Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:

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Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN: Email: Employer Name: Work Phn: Check here if you have no insurance (Cash Account) Insurance #1: Insured DOB: Insurance #2: Insured DOB: I, the undersigned, hereby authorize payment directly to Premier Surgical Associates for medical services rendered. I understand I am financially responsible for all charges not covered or authorzed by my insurance company. I also understand that I am responsible for a fee of $ 25.00 for not showing up for the scheduled appointment. Printed Name: Signature: Date: ** Please be advised, you will be required to complete this form at your first office visit of each year. The information that you provide is updated yearly and ensures we have accurate information to file a claim on your behalf. Thank you for your assistance with this process.

Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Acknowledgement of Privacy Practices According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA,) patients have certain rights to privacy regarding their protected health information. Your protected health information will be used to: Conduct, plan, and direct treatment by the physicians employed by Premier Surgical Associates and will be shared in cooperation with healthcare providers who are involved in your care directly or indirectly. To obtain payment from third party payers. To conduct normal healthcare operations such as quality assessments and physician certifications. By signing below, you agree that you have either received or waved your right to receive the Notice of Privacy Practices, containing a complete description of the uses and disclosures of protected health information. You understand that this organization has the right to change its Notice of Privacy Practices at any time. You also understand that you may request from this organization a current copy of the Notice of Privacy practices. I understand that I may revoke this consent in writing at any time, except to the extent that Premier Surgical Associates has previously released relying on this consent. Print Patient Name: Do we have permission to: 1. Leave a message at your home regarding appointments and/or treatments?... Yes No 2. Leave a message at your place of employment regarding appointments/treatments?... Yes No 3. Leave a name and call back number at your home and place of employment?... Yes No 4. Mail test results and appointment information to your home address currently on file? Yes No 5. Email at filed email address regarding appointments and treatments?... Yes No 6. Discuss your personal information, including appointments and treatments with someone other than yourself?... Yes No Name Relationship Contact Number Patient Signature: Date:

Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Authorization to Release Healthcare Information Patient Name: DOB: SSN: Previous Name: I request and Authorize: Premier Specialty Physicians (Name of Clinic/Practice/Physician) To release the medical records of the person named above to: Name: Dr. Alvin Huang Address: 1650 W Rosedale, Suite 301, City: Fort Worth State: TX Zip Code: 76104 This request and authorization applies to: All healthcare information Other: I understand that my express consent is required to release any healthcare information relating to testing, diagnosis, and/or treatment for HIV (AIDS Virus,) sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use, you are specifically authorized to release all healthcare information relating to such diagnosis, testing or treatment. Signature: Date: Relationship if signed by anyone other than patient (parent, legal guardian, personal representative, etc.)

Physician List Patient Name: DOB: Physician/Specialist Address: Phone & Fax Number: Primary Care Physician Primary Care Physician Cardiologist Cardiologist Pulmonologist Pulmonologist Endocrinologist Endocrinologist Neurologist Neurologist Gastroenterologist Gastroenterologist Hematologist Hematologist Urologist Urologist Other Other

Medication List Patients Name: DOB: Pharmacy: Phn: Allergies: Medication Name Dose Directions

Patient Medical History Questionnaire Name: DOB: Dialysis Days and Times: Please indicate if you have any of the following conditions below: Cardiology: Hypertension Angina Heart Attack Heart Failure Atrial Fibrillation Irregular Heart Beat Heart Murmur Peripheral Vascular Disease Aortic Aneurysm Pulmonary: Asthma Chronic Bronchitis Emphysema COPD Pneumonia Pulmonary Hypertension Clot in the lungs Sleep Apnea Lung Cancer Endocrine: Diabetes Type 1 Diabetes Type 2 Thyroid Issues (high/low) Addison s Disease Cushing s Syndrome Pituitary Adenoma High Cholesterol Obesity Gastrointestinal: Acid Reflux Ulcer Disease Gall Bladder Disease Vomiting Blood Blood in Stool GI Cancer Diverticulosis Polyps Hematology: Anemia Leukemia Bleeding Disorder Blood Clots (legs) Multiple Myeloma Varicose Veins HIV Liver Disease/Pancreas: Hepatitis (type ) Cirrhosis Liver Cancer Gallbladder Stones Pancreatitis Pancreatic Cancer Neurology: Neuropathy TIA Stroke Migraine Seizure Parkinson s Disease Alzheimer s/ Dementia Genitourinary: Recurrent UTI Kidney Stones Chronic Kidney Disease Nephritis Prostate Problem Kidney Cancer Bladder Cancer Arthritis & Musculoskeletal: Rheumatoid Arthritis Osteoarthritis Gout Osteoporosis/Osteopenia Lupus (SLE) Scleroderma Sjogren s Syndrome Fibromyalgia Other:

Patient Medical History Questionnaire Name: DOB: Surgeries: 1. 2. 3. 4. 5. Date/Year Surgeon Name Nature of Surgery Hospitalizations: 1. 2. 3. 4. 5. Date/Year Hospital Name Reason for Hospitalization Procedures: Upper GI Endoscopy Colonoscopy Biopsy Cardiac Stress Test Pap Smear Mammogram Date/Year Performed By Result

Patient Medical History Questionnaire Name: DOB: Family History: Please make a check in the boxes that apply: Status: A=Alive D=Deceased Mother A D Father A D Paternal Grandfather A D Paternal Grandmother A D Maternal Grandfather A D Maternal Grandmother A D Brother(s) A D Sister(s) A D Sons(s) A D Daughter(s) A D Diabetes High BP Heart Disease Kidney Disease Stroke Cancer Social History: Smoking Alcohol Illicit Drug Use Current Use Frequency If use, When? Please CIRCLE your answer below: Married: Y N Living With: Spouse Alone Other: Flu Shot: Y N Date Received: Pneumococcal Vaccine: Y N Date Received:

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