Patient History

Review of Symptoms
Please check any of the following that you recently experienced

Health Questionnaire

Provide any new information since the last visit.

Medication
Please list any medications that you currently take regularly (including non-prescription)

Allergies
Please list any allergies to medications, food or other

Provide the year the illness/condition was contracted

Childhood Diseases

When, if ever, did you last have any of the following:

Gynecological History (Women only)

HIPPA Form

Acknowledgment of Receipt

The Health Insurance Portability and Accountability Act (HIPPA) is a federal regulation designed to ensure that you are aware of your privacy rights and of how your medical information can be used by our staff in providing and arranging your medical care. Family Care USA, PLLC is furnishing you with attached notice, which provides information about how Family Care USA, PLLC and its physician may use and/or disclose protected health information about you for treatment payment, healthcare operations and as otherwise allowed by law. By signing this form, you acknowledge that you have received a copy of Family Care USA, PLLC notice of Health Information Practices.

Patient / Guardian Signature

Approved HIPPA Contacts

Keeping our patient's information private is important to us and by default, we will only disclose information related to the patient's Billing Account, Medical Conditions to the patient, or legal guardian. If you would like to add additional contacts (other than the patient of a legal guardian ) that Family Care USA, PLLC is allowed to disclose this type of information to, please complete the fields below.

Patient / Guardian Signature

Family Care USA PLLC

FINANCIAL POLICY

OUR PRACTICE FINANCIAL POLICY We are dedicated to providing you with the best possible care and service, and regard your understanding of our financial policy as an essential element of your care and treatment. To assist you, we have the following financial policy. If you have any question please feel free to discuss them with our staff. Unless other arrangements have been made in advance by either you or your health coverage carrier, full payment is due at the time of service.

YOUR INSURANCE
We have made prior arrangements with many insurers and other health plans. We will bill those plans with which we have an agreement and will collect any required co-payment at the time of the service. The co-payment will be collected when you arrive for your appointment. In the event your health plan determines a service to be not covered, you will be responsible for the complete charge. In that event we will bill you and payment is due upon receipt of that statement. If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you, on an unassigned basis. In this case, your insurer will send the payment directly to you. Therefore charges for your care and treatment are due at the time of service. We will also bill your health plan for all services we provide in the clinic. Any balance due is your responsibility and is due upon receipt of a statement for our office. Please be advised that there will be a $36 service charge for any returned checks.

MINOR PATIENTS
For all services rendered to minor patients, the adult accompanying the patient is responsible for the payment.

MISSED APPOINTMENT
In order to provide the best possible service and availability to all our patients, it is our policy to charge our office visit fee for any appointments not canceled at least one day prior. Please call us early as possible if you know you will need to reschedule your appointment.

CONSENT TO TREAT
I consent to treatment as necessary or desirable to the care of the patient named below, including but restricted to whatever drugs, medicine, the performance of operations, and conduct of laboratory, x-ray, or other studies that may be used by the attending physician, his nurse or qualified designate. I further understand that the qualified designate in the same case will be the assistant to the Primary Care Physician, all also called an MA. I also acknowledge full responsibility for the payment of such services and agree to pay for them, in full, at the time of service. If the physician must use a collection agency/attorney or court to collect its charges, then I will pay reasonable_attorney fees and costs incurred in collecting the same regardless of insurance coverage. I hereby authorize payment directly to Dr. Hina Zaman of the medical expense benefits otherwise payable to me but not to exceed my indebtedness to said Physician on account of the enclosed charge. I have read and understood the financial policy of the practice and I agree to the bound by its terms that such terms may be amended from time to time by the practice.

Patient Signature or Responsible Party's Signature (Parent/Guardian of Minor)

318 W FM 544 Suite A2 Murphy, Texas 75094

FINANCIAL AGREEMENT

In consideration of the patient receiving services from the Physician, I agree:
• I am responsible for all expenses for treating the patient.

• Payment of charges is due at the time of the appointment.

• If the Physician files my insurance for me, I agree to pay for non-covered insurance benefits, co-insurance, co-pays, and deductibles.

Patient Signature or Responsible Party's Signature (Parent/Guardian of Minor)

AUTHORIZATION TO RELEASE INFORMATION & TO PAY BENEFITS

I authorize the Physician to release any of my medical information, including drug and alcohol and HIV positive test results, to my insurance company(s), as needed to process my insurance claim.

I authorize my insurance company to make payments directly to the Physician for covered medical and/or surgical services.

Patient Signature or Responsible Party's Signature (Parent/Guardian of Minor)