Glenn D. Cohen M.D. Brian D. Rudin M.D.

Orthopedic Surgery

696 Hampshire Rd #180

Westlake Village, CA 91361 805.370.6877

Heading North on Fwy 101

• Exit Hampshire Rd. and turn left • Turn left on Triunfo Canyon (Traffic Signal) • Turn right into the first parking lot • Drive past the building to the end of the parking lot and turn right • Park closest to Hampshire Rd., walk along the front of the building on Hampshire

o Our suite is #180*, the second door on the right *Our entrance is not located within the building; it is a separate entrance from the front of the building facing Hampshire Rd.

Heading South on Fwy 101

• Exit Hampshire Rd. and turn right • Turn left on Triunfo Canyon (Traffic Signal) • Turn right into the first parking lot • Drive past the building to the end of the parking lot and turn right • Park closest to Hampshire Rd., walk along the front of the building on Hampshire

o Our suite is #180*, the second door on the right *Our entrance is not located within the building; it is a separate entrance from the front of the building facing Hampshire Rd.

From the 23

• Merge onto the 101 South • Exit Hampshire Rd. and turn right • Turn left on Triunfo Canyon (Traffic Signal) • Turn right into the first parking lot • Drive past the building to the end of the parking lot and turn right • Park closest to Hampshire Rd., walk along the front of the building on Hampshire

o Our suite is #180*, the second door on the right *Our entrance is not located within the building; it is a separate entrance from the front of the building facing Hampshire Rd.

PATIENT REGISTRATION FORMPatient Information

Last Name ____________________________ First ____________________________ Middle _______________

Street Address ______________________________ City_______________ State ________ Zip Code __________

Home Phone (____)___________ Cell Phone (_____)________ Social Security No. _______________________

Date of Birth ____________ Age ______ Sex M / F Marital Status: Single / Married / Divorced / Widowed

E-Mail Address:________________________________ Who referred you to the Dr.? ______________________

Employer Information

Patient’s Occupation ___________________________________________________________________________

Circle One: Full time / Part time / Retired / Student . If Student, Name of School _______________________

Spouse Information

Spouse’s Name ________________________________________________________________________________

Date of Birth _____________ Soc. Sec. No. ____________________

Responsible Party Information – only fill out if patient is a minor

(this is the person that brings the minor to their first appointment)

Responsible Party____________________ Date of Birth _____________ Soc. Sec. No._____________________

Address _________________________________________________________ Phone (____)___________________

Relationship to Patient: __________________________________________________________________________

AUTHORIZATION FOR MEDICAL TREATMENT

I, _______________________ (Fill in your name), (if patient is a minor, I, ___________________(your name), as

Parent/Guardian of __________________________(Patient’s name)) hereby authorize Glenn D. Cohen, M.D., Brian D. Rudin, M.D., associates and assistants as designated by Dr. Cohen and Dr. Rudin to perform evaluation and treatment of my orthopaedic condition(s). I further require and authorize Glenn D. Cohen, M.D., Brian D. Rudin, M.D., associates and assis-tants, to perform additional procedures, as they may deem immediately necessary on an emergent basis. I understand that elective surgical procedures will be consented separately.

I consent to the administration of medications and injections (also consented separately) deemed necessary in the judgment of Glenn D. Cohen, M.D. , Brian D. Rudin, M.D., associates and assistants as designated by Glenn D. Cohen, M.D. and Brian D. Rudin, M.D.

I also consent to the photographing and the publication of any procedure(s) to be performed provided my identity is not revealed and that the use is limited to medical, scientific, or educational purposes. I waive all rights that I may have to any claims for payment in connection with the exhibition of the photographs.

I recognize that the practice of medicine and surgery is not an exact science, and Dr. Cohen and Dr. Rudin do not guarantee the results of treatment.

Signature Date

Glenn D. Cohen, M.D. • Brian D. Rudin, M.D.Orthopedic Surgery • 805.370.6877

FINANCIAL POLICY

Thank you for choosing Glenn D. Cohen, M.D. and Brian D. Rudin, M.D. The following is our Financial Policy:• All patients will provide accurate and complete personal and insurance information.• All applicable co-pays, coinsurance, deductibles and personal balances (current and prior) are due at the time of service.• Payment can be made by cash, check, Visa or Mastercard.

Insurance: The doctors are not a participating provider in any managed care, HMO products, MediCal or Medicare. Dr. Cohen does participate in some plans administered by Blue Cross. Dr. Rudin does participate in some plans administered by Blue Cross, Blue Shield and Tricare. Dr. Cohen and Dr. Rudin voluntarily withdrew as providers from numerous health plans. There are a large variety of plans and products introduced on almost a daily basis. Therefore, it is YOUR responsibility to contact your insurance company prior to being treated to determine if Dr. Cohen and/ or Dr. Rudin are a provider on your plan and to verify any co-pays, coinsurance, deductibles and non-covered services under your policy.

Financial Difficulties: It is your responsibility to disclose any concerns that you might have regarding payment of your bill prior to seeing the doctor. We will make every effort to assist patients who bring this issue to our attention before services are provided.

Missed Appointments: All appointments not cancelled at least 24 hours in advance will result in a $35.00 charge for the first incident and a $60.00 charge thereafter. Patients with a pattern of canceling or missing appointments will be seen on a walk-in basis only.

Past Due Accounts: Within 30 days of treatment, any additional payment not made at the time of services is expected in full. All accounts will be assessed interest charges at a rate of 18% per annum on all unpaid balances greater than 30 days following the DATE OF SERVICE. We submit claims to your insurance company as a courtesy to all of our patients. If your insurance carrier requires additional information from you in order to process your claim and you do not provide it, you will be responsible for full payment of all services immediately.

Surgery: When possible, prior to scheduling surgery, an estimated surgical cost analysis will be provided. It is your responsibility to pay the deductible, coinsurance or any outstanding balances on your account at least five (5) days prior to the date of your scheduled surgery. There will be a $250 cancellation fee for all non-medical cancellations.

DME Products: All splints dispensed are non-refundable.

Assignment of Benefits: I hereby authorize my insurance benefits to be paid directly to Glenn D. Cohen, M.D. or Brian D. Rudin, M.D. I hereby instruct and direct my insurance company to pay by check made payable to Glenn D. Cohen, M.D. or Brian D. Rudin M.D. and mailed to 1014 S. Westlake Blvd., Suite 14, PMB #228, Westlake Village, CA 91361. I understand that I am personally responsible for payments which my insurance company/managed care company will not cover if they say that an office visit, proce-dure or pathology, etc…is “not medically necessary”, “pre-existing”, etc…or related to deductibles or co-payments, or for any other reason they give for non-payment. I also understand that what my carrier considers “non medically necessary” may, on the contrary, be considered medically necessary by this office. Therefore, I agree to hold Glenn D. Cohen, M.D. and Brian D. Rudin, M.D. harmless for any medical decisions made by my insurance/managed care carrier which may in any way compromise my best care and result in medical damage, loss or death.

I authorize Glenn D. Cohen, M.D. and Brian D. Rudin, M.D. to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. I have read, understand and agree to the above Financial Policy.

Signature Date

Glenn D. Cohen, M.D. • Brian D. Rudin, M.D.Orthopedic Surgery • 805.370.6877

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESI 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 is posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substi-tute for payment. Some companies may pay fixed allowances for certain procedures, they sometimes refer to as “reasonable and customary fees.” We do not accept this as payment in full (unless otherwise restricted by law or agreement we may have with your insurer). Also some of the insurance companies only pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance. IN ORDER TO CONTROL YOUR COST OF BILLINGS, WE DO REQUEST THAT OUR CHARGE FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT. In the event the account is turned over for collection, the collection fee and /or legal fees, including attorney fees, shall be your responsibility. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance and other health plans to Glenn D. Cohen, M.D. or Brian D. Rudin, M.D. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment, via fax transmittal or hard copy.

Name _________________________________ Relationship to patient ______________ Phone (____)__________

Emergency Information – IN CASE OF EMERGENCY

When did you first notice this problem: / /

Height / Weight? Feet Inches

Pounds

Has another physician treated you for this? Yes No

Who?___________________________________________________

Who is your regular doctor? _________________________________

Which hand do you write with? Right Left Both

Where are you having symptoms? Right Left Both

List body parts (s) _________________________________________

Describe the injury or development of your problem:

Have you had X-rays? Yes No

Have medications been prescribed? Yes No

Did you attend therapy? Yes No

Did you receive splints? Yes No

Did you have any special tests (MRI. EMG) Yes No

Have you had surgery for this problem Yes No

Please explain any yes answers:

Circle your worst PAIN? None 1 2 3 4 5 6 7 8 9 10 Severe

Pain occurs? Morning Day Night Always

Circle the number of times a day it occurs 1 2 3 4 5 6 7 8 9 +

How long does the pain last? Seconds Min. Hours

What makes the pain better? Time Nothing Medicine

Other:

What makes the pain worse? Activity Rest

Other:

Where does the pain occur?

My pain feels: Aching, Burning, Cramping, Deep

Diffuse, Dull, Electric, Intolerable, Throbbing

Pressured Severe, Sharp, Shooting, Stinging

Do you have NUMBNESS OR TINGLING? Yes No

When does it occur? Morning Day Night Always

Circle the number of times a day it occurs 1 2 3 4 5 6 7 8 9 +

How long does this last? Seconds Min. Hours

What makes this better? Time Nothing Medicine

Other:

What makes this worse? Activity Rest

Other: ______________________________________

Where does the numbness or tingling occur? I have problems: Cooking Bathing Getting Dressed What percent of the problem is Pain % Tingling % (Total should =100%) Are you ever asymptomatic and feeling well? Yes No Do you think that you are getting better now? Yes No

Have you been hospitalized? YES NEVER If yes, why and when?______________________________________

Indicate any SURGERIES you have had: NONE

Appendix Hernia Uterus Heart Tonsils

Gallbladder Tubes Tied Cosmetic Eye

List other Any previous breaks or sprains of your NONE Neck

Spine Arms Forearms Hands Legs Feet?

Do YOU have any of the following MEDICAL PROBLEMS?

NONE Diabetes Arthritis AIDS Heart

Stroke High Blood Pressure Asthma /Lung Cancer

List other

PATIENT QUESTIONNAIRE

Glenn D. Cohen, M.D.

Name:

Orthopaedic & Hand Surgery

Date: / /Age: Sex (Circle): M F

Occupation:

PLEASE ANSWER ALL QUESTIONS

IF NO, SKIP TO “I HAVE PROBLEMS:”

IF NONE, SKIP TO “DO YOU HAVE NUMBNESS”

For This Problem, Prior to This Visit:

Do any of the following problems run in your FAMILY?

NONE Diabetes Arthritis AIDS Heart

Stroke High Blood Pressure Asthma /Lung Cancer

List other List any previous significant TRAUMA: NONE List any drug ALLERGIES you have: NONE List any MEDICATIONS you take: NONE Year of your last TETANUS shot:

Do you smoke? Yes No

Packs per day for years

Did you quit smoking? Yes No

When? ________________

Do you drink alcohol? Yes No

Drinks per week

Do you take drugs not from a doctor? Yes No

Single Married Divorced Widowed

Children Yes # No Do you live on your own? Yes No

Check any of the following that you have had RECENTLY

Weight Loss

Fever/Chills

Very Tired

Weakness

Drainage from eyes

Hearing Loss

Sinus Problems

Sore Throat

Chest Pain

Check any of the following that you have had RECENTLY

(Continued)

Cough

Phlegm Wheezes

Nausea

Constipation

Vomiting

Abdominal Pain

Diarrhea

Bloody Stool

WOMEN ONLY:

Is there a possibility of pregnancy currently? Yes No

Eye Disease/ Injury/ Pain Recent Vision Changes

Nasal Congestion or Bleeding

Shortness of Breath Heart Palpitations

Ankle / Feet Swelling High Blood Pressure

Spitting up blood

Difficulty Breathing Tuberculosis

No appetite Hepatitis

Pain when Urinating

Blood in Urine

Frequent Urinating

Flank Pain

Discharge

Incontinence

Dribbling Genital Pain

Neck Pain Back Pain

Leg Pain

Rash or Itching

Change in hair or nails

Chronic Sores

Skin Problems

Passing Out Headache

Seizures Dizziness

Depression Anxiety

Hallucinations

Heat or cold intolerance

Excessive thirst Excessive Urination

Hormone problem Thyroid problems

Breast Lumps / Drainage Excessive Bleeding

Swollen Glands

Bruise easily

Cancer

Eczema Allergies

NONE HIV/AIDS

EXTRA ROOM TO ELABORATE ON ANYTHING:

Glenn D. Cohen, M.D.Orthopedic Surgery • 805.370.6877

HAND SCREENING FORM

Please help Dr. Cohen with your diagnosis by mapping out your symptoms on the chart below. Please use the following symbols to indicate which symptoms are occurring:

Pain = XXXXXX Numbness=+ + + + + + Tingling = - - - - - -

Left Dorsal Left Volar Right Volar Right Dorsal

Name: Date: