Inland Valley Cardiovascular Center — New Patient Paperwork

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Are we billing insurance?

If so, who is the subscriber of your insurance?

I give the physicians and office staff of Brian A. Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. permission to discuss my medical condition with the following family members / friends:

Please initial each statement below.

I authorize the release of any Medical Information to process claims.

I authorize the release of payment for Medical Benefits to Brian A. Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D.

I hereby consent to and authorize the performance of all treatments, surgery, and medical/behavioral health services by the staff of Brian Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. which they may deem advisable. I hereby certify that all statements contained herein are true. I understand that I am directly responsible for all charges incurred regardless of insurance coverage.

I furthermore agree to pay legal interest, collection expense, and attorney's fees incurred to collect any amount I owe. I also hereby authorize Brian Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. to release information requested by my insurance company and/or its representatives.

I authorize Brian Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. and staff to leave voicemails regarding appointments and test results.

Consent for Photography

I authorize Brian Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. to photograph me and/or my medical condition for my electronic medical records. This photograph may be used for educational and/or medical research with my consent.

I hereby acknowledge the HIPPA (privacy practices) notice from Brian Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. and is available upon request.

Only complete this section if you are a Medicare beneficiary.

I certify that I am not a member of any captivated Health Maintenance Organization (HMO), such as Secure Horizons, Blue Cross Senior, or Scan. I further understand that membership in such a program prevents Medicare from covering my expenses for services provided by Brian Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. and that I would be fully responsible for those uncovered charges.

I request that payment of authorized Medicare benefits be made to Brian A. Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits of the benefits payable to related service.

I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. If other health insurance indicated in item 9 of the HCFA 1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.

With Medicare assigned cases, Brian A. Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D. agree to accept the allowed amount determined by Medicare and the patient is responsible only for the deductible, co-insurance and non-covered services. Co-insurance and the deductible are based upon the allowed amount by the Medicare carrier.

Co-Payment and Deductible

You are responsible to provide payment for your deductible, co-payment and any non-covered services received. If your deductible has been satisfied, we will bill your health plan. If your deductible has not been satisfied and/or eligibility verification of your plan indicates your coverage is no longer effective, payment is required at the time of service. Your co-payment is also due at the time of service.

Medicare

We do accept Medicare assignment. You are responsible for your deductible and co-payment. If you have a secondary insurance carrier, a portion of your co-payment may be covered.

Non-Covered Services

If we provide services to you that are not covered by your health plan or you are not a covered enrollee under the plan at the time the services in question were rendered, you will be responsible for payment in full for those services. Your signature below constitutes that you agree to pay for such services.

Payment Arrangements

Payments may be made in cash, by check, credit card or Care Credit. Payment is expected at the time of service, payment arrangements will not be granted.

We are happy to discuss with you any questions relating to the information above. We thank you for choosing Inland Valley Cardiovascular Center for your cardiovascular care.

• There is a $25.00 cancellation, no-show or late arrival fee if your appointment is not cancelled within 24 hours of your appointment time.

• Your appointment may be rescheduled if you arrive more than 10 minutes late to your scheduled appointment time and the $25 fee will apply.

• Voicemails left before 11 AM will be returned on the same business day. Any voicemails left after will be returned the next business day (with some exceptions).

• There is a 72 hour turn around for all prescription refills. Please call your local pharmacy and request your refill.

• There will be a $15.00 fee on all personal paperwork completed by our physician (DMV forms, EDD forms, etc.). Please allow 72 hours for all forms to be completed.

• There will be a reasonable clerical fee as well as $0.25 per page for copying your medical records. Clerical fees for subpoenas are limited to $15 if a photocopy service is provided.

• Pursuant to Assembly Bill (AB) 1278, physician offices are required to notify patients that the Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at openpaymentsdata.cms.gov.

Thank you for your understanding and we welcome you to our office.

Inland Valley Cardiovascular Center

Brian A. Bui, M.D., Hoang M. Lai, M.D. & Harit V. Desai, M.D.
39755 Murrieta Hot Spring Rd., Suite E-130, Murrieta, CA 92563

Privacy Officer: Shelly Stephens, Office Manager

Effective Date: 4/8/2011

Purpose

The following privacy policy is adopted to ensure that this medical practice complies fully with all federal and state privacy protection laws and regulations. Protection of patient privacy is of paramount importance to this organization. Violations of any of these provisions will result in severe disciplinary action including termination of employment and possible referral for criminal prosecution.

It is policy of this medical practice that we will adopt, maintain and comply with our Notice of Privacy Practices, which shall be consistent with HIPAA and California Law.

Notice of Privacy Practices

It is the policy of this medical practice that a notice of privacy practices must be published, that this notice be provided to all subject individuals at the first patient encounter if possible, and that all uses and disclosures of protected health information be done in accord with this organization's notice of privacy practices. It is the policy of this medical practice to post the most current notice of privacy practices in our "waiting room" area, and to have copies available for distribution at our reception desk.

Assigning Privacy and Security Responsibilities

It is the policy of this medical practice that specific individuals within our workforce are assigned the responsibility of implementing and maintaining the HIPAA Privacy and Security Rule's requirements. Furthermore, it is the policy of this medical practice that these individuals will be provided sufficient resources and authority to fulfill their responsibilities. At a minimum it is the policy of this medical practice that there will be one individual or job description designated as the Privacy Official.

Deceased Individuals

It is the policy of this medical practice that privacy protections extend to information concerning deceased individuals.

Minimum Necessary Use and Disclosure of Protected Health Information

It is the policy of this medical practice that for all routine and recurring uses and disclosures of PHI (except for uses or disclosure made 1) for treatment purposes, 2) to or as authorized by the patient or 3) as required by law for HIPAA compliance) such uses and disclosures of protected health information must be limited to the minimum amount of information needed to accomplish the purpose of the uses or disclosure. It is also the policy of this medical practice that non-routine uses and disclosures will be handled pursuant to established criteria. It is also the policy of this organization that all requests for protected health information (except as specified above) must be limited to the minimum amount of information needed to accomplish the purpose of the request. It is also the policy of this organization that no employee or contractor may condition treatment, payment, enrollment or eligibility for benefits on the provision of an authorization to disclose protected health information except as expressly authorized under the regulations.

Responsibility

It is the policy of this medical practice that the Privacy Officer is responsible for designing and implementing procedures to carry out this policy.

Verification of Identity

It is the policy of this medical practice that the identity of all persons who request access to protected health information be verified before such access is granted.

Mitigation

It is the policy of this medical practice that the effects of any unauthorized use or disclosure of protected health information be mitigated to the extent possible.

Safeguards

It is policy of this medical practice that appropriate physical safeguards will be in place to reasonably safeguard protected health information from any intentional or unintentional use or disclosure that is in violation of the HIPAA Privacy Rule. These safeguards will include physical protection of premises and PHI, technical protection of PHI maintained electronically and administrative protection. These safeguards will extend to the oral communication of PHI. These safeguards will extend to the PHI that is removed from this organization.

Business Associates

It is the policy of this medical practice that business associates must be contractually bound to protect health information to the same degree as set forth in this policy. It is also the policy of this organization that business associates who violate their agreement will be dealt with first by an attempt to correct the problem, and if that fails by termination of the agreement and discontinuation of services by the business associate.

Training and Awareness

It is the policy of this medical practice that all members of our workforce have been trained by the compliance date on the policies and procedures governing protected health information and how this medical practice complies with the HIPAA Privacy and Security Rules. It is also the policy of this medical practice that new members of our workforce receive training on these matters within a reasonable time after they have joined the workforce. It is the policy of this medical practice to provide training should any policy or procedure related to the HIPAA Privacy and Security Rule materially change. This training will be provided within a reasonable time after the policy or procedure materially changes. Furthermore, it is the policy of this medical practice that training will be documented indicating participants, date and subject matter.

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at appointment.

If signing on behalf of patient, check which applies:

Please take the time to complete this form as it will enable the physician to best assess your current medical status and provide the best course of care. If you do not know the answer to a question or you are unsure, please insert a question mark in the corresponding space.

Please check and date any of the following that applies to you:

Please check and complete the following that pertains to your history / lifestyle.

Please provide vitamins and supplements as well.

Allergies — Please list any drug allergies and the type of reaction that occurs.

Past Medical & Surgical History — Please provide past hospitalizations and surgeries.

Other Health History & Symptoms — Please check any of the following that apply to your history.

Please indicate the health status of each of the following members and state their age. If deceased, please indicate cause and approximate age.