1914 Lelaray St
Colorado Springs, CO 80909
www.pikespeaknephrology.com

Phone : (719) 632-7641
Fax: (719) 632-2925

Melinda L. Hockensmith, M.D. Jesse A. Flaxenburg, M.D. Mark R. Cook, D.O.
Michael D. Ross, M.D. Derian C. Lai, M.D. Mark P. Albright, M.D. Jodi K. Yanagida, D.O.

Welcome to Pikes Peak Nephrology Associates, P.C., and thank you for choosing us as your healthcare provider!
For your upcoming visit, please arrive on time to complete your registration. Please bring your insurance cards, photo ID, and completed new patient packet when you check in to our office. Late arrivals may be asked to reschedule.

OFFICE LOCATION: 1914 Lelaray St
Colorado Springs, CO 80909

850 Eagleridge Blvd
Pueblo, CO 81008

*Patients seen in the Colorado Springs office will be asked to provide a urine specimen*

You will find several forms in this new patient information packet. Please read and complete all forms to the best of your ability. The personal health history you provide will allow us to better serve you.

New Patient Appointment Confirmation: We will send you a text message and/or call you 3 days before your appointment to confirm your appointment. Please contact our office to confirm your appointment if we leave you a message or if you receive a text message from us. If we do not receive confirmation from you within 48 hours prior to your appointment, it will be canceled.

If You Need to Cancel/Reschedule Your Appointment: Kindly notify us 48 hours in advance of your appointment if you need to cancel or reschedule. Please note that rescheduled appointments may take 3 to 4 months to accommodate. If we do not receive a request to cancel or reschedule 48 hours prior to your appointment or your appointment is missed, your referring physician will be notified, and you may incur a $25.00 charge.

Thank you and we look forward to serving you for your kidney healthcare needs!

PLEASE COMPLETE ALL INFORMATION ON THIS FORM IN ORDER TO SERVE YOU BETTER

For your privacy, please indicate what telephone number we should use to contact you with communication (appointment reminders, lab results, etc.) from our office.

If we are unable to speak with you directly and must leave a message, please indicate with whom we may leave a message or speak to:

We communicate with our patients via patient portal and/or text messaging. Text messaging may incur a charge with your cell phone carrier. If you do not want to receive communication through these methods, please notify the office.

Missed appointments keep other patients waiting longer to see their Nephrologist. We understand that on occasion an appointment will have to be canceled or rescheduled. If we do not receive notice of cancellation/reschedule within 48 hours prior to your appointment, it is our policy to charge $25. This is not payable by your insurance and is your responsibility.

Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign below to acknowledge receipt of this notice. You may refuse to sign this acknowledgment if you wish.

I acknowledge that I have received a copy of this office's Notice of Privacy Practices. I understand that I may revoke this authorization form at any time by notifying this office in writing.

PLEASE TURN THE PAGE

You will be asked to confirm or update this information at each visit. It is your responsibility to notify us of any changes in your healthcare coverage. If you opt not to provide this information, we require payment in full at the time of service.

All applicable co-payments and/or cost shares, and any outstanding patient-due balances, are due at the time of service. If co-payments are not paid on the date of service, a $10 billing fee may be charged to your account. We accept cash, checks, debit, and credit cards. Obtaining referrals to our office is your responsibility.

It is your responsibility to understand and comply with the terms of the insurance agreement you have purchased. We are not contracted as a fiscal intermediary between you and your insurance. Please be aware that some services we provide, and perhaps all, may be non-covered or may not be considered medically necessary under Medicare or other insurance companies. In these cases, you are responsible for all charges. Patients with High Deductible Plans (HDP) will be asked to pay for the services after the visit.

If you do not have insurance coverage, please be prepared to pay for your services in full at the time of your appointment. Payment arrangements may be made in advance with the billing department at PPNA.

For checks returned to us as unpaid by your bank, we will charge a $30 fee.

In the event your account becomes past due, additional billing fees may be assessed. If your account becomes delinquent, it may be forwarded to an outside collection agency. If this happens, you will be responsible for all additional charges related to this process.

By providing your credit/debit card information for a payment plan, you permit Pikes Peak Nephrology Associates to securely store your payment details and charge your card as authorized. Authorization will be documented, including the agreed-upon payment amounts and frequency. You may request a receipt for charges, modify, or cancel the payment plan you enter into by contacting our Billing Office.

I request that payment of authorized insurance benefits, including Medicare if I am a Medicare beneficiary, be made on my behalf to the organization. I authorize the release of any medical or other information obtained by our office necessary to determine these benefits or the benefits payable for services to the organization, the Health Care Financing Administration, my insurance carrier, or the medical entity.

I understand that I am financially responsible to this organization for any charges not covered by my health care benefits. Please contact our Billing Office at (719)955-2656 if you have any questions or concerns.

PIKES PEAK NEPHROLOGY ASSOCIATES, P.C.

PERSONAL HEALTH HISTORY

PIKES PEAK NEPHROLOGY ASSOCIATES, P.C.
REVIEW OF SYSTEMS
(Please select all that apply to your condition in the last 6 months)

**All symptoms that are not circled are negative.

Please tell us what prescriptions and over-the-counter medications you take, and any drug allergies.

(This page left blank intentionally)

At Pikes Peak Nephrology we submit all prescriptions electronically. We can send your prescriptions to your local pharmacy, a mail-order pharmacy, or a military facility. You will be notified by text message when any prescription or refill is sent from your chart, if we have your mobile phone number on file. Let us know your pharmacy of choice.

We do not prescribe or refill any medications that are managed by other Specialists or your Primary Care provider (PCP).

When requesting a refill of a medication prescribed by our office, contact your pharmacy before you run out of the medication. Requests and refills for prescriptions will be processed within 2 business days. Refills are not processed on holidays or weekends.

Colorado state law requires that our providers report all controlled prescriptions received from this office. Drug class II through V prescription information will be entered into Colorado's Electronic Prescription Drug Monitoring Program database when the medication is dispensed to you.

All follow-up appointments at PPNA require you to obtain lab work 1 to 2 weeks prior to your next scheduled appointment with our doctors, unless otherwise directed. In the event your lab work is not available to us prior to your appointment, you may be asked to reschedule your appointment. Lab testing is very important for all appointments. Testing done on military bases is difficult to obtain, and you may be asked to pick up the results.

We prefer that all PPNA patients obtain their laboratory testing at LabCorp, Quest Diagnostics, or UCHealth facilities. Military/Tricare patients may obtain their laboratory testing at LabCorp. We encourage you to go directly to the lab facility and present the lab order that our provider gave to you to ensure that we receive the results in a timely manner. As a general rule, our physicians review lab results with you at each appointment. Please retain your lab order to streamline testing when the time comes for you to have the blood test. If you have misplaced the original order, contact our office at least 2 business days in advance to request a pickup or fax another copy.

If your Nephrologist has ordered additional testing for any radiology/ultrasound procedures, your orders will be sent to Penrad Imaging, unless you tell us your preference. Penrad Imaging will contact you to schedule your imaging test. If you have not been contacted within 3 business days for scheduling, please call Penrad's scheduling department. Penrad is contracted with all major insurances. Penrad has numerous locations along the Front Range.

Pikes Peak Nephrology Physicians provide 24/7 coverage at both hospital systems in Colorado Springs. Hospital rounding is provided by the assigned practice physician. Although you may not see your primary Nephrologist if you are hospitalized, rest assured, you are being taken care of by your Nephrologist's partner.

Pikes Peak
Nephrology
Associates P.C.

Our physicians are with scheduled patients during regular office hours, Monday - Friday, 7:30 am to 4:30 pm. If you require contact with your provider prior to your next scheduled appointment, you will need to leave a detailed message with the office operator. The Medical Assistant will speak with the doctor and return your telephone call within 2 business days. You can also message the Medical Assistant through your Patient Portal. The patient portal is available to all PPNA patients. You can view your test results from LabCorp/Quest and send messages to PPNA staff through the portal. Please speak with any staff member to get registered. The Patient Portal sign-up is quick and easy.

Pikes Peak Nephrology Associates, P.C. endorses, supports, and co-participates in electronic Health Information Exchange (HIE) as a means to improve the quality of your health and healthcare experience.
HIE provides us a way to securely and efficiently share patients' clinical information electronically with other physicians and healthcare providers who participate in the HIE network.
Using HIE helps your healthcare providers to more effectively share information and provide you with better care.
The HIE also enables emergency medical personnel and other providers who are treating you to have immediate access to your medical data that may be critical for your care.
Making your health information available to your healthcare providers through the HIE can also help reduce your costs by eliminating unnecessary duplication of tests and procedures. However, you may choose to opt out of participation in the Contexture – HIE, or cancel an opt-out choice, at any time. Ask for more information from our staff if you choose to opt-out of this electronic system.

Pikes Peak Nephrology Associates, P.C.
Effective date: February 19, 2021

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. We welcome any questions you may have to assist in understanding this document.

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on our
website: www.pikespeaknephrology.com, or we will mail a copy to you upon request.

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say "no" to your request, but we'll tell you why in writing within 60 days.

• You can ask us to contact you in a specific way about your medical information (for example, home or office phone) or to send your medical information to a different address.
• We will say "yes" to all reasonable requests.

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.
• If you pay for a service or healthcare item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

• You can ask for a list (accounting) of the times we've shared (disclosed) your health information for up to six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

You can file a complaint with us if you feel we have violated your rights by contacting our Privacy Officer.

• To file a complaint with our organization, please submit your request in writing to the Privacy Officer, 1914 Lelaray St, Colorado Springs, CO, 80909.
• You can file a complaint with the U.S. Department of Health and Human Services' Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W, Washington, D.C. 20201, by calling 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/
• We will not retaliate against you for filing a complaint.

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, contact us, tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference - for example, if you are unconscious, we may share your information if we believe it is in your best interest to do so. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Pikes Peak Nephrology Associates, P.C. 1914 Lelaray Street Colorado Springs, CO 80909 Phone 719-632-7641 Fax 719-632-2925 pikespeaknephrology.com

In the following cases, we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your protected health information.
• Most sharing of psychotherapy notes

• We may contact you for fundraising efforts, but you can tell us not to contact you again. We will honor your request to not contact you again.

We typically use or share your health information in the following ways:

• Treatment
  We can use your health information and share it with other professionals who are treating you.
  Example: A doctor treating you for an injury asks another doctor about your overall health condition.
• Run our organization
  We can use and share your health information to run our practice, improve your care, and contact you when necessary.
  Example: We use health information about you to manage your treatment and services.
• Bill for our services
  We can use and share your health information to bill and get payment from health plans or other entities.
  Example: We give information about you to your health insurance plan so it will pay for your services.

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone's health or safety

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

We can share health information about you with organ procurement organizations.

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

We can use or share health information about you:

• For workers' compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Pikes Peak Nephrology Associates, P.C. 1914 Lelaray Street Colorado Springs, CO 80909 Phone 719-632-7641 Fax 719-632-2925 pikespeaknephrology.com