Please review the following summary of our billing and payment policy:

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Welcome to AKDHC! Our goal is to provide the best care possible in a professional and friendly environment. Please review the following summary of our billing and payment policy: Payment: Payment is expected at the time of service unless other arrangements have been made. You are responsible for all fees associated with your care. Insurance Information: If we are billing your insurance, please provide the receptionist with your insurance information, including any updates or changes as they occur. Co-Pays: For physician visits, your co-pay will be collected at the time of service. You will be billed for any co-pay associated with the services listed below. Anemia Management Iron Infusions, Office anemia visits with medication injections AKDHC Ultrasound Kidneys, Fistula, Vessel Mapping Nutrition Services Consultations with the AKDHC Dietitian AKDHC Access Center Dialysis access procedures Clinical Research CKD and ESRD Transplant Management Referral to Transplant Center thru Immunosuppression maintenance and prevention of complications Educational Services Kidney Beginnings, Prevention, FAQ s, Modality Insurance Coverage: Insurance coverage does not guarantee full payment for services provided. You will be billed for any fees determined by your insurance plan to be your responsibility. If you would like information regarding your payment responsibility for any of the above services, including physician office visits, please contact our billing office at 602-997-1098. Our knowledgeable staff will be happy to answer your questions. If we can assist you in any way, please do not hesitate to ask, and we thank you for choosing AKDHC for your medical care. AKDHC, LLC. (Rev. 12-01-15) Page 1 of 9

To Our Valued Patients: Thank you for selecting our physician as your nephrology provider. An important part of your care plan is information regarding financial responsibility as it relates to your nephrology care. We would like to share with you our collection procedures regarding co-pay and co-insurance collection. Contracted providers with your insurance company are contractually obligated to collect a portion of the payment from you. These portions could be any of three different types of payment: Co-Pays Network physicians with your payor are obligated to collect the co-pay at the time of service. Co-pays are associated with physician visits and are payable at the time of service. CO-INSURANCE In addition to co-pays, some payors have a co-insurance amount that is due as part of the service delivered. The amount of co-insurance due is based upon the individual policy for each patient. Yearly Deductible Some patients have a set yearly deductible in addition to co-pays, or co-insurance. This is an amount set by your insurance carrier. Charges that are applied to your deductible will be billed to you. We will not be able to determine the deductible amount due prior to your service. If you have questions regarding your deductible you will need to direct those to your insurance carrier. Patient Portal Our portal gives patients secure and convenient access to their health information. Patients can use the Patient Portal to view, download, and transmit their health information, and send secure messages to their provider. We are committed to providing high quality care to our patients and strive to provide the best communication possible regarding our billing procedures. Thank you for your cooperation in this matter. If you have any questions concerning this procedure, please do not hesitate to call our billing department at 602-997-1098. Arizona Kidney Disease and Hypertension Centers, LLC. AKDHC, LLC. (Rev. 12-01-15) Page 2 of 9

Pediatric Patient History PATIENT NAME: DOB: PREFERRED LANGUAGE: INTERPRETER NEEDED? YES NO PHARMACY NAME/CROSSROADS: PRIMARY CARE PHYSICIAN (PCP): PHONE: PCP ADDRESS: FAX: RACE/ETHNICITY African American Asian American Indian or Alaska Native Caucasian RACE Hispanic or Latino Native Hawaiian or Pacific islander Unknown Decline to answer ETHNICITY Hispanic/Latino Not Hispanic/Latino Decline to answer MEDICATION ALLERGIES Please list names of medications with specific allergy or reaction that you have experienced DRUG NAME ALLERGY or REACTION Have you ever experienced a reaction when given X-ray dye or IV Contrast? No Yes please identify reaction: FOOD ALLERGIES Please list the foods with the specific allergy or reaction that you have experienced FOOD ALLERGY or REACTION **Please Bring A List Of Your Current Medications** NSAID HISTORY Are you currently, or have you taken any of the following medications in the past? Advil Aleve Asprin/Ecotrin Baclofen Celebrex Celecoxib Ibuprofen Indomethicin Meloxicam Midol-IB Mobic Motrin Naprosyn Naproxen Toradol Tylenol and Extra Strength Tylenol are the medication of choice for pain management for people with Kidney problems. AKDHC, LLC. (Rev. 12-01-15) Page 3 of 9

MEDICAL HISTORY RENAL (KIDNEY)-HYPERTENSION-DIABETES Do you have a history of kidney disease? No Yes (check all that apply from below list) Name Diagnosed Name Acute Renal Failure/Acute Kidney Injury Interstitial Nephritis Anemia - Chronic Kidney Cyst (s) Anemia Iron Deficient Lupus Nephritis Chronic Kidney Disease Membranous Nephropathy Cystic dysplasia Nephrolithiasis End Stage Kidney Disease Nephrotic Syndrome Glomerulonephritis - Chronic Polycystic Kidney Disease Glomerulonephritis - FSGN Proteinuria Glomerulonephritis - RPGN Renal Tumor Hypertension/High Blood Pressure Solitary Kidney IgA Nephropathy ENDOCRINE Adrenal Gland Tumor Hyperparathyroidism Diabetes Mellitus type 1 Hyperthyroidism Diabetes Mellitus Type 2 Hypoaldosteronism Hyperaldosteronism Hypothyroidism ELECTROLYTE (Salts/minerals) IMBALANCE Hypercalcemia Hypokalemia Hyperkalemia Hypomagnesemia Hypermagnesemia Hyponatremia Hypernatremia Hypophosphatemia Hyperphosphatemia Metabolic disorder Hypocalcemia HEART Congenital heart disease Heart Murmur Name of Cardiologist: Left ventricular hypertrophy VASCULAR DVT/ Clotting Disorder Anticoagulant use? PULMONARY/LUNGS Asthma Obstructive Sleep Apnea Tuberculosis Valley Fever Diagnosed MEDICAL HISTORY (Continued on next page) AKDHC, LLC. (Rev. 12-01-15) Page 4 of 9

Name GASTROINTESTINAL GERD Irritable Bowel Syndrome Colon Ulcers/Colitis GENITOURINARY/UROLOGIC Catheterization dependent Cystitis Hematuria Hydronephrosis Mitrofanoff RHEUMATOLOGY Erythematosus Fibromyalgia Gout HIV Rheumatoid Arthritis SKELETAL Kyphosis Osteopenia Osteoporosis CANCER Bladder Breast Colon Lung OTHER Genetic disorder Hyperlipidemia Obesity Vitamin B Deficiency Vitamin D Deficiency Other: Diagnosed Name Recurrent UTI s Incontinent of urine Vacterl association Vesicoureteral reflux Name of Urologist: Scleroderma Sjorgen s Syndrome Systemic Lupus Wegner s Granulomatosis Scoliosis Ovarian/Uterus/Cervix Pancreatic Renal Other: Diagnosed AKDHC, LLC. (Rev. 12-01-15) Page 5 of 9

Name Adenoidectomy Adrenal Surgery Any metal in body, where? Appendectomy AV Fistula Bladder Augmentation Bladder Surgery, Type: Cancer Surgery, Type: Cecostomy Colostomy Cystoscopy Defibrillator AICD Implant Eye Surgery Gastrostomy Tube (G-tube) Gastrojejunal tube (GJ tube) Heart Transplant Heart/ Cardiac Catheterization Hemodialysis Catheter Hernia Repair Kidney Ablation Kidney Artery Angioplasty Kidney Biopsy Lithotripsy Liver Transplant Mitrofanoff Nephrectomy Nephrostomy Tube Open heart surgery Orthopedic Surgery Pacemaker Parathyroid Surgery Peritoneal Catheter Percutaneous Coronary Intervention (PTCA) Renal Artery Angiogram SURGICAL HISTORY Renal Transplant, Living-related or unrelated, cavdaveric/deceased, left or right side, facility where transplant was performed: Thyroid Surgery Tonsillectomy Ureteral Stent Vascular Surgery Of Surgery AKDHC, LLC. (Rev. 12-01-15) Page 6 of 9

DIET/ACTIVITY Diet: Regular Vegan Vegetarian Carbohydrate Diabetic Cardiac Gluten Free Specific Caffeine intake: None Occasional Moderate Heavy Exercise Level: None Occasional Moderate Heavy Do you play any Sports? Yes No If Yes, Which Sports? What grade in school are you in? SOCIAL HISTORY Smoking Status: Passive smoke exposure: Yes No How many smokers live with you? Current every day smoker: packs smoked per day Year started: Current some day smoker: packs per week Year started: Former smoker: Year started: Years smoked: Packs smoked per day Never smoked Heavy tobacco user : Year started: Light tobacco user: Year started: Alcohol Use: No history of alcohol use Currently consume alcohol (provide quantity and frequency): Former Drinker: Sober since: Previous quantity and frequency: Recovering alcoholic: Sober since: Previous quantity and frequency: Rehabilitation: Year treatment received for alcohol abuse: Illicit Drug Use: No history of illicit drug use Current use: Type of drug, frequency: s/years of use Previous use: Type of drug, frequency: s/years of use Rehabilitation: Year treatment received for drug abuse: Claustrophobic YES NO Parents Marital status: Married Unmarried Divorced Widowed Separated Do you live with: Both Parents Mother Father Relatives Adoptive parents Foster parents Other: FAMILY HISTORY Adopted Family History Unknown Living Deceased Age at Death Cause of Death Father Mother Please indicate if a family member has/had any of the following: Father Mother Siblings Children Other (identify) Diabetes: High Blood Pressure: Kidney Disease (stones/cysts/failure) Specify Type: Kidney Transplant: Dialysis (identify cause): Hematuria: Proteinuria: Bladder Surgery: Cancer (identify type): Other (specify): AKDHC, LLC. (Rev. 12-01-15) Page 7 of 9

AKDHC has adopted standards for certain questions that have been asked in the forms contained in this packet. To help our patients better understand some of these standards the below information may be helpful. The difference between Race and Ethnicity Race Ethnicity Race is an indication of the heritage with which you were born, regardless of location or learned behavior. Race cannot be altered. Ethnicity is about the learned cultural behaviors celebrated throughout regions around the world. Ethnicity can be altered or mimicked through choice and beliefs. Source: http://www.differencebetween.net/science/nature/difference-between-ethnicity-and-race Race Reference Guide American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam A person having origins in any of the black racial groups of Africa. Terms such as Haitian or Negro can be used in addition to Black or African American. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, Spanish origin, can be used in addition to Hispanic or Latino. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. AKDHC, LLC. (Rev. 12-01-15) Page 8 of 9

Smoking Status Reference Guide Current Every Day Smoker An individual who has smoked at least 100 cigarettes during his/her lifetime and still regularly smokes every day. Current Some Day Smoker An individual who has smoked at least 100 cigarettes during his/her lifetime and still regularly smokes periodically, yet consistently. Former Smoker Never Smoker Smoker, Current Status Unknown An individual who has smoked at least 100 cigarettes during his/her lifetime but does not currently smoke. An individual who has not smoke 100 or more cigarettes during his/her lifetime. An individual who has smoked at least 100 cigarettes during his/her lifetime, but whether they currently still smoke is unknown Unknown if Ever Smoked Heavy Tobacco Smoker Light Tobacco Smoker Unknown if an individual has ever smoked An individual who smokes more than 10 cigarettes per day, or an equivalent (but less concretely defined) quantity of cigar or pipe smoke. This option can also be selected to identify chewing tobacco use. An individual who smokes less than 10 cigarettes per day, or an equivalent (but less concretely defined) quantity of cigar or pipe smoke. This option can also be selected to identify chewing tobacco use. Source: Center for Disease Control (CDC) http://www.cdc.gov/nchs/nhis/tobacco/tobacco_recodes.htm AKDHC, LLC. (Rev. 12-01-15) Page 9 of 9

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