***********************VERY IMPORTANT************************
BECAUSE MANY OF OUR PATIENTS HAVE ALLERGIES AND
SENSITIVITIES TO VARIOUS SUBSTANCES, WE ASK THAT YOU PLEASE
NOT WEAR ANY PERFUME, COLOGNE, FRAGRANCED BODY OR HAND
LOTION, AFTERSHAVE, ETC., TO YOUR APPOINTMENT.

WE APPRECIATE THAT YOU HAVE SELECTED OUR PRACTICE TO SERVE
YOUR MEDICIAL NEEDS. TO HELP US PROVIDE YOU THE BEST MEDICAL CARE,
WE ASK THAT YOU PLEASE READ THE FOLLOWING SO YOU WILL BECOME MORE
FAMILIAR WITH US.

APPOINTMENTS:
PLEASE ARRIVE 15 MINUTES PRIOR TO YOUR ACTUAL APPOINTMENT TIME
APPOINTMENTS MAY BE SCHEDULED FROM 8:30 A.M. TO 4:15 P.M.,
MONDAY THROUGH THURSDAY. THE OFFICE IS CLOSED FOR LUNCH BETWEEN
1:00 P.M. – 2:15 P.M. IF FOR ANY REASON YOU ARE UNABLE TO KEEP YOUR
APPOINTMENT, PLEASE CONTACT US WITHIN 24 HOURS TO CANCEL OR
RESCHEDULE.

APPOINTMENTS AT OUR OFFICE MAY TAKE LONGER THAN YOU ARE ACCUSTOMED TO. PLEASE ALLOW UP TO 2 HOURS FOR YOUR INITIAL CONSULTATION. IF YOU HAVE ANY TIME CONSTRAINTS, PLEASE LET THE FRONT DESK KNOW WHEN YOU CHECK IN SO THAT WE CAN ALERT THE DOCTOR OF YOUR REQUEST.

MEDICATION REFILLS:
IF YOU NEED A REFILL ON YOUR MEDICATION(S), PLEASE CALL YOUR
PHARMACY. IF YOU HAVE NO MORE REFILLS LEFT, THE PHARMACY
WILL FAX A REFILL REQUEST TO OUR OFFICE AT WHICH TIME THE NURSE WILL
SPEAK WITH THE DOCTOR. YOU WILL EITHER GET AN AUTHORIZED REFILL
FAXED BACK TO THE PHARMACY OR THE NURSE WILL CALL YOU IF FURTHER
APPOINTMENTS OR COMMUNICATION IS NEEDED.

AFTER HOURS/EMERGENCIES:
AFTER OFFICE HOURS, EMERGENCIES OR COMPLICATIONS ARE
HANDLED THROUGH OUR ANSWERING SERVICE. THE ANSWERING SERVICE
CANNOT TAKE REFILL REQUESTS OR ADVISE IN ANY MEDICAL TREATMENT.
PLEASE TRY AND MAKE ALL NON-EMERGENCY CALLS DURING REGULAR OFFICE
HOURS.

PLEASE FEEL FREE TO CALL OUR OFFICE IF YOU HAVE ANY QUESTIONS
REGARDING YOUR CONDITION, MEDICATION, OR TREATMENT. TRAINED
MEDICAL PERSONNEL WILL BE HAPPY TO ANSWER YOUR QUESTIONS.

PAYMENT FOR PROFESSIONAL SERVICES IS DUE AT THE TIME TREATMENT IS RENDERED.

IF YOU HAVE MEDICAL INSURANCE THAT YOU WOULD LIKE TO FILE, YOU WILL BE GIVEN A RECEIPT UPON CHECKING OUT THAT WILL ENABLE YOU TO FILE YOUR CLAIM WITH EASE.

PLEASE REMEMBER THAT YOUR INSURANCE POLICY IS AN AGREEMENT BETWEEN YOU AND YOUR INSURANCE COMPANY. YOU ARE RESPONSIBLE FOR PAYMENT OF ALL CHARGES AT THE TIME OF SERVICE.

PLEASE DON’T HESITATE TO ASK ANY OF OUR STAFF FURTHER QUESTIONS THAT YOU MAY HAVE. CINDY, OUR OFFICE MANAGER, IS ALSO AVAILABLE TO ASSIST YOU WITH ANY QUESTIONS OR CONCERNS YOU MAY HAVE.

Dr. Howard J. Lang, D.O., F.A.A.E.M. Dr. Derek H. Lang, D.O.

I understand that my signature represents that I have read and understand the above policies. I agree to make payment in full at the time of my office visit(s).

PLEASE LIST THE NAMES OF FAMILY OR FRIENDS THAT MAY PICK UP YOUR ALLERGY VIALS, VITAMINS OR PRESCRIPTIONS

Your insurance company may request additional information sothat your claim may be processed. We will need your signature to authorize us to send any additional inormation they may need to process your claim. If you choose not to sign, your claim may not be able to be processed efficiently, therefore delaying or possibly denying any reimbursement due to you.

Person(s) we may contact in case of an emergency:

Although we do not file medical insurance or Medicare, we still work closely with

pharmacies, outside labs, and imaging clinics that may take your coverage.

We may need to send you outside of our clinic for various testing, labs, x-rays or other types of imaging. We may also need to provide referrals to other medical offices or pharmacies on your behalf.

In order to do this efficiently and as quickly as possible, we may need to give the name of your insurance company to any of the above mentioned entities. If applicable, please provide us with the following information:

We have accounts with Quest and LabCorp. Which lab does your insurance company prefer?

If your medical insurance changes at any time, please let us know so that we can let you update your insurance information.

3.ALLERGIES: (to drugs, antibiotics, pollens and/or chemicals) Describe reaction to each.

5.SURGERIES: Inpatient & Outpatient (List the surgery/procedure, month and year (if known), and physicians name (if known).

6.HOSPITALIZATIONS: (List the cause/diagnosis, month and year (if known), and physicians name (if known).

7.INJURIES: (List the injury, month and year (if known), and physicians name (if known

8.CHILDHOOD DISEASES AND VACCINATIONS: (copy of vaccination record OK)

9.LIST FOODS THAT YOU REACTED TO AS A CHILD OR NOW:

Alcohol history: (type, frequency of use, number of years used)

f.Other pertinent social history: (names of children; significant changes in job, relationships, pets, home, health, etc., that have caused stress or relieved stress.

********************************REVIEW OF SYMPTOMS**********************************

******************************* REVIEW OF SYMPTOMS CONT’D. **********************************

HIPAA Notice of Privacy Practices

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 Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out Treatment, Payment or health care Operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

1. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

HOWARD J. LANG, D.O., F.A.A.E.M. FAMILY MEDICINE ENVIRONMENTAL MEDICINE OSTEOPATHIC MEDICINE

DEREK H. LANG, D.O. FAMILY MEDICINE INTEGRATIVE MEDICINE OSTEOPATHIC MEDICINE

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative

location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate

against you for filing a complaint.

This notice was published and became effective on April 14, 2003.

HIPAA Notice of Privacy Practices

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Physician agrees to provide medical services to Patient.

In exchange for the Services, the Patient agrees to make payments to the Physician pursuant to the Fee Schedule upon completion of services provided. Patient also agrees, understands and expressly acknowledges the following:

• Patient agrees not to submit a claim (or to request that Physician submit a claim) to the Medicare program with respect to the Services, even if covered by Medicare Part B.
• Patient is not currently in an emergency or urgent health care situation.
• Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the Services.
• Patient acknowledges that Medi-Gap plans will not provide payment or reimbursement for the Services because payment is not made under the Medicare program, and other supplemental insurance plans may likewise deny reimbursement.
• Patient acknowledges that he/she has a right, as a Medicare beneficiary, to obtain Medicare-covered items and services from physicians and practitioners who have not opted-out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have opted-out.
• Patient agrees to be responsible, whether through insurance or otherwise, to make payment in full for the Services, and acknowledges that the Physician will not submit a Medicare claim for the Services and that no Medicare reimbursement will be provided.
• Patient understands that Medicare payment will not be made for any items or services furnished by the physician that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim were submitted.
• Patient acknowledges that a copy of this contract has been made available to him/her.

I hereby authorize and request you to release the following medical records in your possession to:

Howard J. Lang, D.O., F.A.A.E.M. Derek H. Lang, D.O.

Family Medicine, Allergy & Environmental Medicine 789 Lonesome Dove Trail Hurst, TX 76054 Ph: (817) 577-0480 Fax: (817) 581-0167

PLEASE LIMIT FAXED RECORDS TO 25 PAGES.

ANYTHING OVER 25 PAGES SHOULD BE MAILED TO THE ADDRESS ABOVE.