on not be d isc losed to f am i l y m e m b e r s or f r iends who may be invo lved in you r care or fo r not i f i ca t ion purposes as descr ibed in t h e Not ice o f Privacy Practices. Your reques t m u s t s tate the specif ic res t r i c t ion requested and to w h o m you wan t the res t r i c t i on to app ly .

Your physic ian is not requ i red t o agree to a rest r i c t ion t h a t you may request . I f t he phys ic ian bel ieves it is in y o u r best in terest to p e rm i t use and disc losure of you r p ro tec ted hea l th i n f o rma t i on , y ou r p ro tec ted hea l th i n f o rma t i on wi l l no t be res t r i c ted . You have the r igh t t o use ano the r Health Professional.

You have the r i gh t to request t o receive conf ident ia l c ommun i ca t i ons f r o m us by a l t e rna t i ve means or at an a l t e rna t i ve locat ion. You have the r i gh t t o obta in a paper copy of th i s not ice f r o m us, upon request , even if y ou have agreed t o accept th is not ice a l te rna t i ve ly , i.e. e lect ron ica l ly .

You have the r i gh t t o have you r phys ic ian amend you r p ro tec ted hea l th i n f o rma t i on . I f we deny reques t fo r a m e n d m e n t , you have the r igh t t o fi le a s t a t emen t of d i sag reement w i th us and we may prepare a r ebu t ta l t o y ou r s t a t emen t and wil l p rov ide you w i t h a copy of any such rebu t ta l .

You have the r i gh t t o rece ive an account ing of cer ta in d isc losures we have made , if any, of y o u r p ro tec ted hea l th i n f o rma t i on .

We reserve the r i gh t t o change the t e rms of th is not ice and wi l l i n f o rm you by mai l of any changes . You then have the r i gh t to ob jec t or w i t hd raw as prov ided in th is not ice.

C o m p l a i n t s You may compla in t o us or the Secretary of Health and Human Services if you bel ieve you r pr ivacy r ights have been v io la ted by us. You may f i le a comp la in t w i th us by no t i f y ing our pr ivacy contac t o f y ou r comp la in t . We wi l l no t re ta l ia te aga ins t you fo r f i l l ing a comp la in t .

We are requ i red by law to ma in ta in the pr ivacy of, and prov ide ind iv iduals w i t h , th is not ice of ou r legal dut ies and pr ivacy pract ices w i t h respect t o p ro tec ted heal th i n f o rma t i on . I f you have any ob jec t i ons t o th i s f o r m , please ask to speak w i th our HIPAA Compl iance Off icer in person or by phone a t ou r Main Phone Number .

S igna tu re below is on ly an a cknow l edgmen t t ha t you have rece ived th is Notice of ou r Privacy Practices.

Signature Date

Print Name DOB

ADVANCED D I R E C T I V E S

Susan Biegel M.D. 1113 Alta Ave. Ste. 220

Upland, CA 91786 Tel (909) 985-1908 Fax (909) 963-1800

This acknowledgment states that the physician, or one of his/her staff members, has provided me informat ion concerning Advanced Directives.

2. I realize that I have the option of putt ing together Advanced Directives for my healthcare. My physician has provided me wr i t ten in format ion concerning these Advanced Directives. I understand tha t it is my responsibi l ity to provide my doctor(s) wi th any documents tha t are required to carry out my Advanced Directives.

3. I am aware that the Advanced Directives may be any one of the fo l lowing:

a. A Durable Power of Attorney for Health Care. b. The Declaration in the A Natural Death Act - e.g. A Living Will c. I may wr i te down my wishes on a piece of paper so tha t my

fami ly may use the document in deciding my medical t rea tment , in the event I am unable to do so.

1. I am age 18 or older. Yes No

Signature Date

Print Name DOB

This document wil l become part of my medical record.

Susan Biegel M.D. 1113 Alta Ave. Ste. 220

Upland, CA 91786 Tel (909) 985-1908 Fax (909) 963-1800

Signature Date

Print Name DOB

P l e a s e let us know w h o w e could thank for the re ferra l ! ! !

• Family:

• Friend:

• Physician:

• Insurance Roster:

• Yellow Pages:

• Other: (please specify)

Thank you for your support!!

Dr. Susan Biegel and Staff

A U T H O R I Z A T I O N TO R E L E A S E HEALTH INFORMAT ION

Print Name DOB

NOTICE Susan Biegel M.D. and many other organizat ions and individuals such as physic ians, hospitals and heal th plans are required by law to keep you health in fo rmat ion conf ident ia l .

I author ize the doctors below to release heal th in fo rmat ion to:

Susan Biegel M.D. 1113 Alta Ave. Ste. 220 Upland, CA 91786 T e l ( 9 0 9 ) 985-1908 Fax (909) 909-963-1800

Signature (of Patient or Patient's Legal Representat ive) Date

Doctor # 1 Name:

Address:

Phone # : Fax # :

Doctor # 2 Name:

Address:

Phone # : Fax #:

Doctor # 3 Name:

Address:

Phone #: Fax # :

Witness (only if pat ient is unable to s ign) Relat ionship to Patient

In te rp re te r Relationship to Patient

* * * * * * * * * y n | e s s otherwise revoked, this author izat ion expires in 1 year*********

Susan Biegel M.D. Inc. 1113 Alta Ave. Suite 220

Upland, CA 91786 Tel. (909) 985-1908 Fax (909) 963-1800

Dear Patient,

This is our office policy: if a service is performed and your Insurance is not eligible for the period in which the service was rendered, you are respons ib le for the payment of the s e r v i c e ( s ) that w a s rendered .

Thank you for your courtesy.

Signature Date

Print Name DOB

Susan Biegel M.D.

Phys i c i an O rde r s of L i fe -Susta in ing T r e a tmen t ( P O L S T )

HIPAA pe rm i t s d isc losure of POLST to o the r hea l th care profess ionals as necessary.

Name (please p r i n t ) DOB Date f o r m prepared

: i r s t f o l l ow t h e s e o r d e r s , t h e n c o n t a c t p h y s i c i a n . This is a Physician Order Sheet based on the person's cu r r en t medica l cond i t ion and vishes. Any sect ion not comp le ted impl ies fu l l t r e a t m e n t fo r t ha t sect ion. Everyone shal l be t r ea t ed w i th d i gn i t y and respect.

A (check one)

C A R D I O P U L M O N A R Y R E S U S C I T A T I O N ( C P R ) : P e r s o n h a s no p u l s e a n d is not b r e a t h i n g .

• A t t e m p t Resusc i tat ion/ CPR (Sect ion B: Full t r e a t m e n t requ i red)

O Do NOT a t t e m p t resusc i tat ion (A l low Na tu ra l Dea th )

When not in ca rd i opu lmona ry ar res t , fo l low orders in B and C.

B (check one)

M E D I C A L I N T E R V E N T I O N S : P e r s o n h a s p u l s e a n d / o r is b r e a t h i n g .

• C o m f o r t M e a s u r e s O n l y Use med ica t ion by any rou te , pos i t i on ing , wound care and o the r measures t o re l ieve pain and su f fe r ing . Use oxygen , suct ion and manua l t r e a t m e n t of a i rway obs t ruc t i on as needed fo r c om fo r t . Ant ib io t i cs on ly t o p r omo t e comfo r t . T r a n s f e r if c om fo r t needs cannot be m e t in cu r r en t locat ion.

• L i m i t e d A d d i t i o n a l I n t e r v e n t i o n s Inc ludes care descr ibed above. Use medica l t r e a t m e n t , ant ib io t i c , and IV

f lu ids as ind ica ted. Do not incubate. May use non- invas ive pos i t ive a i rway pressure. Genera l ly avo id in tens ive care. • Do N O T t r a n s f e r to h o s p i t a l for m e d i c a l i n t e r v e n t i o n s . T r a n s f e r if c om fo r t needs canno t be m e t a t cu r r en t locat ion.

• Fu l l T r e a t m e n t Inc ludes care descr ibed above. Use i n tuba t i on , advanced a i rway i n te rven t i ons , mechan ica l

ven t i l a t i on , and de f ib r i l l a t ion/card iovers ion as ind ica ted. T r a n s f e r to hospi ta l as ind ica ted. Includes Intensive care.

A d d i t i o n a l o r d e r s

B (check one)

C (check one)

A R T I F I C I A L L Y A D M I N I S T E D N U T R I T I O N : O f fe r food by m o u t h if f e a s i b l e a n d d e s i r e d .

• No art i f i c ia l nu t r i t i on by tube .

• Def ined t r ia l per iod of art i f ic ia l nu t r i t i on by t ube .

• Long - t e rm art i f ic ia l nu t r i t i on by tube .

A d d i t i o n a l o r d e r s

C (check one)

D S I G N A T U R E S AND SUMMARY O F M E D I C A L C O N D I T I O N :

D i s c u s s e d w i t h :

• Pat ient • Health Care Dec is ionmaker • Parent of Minor • Cour t Appo in ted Conserva tor • Other:

D

P H Y S I C I A N ' S I N F O R M A T I O N :

Susan Biegel M.D. 1113 Alta Ave. Ste. 220 Up land, CA 91786 ( 909 ) 9 8 5 - 1 9 0 8 Fax ( 9 0 9 ) 9 6 3 - 1 8 0 0

D

S I G N A T U R E O F PAT IENT , D E C I S I O N M A K E R , PARENT O F M INOR OR C O N S E R V A T O R By s ign ing th is f o r m , the legal ly recognized dec i s i onmaker acknowledges t h a t th is reques t regard ing resusc i ta t ive measures is cons is tent w i t h the known desires of, and w i t h the best in te res t of, t h e ind iv idua l who is the sub jec t of th is f o r m .

D

S ignature Print Name Relat ionship

D

SUMMARY OF M E D I C A L C O N D I T I O N

Phys i c i an O rde r s of L i fe -Susta in ing T r e a tmen t ( P O L S T )

HIPAA pe rm i t s d isc losure of POLST to o the r hea l th care profess ionals as necessary

P A T I E N T I N F O R M A T I O N

Name DOB Date f o r m prepared

Address Phone n u m b e r

CONTACT I N F O R M A T I O N FOR D E C I S I O N M A K E R , PARENT OF MINOR OR C O N S E R V A T O R

Name DOB Date f o r m prepared

Address Phone n u m b e r

Di rec t i ons for Hea l th Ca r e P ro f e s s i ona l

C o m p l e t i n g P O L S T

• Must be comp le ted by heal th care profess ional based on pa t i en t pre ferences and medica l ind icat ions. • POLST m u s t be s igned by the pa t i en t /dec i s i onmaker to be va l id . Verba l orders are acceptab le w i t h fo l l ow-up s i gna tu re by phys ic ian

in accordance w i th f a c i l i t y / commun i t y pol icy. • Certa in medica l cond i t ions or med ica l t r e a tmen t s may proh ib i t a person f r o m res id ing in a res ident ia l care fac i l i ty fo r the e lder ly . • Use of or ig ina l f o r m is s t rong ly encouraged . Photocopies and faxes of s igned POLST f o rms are legal and va l id .

U s i n g P O L S T

• Any i ncomp le te sect ion of POLST impl ies ful l t r e a t m e n t for t ha t sect ion.

S e c t i o n A:

• No de f ib r i l l a to r ( inc lud ing a u t oma t ed ex te rna l de f ib r i l l a to rs) shou ld be used on a person who has chosen "Do Not A t t e m p t Resusc i tat ion".

• When comfo r t cannot be ach ieved in the cu r ren t se t t ing , the person, inc lud ing someone w i t h " Com fo r t Measures Only", shou ld be t rans fe r red to a se t t ing able to p rov ide c omfo r t (e .g . , t r e a t m e n t of a hip f r a c t u r e ) .

• IV med i ca t i on t o enhance c om fo r t may be appropr ia te fo r a person who has chosen "Comfo r t Measures Only". • Non- invas ive pos i t ive a i rway pressure inc ludes cont inuous pos i t ive a i rway pressure (CPAP), b i- level pos i t ive a i rway pressure (BiPAP),

and bag va lve mask (BVM) ass isted resp i ra t ions . • T r e a tm en t of dehyd ra t i on pro longs l i fe. A person who desires IV f lu ids should ind icate " L im i ted I n t e r v e n t i o n s " or "Full T r e a tmen t " .

R e v i e w i n g P O L S T

I t is r e commended t h a t POLST be rev iewed per iodica l ly. Review is r e commended when :

• The person is t r ans fe r red f r o m one care se t t ing or care level t o ano ther , or

• There is a substant ia l change in the person's hea l th s ta tus , or • The person's t r e a t m e n t pre ferences change.

Modi fy ing a n d V o i d i n g P O L S T

• A person w i th i n capac i ty can, a t any t ime , vo id the POLST f o r m or change his/her m ind abou t h is/her t r e a t m e n t pre ferences by execu t ing a verba l o r w r i t t en advance d i rec t ive or a new POLST f o r m .

• To vo id a POLST, draw a l ine t h r o u g h Sect ions A t h r ough D and wr i t e "VO ID" in large le t te rs . Sign and da te th is l ine. • A hea l th care dec i s i onmaker may request to mod i fy the orders based on the known des ires of t he ind iv idua l or, if u n known , the

ind iv idual 's best in terest .

S e c t i o n B:

S E N D F O R M W I T H P E R S O N W H E N E V E R T R A N S F E R R E D O R D I S C H A R G E D