BodEvolve

PATIENT INFORMATION
Name*

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
AGE
GENDER

MaleFemaleOther
HOME ADDRESS*
CITY*
STATE*
ZIP*
SS#
EMPLOYER
OCCUPATION
CELL PHONE *
WORK PHONE
HOME PHONE
NAME OF PHARMACY
PHARMACY CITY
PHARMACY PHONE
EMAIL ADDRESS*
example@example.com
HOW WERE YOU REFERRED?*
REASON FOR VISIT
SPOUSE'S NAME
SPOUSE'S DATE OF BIRTH

MonthDayYear
Date
SPOUSE'S CONTACT PHONE NUMBER

INSURANCE INFORMATION
INSURANCE PROVIDER (If no insurance, say "None" and skip to the next section.)*
ELIGIBILITY/PROVIDER PHONE NUMBER
ARE YOU THE POLICY HOLDER?

YesNo
POLICY HOLDER'S: NAME
POLICY HOLDER'S DATE OF BIRTH

MonthDayYear
Date
POLICY HOLDER'S EMPLOYER
MEMBER ID/SUBSCRIBER ID
GROUP NUMBER

EMERGENCY CONTACT INFORMATION
EMERGENCY CONTACT NAME*
RELATIONSHIP
PHONE NUMBER *
ALTERNATNE PHONE NUMBER
I authorize the release of any medical information about me to Dr. Clayton A. Frenzel, his assistants or insurance company that is needed in the course of examination or treatments. Benefits to be paid to BodEvolve. I understand there is a $500.00 fee to schedule surgery. Payment for office visits is required at the time services are rendered. For all procedures, advanced payment is required two weeks prior to surgery. For all procedures less than $500.00, payment must be at the time of treatment or before.
PATIENT SIGNATURE*

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DATE*

MonthDayYear
Date

PATIENT MEDICAL HISTORY
Name*

First NameLast Name
AGE
HEIGHT IN INCHES *
CURRENT WEIGHT IN POUNDS *
HIGHEST ADULT WEIGHT*
LOWEST ADULT WEIGHT*

SOCIAL HISTORY
DO YOU DRINK ALCOHOL?*

YesNo
HOW MANY DRINKS PER WEEK?
DO YOU SMOKE?*

YesNo
HOW MANY PACKS PER DAY?
WHEN DID YOU QUIT?
DO YOU CONSUME RECREATION DRUGS?*

YesNo
TYPE / FREQUENCY

WOMEN ONLY
DATE OF LAST MENSTRUAL CYCLE

MonthDayYear
Date
ARE YOUR CYCLES REGULAR?
ARE YOU USING BIRTH CONTROL?

YESNO
WHAT TYPE
NUMBER OF PREGNANCIES
NUMBER OF LIVE BIRTHS
NUMBER OF MISCARRIAGES
NUMBER OF TERMINATIONS
FIRST PREGNANCY: YEAR WEIGHT AT START WEIGHT AT DELIVERY
SECOND PREGNANCY: YEAR WEIGHT AT START WEIGHT AT DELIVERY
THIRD PREGNANCY: YEAR WEIGHT AT START WEIGHT AT DELIVERY
FOURTH PREGNANCY: YEAR WEIGHT AT START WEIGHT AT DELIVERY
PROBLEMS DURING OR AFTER PREGNANCY?

MEDICATION HISTORY
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR
MEDICATION NAME DOSEAGE REASON PRESCRIBING DOCTOR

SURGICAL HISTORY
SURGERY TYPE AND YEAR
COMPLICATIONS WITH ANESTHESIA?

YesNo
WHAT WAS THE COMPLICATION?
FAMILY HISTORY (PLEASE LIST WHICH, IF ANY, OF YOUR FAMILY MEMBERS HAD ANY OF THE FOLLOWING CONDITIONS, I.E. MOM, DAD)
ANEMIA
STROKE
SLEEP APNEA
OBESITY
KIDNEY DISEASE
CANCER
DIABETES
GALLSTONES
GOUT
HEART DISEASE
HIGH BLOOD PRESSURE
BLOOD CLOTS
BLEEDING PROBLEMS
OBESITY RELATED ISSUES
PATIENT SIGNATURE*

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EPWORTH SLEEPINESS SCALE (ESS)
The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze off or fall asleep during different routine daytime situations. Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3: with 0 meaning you would never doze or fall asleep in a given situation; and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation.

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
Even if you haven’t done some of the activities recently, think about how they would have affected you.

Use this scale to choose the most appropriate number for each situation:

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

It is important that you circle a number (0 to 3) for EACH situation.
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP WHILE SITTING AND READING? *
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP WHILE WATCHING TV? *
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP WHILE IN A MEETING OR MOVIE THEATER?*
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP AS A PASSENGER IN A CAR FOR AN HOUR WITHOUT A BREAK?*
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP LYING DOWN TO REST IN THE AFTERNOON? *
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP SITTING AND TALKING TO SOMEONE?*
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP SITTING QUIETLY AFTER LUNCH (NO ALCOHOL)? *
HOW LIKELY ARE YOU TO DOZE OFF OR FALL ASLEEP IN A CAR WHILE STOPPED IN TRAFFIC? *
PATIENT SIGNATURE *

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Date*

MonthDayYear
Date

CONTRACT FOR COMPLIANCE
I {patientName}, acknowledge and agree that upon consenting to and undergoing bariatric surgery, I will participate in the following items whose purpose is to promote the success of the bariatric

1. I agree to be seen for regularly scheduled follow up appointments and be an active participant in my aftercare to achieve my best outcome.

2.I will start an aerobic fitness program. I will build my endurance until I am able to exercise for a minimum of 30 minutes per day within the first 60 days.

3.I will follow all dietary guidelines recommended by Dr. Frenzel and/or his representatives (P.A., dietitian, and

4. If deemed necessary, I will participate in psychotherapy sessions with a licensed professional to resolve any psychological issues that may limit my successful weight loss.

5. I acknowledge that monthly support groups are available at the hospital where I have surgery and I am encouraged to attend these meetings.

6.I agree that in order for me to achieve the greatest degree of success with this surgery, I must strictly follow the guidelines as provided by Dr. Frenzel and his office.

By signing this agreement, I acknowledge my understanding, agreement, and compliance with the stated items.
Signature*

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AUTHORIZATION FOR RELEASE OF INFORMATION
I HEREBY AUTHORIZE THE USE OR DISCLOUSURE OF MY INDIVIDUAL IDENTIFIABLE HEALTH INFORMATION AS DESCRIBED BELOW. I UNDERSTAND THAT THIS AUTHORIZATION IS VOLUNTARY. I UNDERSTAND THAT IF THE ORGANIZATION TO RECIEVE THE INFORMATION IS NOT A HEALTH PLAN OR HEALTH CARE PROVIDER, THE RELEASED INFORMATION MAY NO LONGER BE PROTECTED BY PRIVACY REGULATIONS
PATIENT NAME
DATE OF BIRTH

MonthDayYear
Date
PHONE NUMBER
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER
SPECIFIC REQUESTS

ALL DATESPROGRESS NOTESLABSOPERATIVE REPORTSRADIOLOGY REPORTSHOSPITAL RECORDS TEST RESULTSCORRESPONDENCE
I UNDERSTAND THIS AUTHORIZATION WILL EXPIRE 180 DAYS FROM THE DATE SIGNED

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CONSENT TO TREATMENT
Purpose: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy. This disclosure is not intended to alarm or frighten you, but rather to make you better informed so that you may give or withhold your consent to the proposed treatment.

Consent to Treatment: I voluntarily request Dr. Clayton Frenzel, as my physician, and such associates, assistants, nurses and other health care providers as deemed necessary or advisable, to treat my condition. I understand that it is my responsibility to actively participate in my care in order to maximize improvement in my condition.

I understand that I may undergo extensive diagnostic tests and examinations during my treatment with Dr. Frenzel. If I am unable or unwilling to undergo such testing, my treatment plan may be revised and my condition outcome may be affected. During the course of treatment, I may be required to make frequent follow-up visits to review diagnostic test results. I will be required to personally attend office visits for appropriate care and treatment.

I agree to keep my physician and authorized associates apprised of any changes in my medical condition. Certain diagnostic tests, treatments, and drug therapies can be dangerous under certain medical conditions or medication use.

Pregnancy is one such medical consideration and females must be certain to acknowledge this condition prior to diagnostic imaging and initiation of any medication therapy. Female patients who become pregnant during the course of their treatment with Dr. Frenzel will notify their prescribing physician if they are on medication therapy.

Furthermore, I understand that no warranty or guarantee will be made to me as a result of any medication therapy, treatment or cure of my condition. I have the opportunity to ask questions about my condition and treatment, risks of non-treatment and the medication therapy, medical treatment(s) or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such medication therapy, treatment(s) and procedure(s), and I believe I have sufficient information to give this informed consent.

I hereby consent to treatment.
Signature*

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ACKNOWLEDGEMENT TO RECEIPT OF NOTICE OF PRIVACY PRACTICES
I understand that as part of my healthcare, BodEvolve ("PROVIDER") originates and maintains health records describing

my health history, symptoms, examination and tests results, diagnoses, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and in other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals and as required or permitted by law without my consent.

The PROVIDER'S Notice of Privacy Practices provides specific information and complete description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and understand that I have the right to review the notice prior to signing this acknowledgment. I understand that the PROVIDER reserves the right to change the Notice of Privacy Practices.

I have been provided and have reviewed the PROVIDER'S Notice of Privacy Practices dated March 25, 2011.
Signature *

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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.

PATIENT FINANCIAL RESPONSIBILITY LETTER
Dr. Clayton Frenzel for your surgical/medical needs. We are committed to providing you with the highest choosing quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.

Our coordinators, both bariatric and cosmetic will do their best to get your surgical/medical services pre-authorized by your insurance. If surgical/medical services are denied either prior to or after your procedure, the financial responsibility remains with the patient. WE CANNOT GUARANTEE THAT YOUR INSURANCE WILL APPROVE THE PROCEDURE YOU ARE ATTEMPTING TO GET COVERED OR WILL MAKE PAYMENT.
PATIENT FINANCIAL RESPONSIBILITIES
The patient is ultimately responsible for the payment for treatment and care. We will bill your insurance for you. However, the patient is required to provide the most current and updated information regarding insurance. Patients are responsible for payment of copays, coinsurance, deductibles and all other procedures or treatment not covered by their insurance plan. Copays are due at the time of service Coinsurance, deductibles and non-covered items are due two weeks prior to your procedure. If your services are denied after billing the health insurance, you will have 30 days to pay after receiving the first statement. Patients may incur, and are responsible for payment of additional charges, if applicable. These charges may include a charge for returned checks in the amount of $30.00

By my signature below, I hereby authorize assignment of financial benefits directly to Dr. Clayton Frenzel / BodEvolve. I understand that I am financially responsible for charges not covered by this assignment.
Signature*

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ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND/OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE.

I hereby assign and convey directly to Dr. Clayton Frenzel, P.A., BodEvolve LLC, AC Surgery Center LLC, Keystone Partners PLLC as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above-named healthcare providers, regardless of its managed-care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named healthcare providers to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named healthcare providers all Plan documents, summary benefit descriptions, insurance policy(s), and/or settlement information upon written request from the above-named healthcare providers or its attoneys to claim such medical benefits.

In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above-named healthcare providers any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named healthcare providers (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.

I intend by this assignment and designation of authorized representative to convey to the above-named providers all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or medications provided by the above-named healthcare providers including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (abovenamed providers) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, healthcare benefit plan, or plan administrator. The above-named providers as my assignee and my designated authorized representative may sue any such healthcare benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider’s expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (healthcare reform legislation), ERISA, Medicare, and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original. I also herby authorize the release of any medical information about me to the Social Security Administration and Health Care Financing Administration or its intermediaries, and request payment of my medical insurance benefits to be paid directly to Dr. Clayton Frenzel, P.A., BodEvolve, LLC.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.
Signature*

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DISCLOSURE OF PHYSICIAN OWNERSHIP AND FINANCIAL INTEREST
State and Federal guidelines require that physicians that have an ownership interest in a facility to which the physician may refer patients, disclose their affiliation. In the interest of providing our patients with complete information, we are providing the names of the outside facilities where Dr. Clayton A. Frenzel may have an ownership interest.

Dr. Clayton Frenzel, P.A.

1000 North Davis Dr. Suite B

Arlington, TX 76012 817-342-0232

BodEvolve, PLLC

1000 North Davis Dr. Suite C

Arlington, TX 76012 817-342-0232



Keystone Anesthesia Partners, PLLC

1000 North Davis Dr. Suite C

Arlington, TX 76012 817-342-0232



Texas Surgery Specialists

1000 North Davis Dr. Suite C

Arlington, TX 76012 817-342-0232



Horizon Medical Center (DBA: Peak Health Surgicare)

2813 South Mayhill Road, Second Floor

Denton, TX 76208

610 North Coit Road, Suite 2120

Richardson, TX 75080                                972-954-3588

1190 North Haskell Avenue

Dallas, TX 75244 214-821-2001

During your course of treatment with Dr. Frenzel, you may be referred to one of these facilities for medical services. You have the right to choose the facility where you receive medical treatment/services, including the right to choose a facility other than the ones listed above.

By signing below, I acknowledge receipt of the above disclosure information.
Signature*

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Date

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Date
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PATIENT FINANCIAL RESPONSIBILITIES