PATIENT DEMOGRAPHIC INFORMATION SHEET

PatientName: Date:

DateofBirth: SocialSecurityNumber:

Address: City:

State: ZipCode: Gender:

PatientPhone: EmailAddress:

ReferringDoctor:

Address:

PrimaryDoctor:

Address:

PrimaryInsurance: Claim/ID:

PolicyHolder/RelationshiptoHolder: DateofBirth:

Address: Phone:

SecondaryInsurance: Claim/ID:

PolicyHolder/RelationshiptoHolder: DateofBirth:

Address: Phone:

PatientSignature:

*Pleasebringthefollowingtoyourappointment:PhotoI.D.andinsurancecard,completelistofmedications,

vitamins/supplementsyouaretaking,andanylabsortestingyou’vehadinthelast6months*

MEDICAL HISTORY QUESTIONAIRE

Height: Weight: Age: Sex:

1. Areyouingoodhealthatthispresenttimetothebestofyourknowledge?□Yes□No

2. Areyouunderadoctor’scareatthepresenttime?□Yes□No

Ifyes,pleaseexplain

3. ALLERGIES:

Doyouhaveanyallergiestomedicationsand/orlatex,foods,environmentaletc.?□Yes□No

Ifyes,pleaseexplainandlisttheinteractions

4. Medications:

Areyoucurrentlytakinganymedications? □Yes□No

Ifyes,pleaselistthename,dosage,andfrequency.

5. Doyouhavehistoryof:

□ HeartAttack□ChestPain □Arrhythmia □Palpitations

□ AbnormalEKG□HeartMurmur□Shortnessofbreathwithexertion

6. Haveyoueverbeentoldyouhavediabetes?□Yes□No

Ifyes,pleaseexplain

7. Doyouhaveleg:

□ Pain □Swelling □Tingling □Burning□Numbness

8. Doyouhaveshortnessofbreathatrest? □Yes□No

Doyouhaveshortnessofbreathatmildexertion? □Yes□No

9. Inthepast2-4weekshaveyouhadabdominalpain?□Yes□No

Ifyes,checkallthatapply:

□ Tenderness □Nausea □Vomiting □Cramping□Diarrhea□Constipation□Bloating

10. PastMedicalHistory(pleasecheckallthatapply):

□ AlcoholAbuse□Anemia □Arthritis □BleedingDisorder□BloodTransfusion□ Constipation

□ Cancer□ChronicFatigue □DrugAbuse □Diabetes□EatingDisorder □FrequentHeadaches

□ GallbladderDisease □Gout □HeartDisease □HeartValveDisorder □HighCholesterol

□ HighBloodPressure□KidneyDisease□LiverDisease□LungDisease□Osteoporosis□ PsychiatricIllness □RheumaticFever□SexuallyTransmittedDiseases□Stroke

□ Swellingoffeet□ThyroidDisease□Ulcers□Other:

11. SurgicalHistory:Haveyouundergoneanysurgicalprocedures?□Yes□No

Ifyes,pleaselistsurgeries/proceduresandtheirapproximatedates

12. FamilyMedicalHistory:

Pleasecheckallthatapplyalongwithwhichfamilymemberitappliesto.

□ AlcoholAbuse □Anemia □ Arthritis □ BleedingDisorder

□ BloodTransfusion □Constipation □Cancer □ChronicFatigue

□ DrugAbuse □Diabetes □EatingDisorder

□ FrequentHeadaches □GallbladderDisease □Gout

□ HeartDisease □ HeartValveDisorder □ HighCholesterol

□ HighBloodPressure □KidneyDisease □LiverDisease

□ LungDisease □Osteoporosis □PsychiatricIllness

□ RheumaticFever □SexuallyTransmittedDiseases □Stroke

□ Swellingoffeet □ThyroidDisease □Ulcers

□ Other: _

13. SocialHistory(pleasecheckallthatapply):

Whatisyouroccupationalstatus?□Fulltime□Parttime□Retired□Student□Disabled

TobaccoHistory:□CurrentSmoker;everyday □Never □Socially □Vape

□ SmokelessTobacco □FormerSmoker(listlengthoftime):

Doyoudrinkalcohol?□Yes□No

Ifyes,pleaselistwhatkindandhowoften:

Haveyoueverusedanyillicitdrugs?□Yes□No

Ifyes,pleasecheckallthatapply: □Never□MarijuanaUse □CocaineUse □HeroinUse

14. HealthMaintenance:Pleaselistapproximatedatesforeachofthefollowingbelow:

□ Colonoscopy: / / □Mammogram: / /

□ StressTest: / / □ PapSmear: / / □ PSATest: / /

□ BoneDensityScan(DEXA): / / □Echocardiogram: / / □EKG: / /

WomenOnly:

Haveyoueverbeenpregnant?□Yes□No

Ifyes,pleaselisthowmanypregnanciesand/ormiscarriagesyou’vehad:

Firstdayofyourlastmenstrualcycle: / /

Natureofmenstrualcycles:□Regular□Irregular □Light □Normal□Heavy

□Morethan1timepermonth

Whenyouhaveyourcycle,doesittakeawayfromyournormaldailyactivities?□Yes□No

Ifyes,pleaseexplain:

Areyoucurrentlyusingbirthcontrol?□Yes□No

Ifyes,pleaseexplainthetypeanddosage:

AreyoucurrentlyonHormoneReplacementTherapy?□Yes□No

Ifyes,pleaseexplainwhattypeanddosage:

15. Whatisyourdesiredweight?

16. Whatisthemainreasonforyourdecisiontoloseweight?

17. Whatwasyourweight1yearago? 5yearsago? Maximumweight?

18. Whendidyoubegingainingexcessiveweight?□1-12monthsago □1-2yearsago □3+yearsago

19. Haveyouevertakenanappetitesuppressant?

Ifyes,pleaselistthemedicationanddosage:

20. Pleasecheckallthedietprogramsthatyouhavefollowed/triedandiftheyweresuccessful:

WeightWatchers:□Yes □No Low-Fat:□Yes□No

JennyCraig:□Yes □No Mediterranean:□Yes□No

OptiFast:□Yes □No NutriSystem:□Yes□No

Atkins:□Yes □No Medifast:□Yes□No

Other:□Yes□No

Ifyes,pleaseexplainwhichprograms:

21. Howoftendoyoueatout?□1-2timesweekly □2-5timesweekly □5ormoretimesweekly

Doyousnackinbetweenmeals?□Yes□No

Ifyes,checkallthatapply: □Morning□BetweenMeals□Evening

22. Whatfoodsdoyoucrave?

23. Doyoudrinkanyofthefollowingpleasecheckandlisthowmanyperweek:

□ Coffee: □Water:

□ Sweet-Tea: □Non-SweetTea:

□ Soda: □DietSoda:

24. Doyouuseartificialsweeteners?□Yes□No

Ifyes,checkallthatapply: □Saccharine□Equal□Splenda□Stevia□Truvia

□ Justlikesugar25. ActivityLevel:

□ Inactive-Noregularphysicalactivitywithasit-downjob□ LightActivity-Noorganizedphysicalactivityduringleisuretime

□ ModerateActivity-Occasionallyinvolvedinactivitiessuchasweekendgolf,tennis,jogging,

swimming,orcycling

□ HeavyActivity-Consistentlifting,stairclimbing,heavyconstruction,orregularparticipationin

jogging,swimming,orcycling.

□ VigorousActivity-Participationinextensivephysicalexerciseforatleast60minutespersession4

timesperweek

26. Hasyourdoctoreversaidthatyouhaveaheartconditionandyoushouldonlydophysicalactivity

whenrecommended?□Yes□No

27. Doyoufeelpaininyourchestwhenyoudophysicalactivity?□Yes□No

28. Inthepastmonthhaveyouhadchestpainwhenyouwerenotdoingphysicalactivity?□Yes□No

29. Doyouloseyourbalancebecauseofdizzinessorhaveyoueverlostconsciousness? □Yes□No

30. Doyouhaveaboneorjointproblem(back,knee,hip.etc.)thatcouldbemadeworsebyachangein

physicalactivity? □Yes□No

31. Isyourdoctorcurrentlyprescribingmedicationforbloodpressureorheartcondition? □Yes□No

32. Doyouknowofanyotherreasonwhyyoushouldnotdophysicalactivity? □Yes□No

Ifyes,pleaseexplain:

33. Haveyoueverlostvisioninoneorbotheyesthatwasnotpermanent? □Yes□No

DoubleVision?□Yes□No

34. Haveyoueverhadhearingloss,speechdifficulty,orintermittentnumbnessorlossofmovementofa

limb? □Yes□No

35. Areyoucurrentlytakinganysupplements?

Ifyes,pleaselist:

36. Pleaselistallfoodsthathavecausedproblemsforyou,ifany:

37. Haveyoueverhadananaphylacticreaction(severeallergicreactionthatneededtreatmentright

away)? □Yes□No

Ifyes,pleaseexplaintowhat:

38. Haveyoueverbeendiagnosedwithanyofthefollowing:

□ Asthma □Urticaria(hives,swellingonsurfaceofskin) □Rhinitis(chronicrunningnose)

□ VenomAllergy(insects,snakes,bees,fireants) □MedicationAllergies

□ Angioedema(hives/swellingundertheskin) □LatexAllergy

□ Eczema(itchy,red,crackedinflamedand/orroughskin)

39. Doyouknowifyourfamilyhashistoryofallergies? □Yes□No

Ifyes,pleaselistbelowandwhotheallergiesbelongto:

40. Doyoueverexperienceanyofthefollowingsymptoms?

DigestiveTract

□ Belching/Bloating □Bloated

□ AbdominalDistention □Cramps

□ Gas(rectal) □Constipation

□ Diarrhea □Nausea

□ StomachPains □Vomiting

□ LactoseIntolerance □Heartburn,acidreflux,indigestion

□ MucousyStools

Head

□ Dizziness □LightHeadedness

□ Faintness □Headaches

Mouth&Throat

□ Chroniccoughing □Gagging

□ Clearthroatoften □Sorethroat

□ Swollentongue,lips,orgums

JointMuscles

□ MuscleAches □Arthritis

□ Feelingofweakness □Limitedmovement

□ JointPain □Stiffness

Respiratory

□ Asthma/bronchitis-chronic □Chestcongestion

□ DifficultyBreathing □Shortnessofbreathrestingorwithmildexertion

□ Wheezing □Excessivemucous

□ Hayfever □Sinusproblems

□ Sneezingattacks □Stuffynose

□ Nasalcongestion □Postalnasaldrip

□ Nasalpolyps□ SinuspressureorpainEars

□ Earaches □EarInfection

□ HearingLoss □ItchyEars

□ Ringinginears

Eyes

□ BlurredVision □Darkcircles

□ ItchyEyes □Stickeyelids

□ Swolleneyelids □Wateryeyelids

Weight

□ Bingeeating □Compulsiveeating

□ Cravings □Excessiveweight

□ Underweight □Waterretention

□ Nighteating

Skin

□ Acne □Dermatitis

□ Eczema(red,dry,patches) □Flushing/hotflashes

□ Excessivesweating □Hairloss

□ Itching □Dryskin

Emotions

□ Aggressiveness □Anxiety/fear

□ Depression □Irritability/anger

□ Moodswings □Nervousness

Mind

□ Confusion □Learningdisabilities

□ Poorconcentration □Poormemory/brainfog

□ Stuttering/stammering □Forgetfulness

Energy&Activity

□ Apathy/fatigue □Hyperactivity

□ Restlessness □Sluggishness

Other

□ Chestpain □Frequentillness

□ Generalitching □Irregularorrapidheartbeat

□ Urgenturination □Lossoftasteorsmell

ForOfficeUseOnly

Height: Weight: WeightChange:

BloodPressure: Pulse: BMI:

NeckCircumference: WaistCircumference:

LMP: LastMMG: LastPap:

ChiefComplaint:

What’sDiscussed:

Name: DOB: Date:

FemalePatientConsultForm

Menopause/HormoneImbalanceChecklist

1. HotFlashes,sweating…………………………………..……..… □Yes□No□Sometimes(EpisodesofSweating)

2. HeartDiscomfort………………………………….…………….. □Yes□No□Sometimes(UnusualawarenessofHeartBeat,HeartSkipping,HeartRacing,Tightness)

3. SleepProblems…………………………………………………... □Yes□No□Sometimes(Difficultyinfallingasleep,Difficultyinsleepingthrough,wakingupearly)

4.DepressiveMood…………………………………………………(Feelingdown,Sad,Lackofdrive,Tearful,MoodSwings)

□Yes □No □Sometimes

5.Irritability…………………………………………………………(Feelingnervous,Feelingaggressive,Innertension)

□Yes □No □Sometimes

6.Anxiety…………………………………………… □Yes □No □Sometimes(Innerrestlessness,Feelingpanicky)

7.PhysicalandMentalExhaustion………………………………..(Impairedmemory,Decreasedinconcentration,Forgetfulness)

□Yes □No □Sometimes

8.SexualProblems………………………………………………….(Changesinsexualdesire,Sexualactivity,andSatisfaction)

□Yes □No □Sometimes

9.BladderProblems………………………………………………... □Yes □No □Sometimes(Difficultyinurinating,Increasedneedtourinate,Bladderincontinence)

10. DrynessofVagina……………………………………………….. □Yes □No□Sometimes

11. JointandMuscularDiscomfort………………………………… □Yes□No□Sometimes(Paininthejoints,Rheumatoidcomplaints)

Location:1400Route70,2ndfloor,CherryHillNJ08034 Phone:(888)985-2727

/25 (Multiply raw score by 4)

This Allergy History worksheet is meant for use by a licensed medical professional only. This worksheet is in no way meant to confer a diagnosis or dictate a specific course of either testing or treatment in lieu of a medical professional's opinion. Scores and descriptions of severity are relative to questions asked and may not be seen in and of themselves as conveying medical advice or medical necessity.

ALLERGY HISTORY BASE ver. 2020

NAME DOB DATE

COMPLAINTS: Please circle the appropriate number 0 to 3 according to severity: 0 = absent (no symptoms evident) 2 = moderate (tolerable)

1 = mild (symptoms present, but minimal awareness), 3 = severe

Nasal discharge (runny nose) 0 1 2 3 Headache 0 1 2 3 Nasal obstruction (stuffy nose) 0 1 2 3 Hives 0 1 2 3 Nasal itching 0 1 2 3 Eczema 0 1 2 3 Sneezing 0 1 2 3 Itching ears 0 1 2 3 Watery eyes 0 1 2 3 Sinus or ear infections 0 1 2 3 Itchy eyes 0 1 2 3 Frequent colds or sore throat 0 1 2 3 Gritty feeling (eyes) 0 1 2 3 Sensitivity to pet hair 0 1 2 3 Cough 0 1 2 3, Itchy throat 0 1 2 3 Wheezing 0 1 2 3 Sinus pressure 0 1 2 3 Difficulty breathing 0 1 2 3 Sinus pain 0 1 2 3

Other symptoms causing you problems?

MEDICATIONS: How often do you take medications for your allergy symptoms? 0 = never 1 = occasionally (several times a month or less) 2 = frequently (several times a week) 3 = daily Antihistamines 0 1 2 3 Nasal Steroids (Flonase, Nasacort) 0 1 2 3 Oral Steroids 0 1 2 3 Asthma medication (Inhaler, Singulair, Advair) 0 1 2 3 Eye drops 0 1 2 3 Other allergy-related medications

Does any medication give you complete relief of symptoms?

GENERAL ALLERGY HISTORY: How many months of the year do you have allergies? How many years?

In what season are they worse (check all that apply): O Spring O Summer O Fall O Winter Have you been allergy tested before? O Yes O No If yes, which type: O Skin prick/Puncture O Blood draw Have you previously received allergy shots? Allergy drops? If yes, when? Do you smoke or use tobacco products? List any animals you have in or around the home Who else in your family has allergies?

PROVIDER ONLY RAWSCORE: SCORE: ----

0-25= MILD 26-S0=SIGNIFICANT 51-100=SEVERE 100+= VERY SEVERE

OFFICE USE ONLY:

Eligible None Eligible

Edited by SL 5/19/2021

Patient Phone Number:____________________________

RISK ASSESSMENT

Patient Name _______________________________________________ Date of Birth:_____________

1. Do you have diabetes? YES NO

2. Do you have high blood pressure? YES NO

3. Do you have high cholesterol? YES NO

4. Do you have sleep apnea? YES NO

5. Do you have erectile dysfunction (if applicable)? YES NO

6. Do you have chronic kidney disease? YES NO

7. Do you have heart disease? YES NO

8. Do you smoke or have a history of smoking? YES NO

9. Do you ever have pain or numbness in your fingers, hands, toes

or feet or do they ever feel cold?YES NO

10. Do you ever get pain in your legs when you walk? YES NO

If the patient answers yes to the following, DO NOT PERFORM SUDOMOTOR: (circle one)

Does patient have pacemaker, defibrillator? YES / NO

Cardiac stents and/or hip replacement in past 3 months? YES / NO

If the patient answers yes to the following, DO NOT PERFORM ANS: (circle one)

Has the patient had Laser Retinopathy Surgery in past 3 months? YES / NO

Has the patient been told they have an Atrioventricular (AV) block? YES / NO

Is the patient pregnant? YES / NO

Patient Name: ___________________________________

Patient Signature: ________________________________

Date:_______________

Did the patient have COVID-19or were they exposed?

YES / NO

MA Initial: ___________

DOCUMENTATION OF MEDICAL NECESSITY 

Subjective Memory Complaints (by patient or caregiver) that may justify Neurocognitive Testing:

o Belief that memory is significantly worse than 10 years ago

o Belief that memory is poorer than other people of similar age

o Perception that everyday life is more difficult due to memory decline

o Reports of losing items in the home (keys, phone, etc.)

o Recurrent, significant difficulty in word finding

o Reports that patient forgets something they were told a few minutes before

o Frequently forgetting appointments, recent conversations, recent events

o Getting lost near home

o Failing to recognize a place visited before

o Others remark that patient repeats the same stories

o Difficulty in recognizing familiar people

Note: Subjective memory complaints may or may not be reported by patients with cognitive

impairment or their caregivers and are not always reliable indicators of cognitive impairment.

However, assessment of cognition based on subjective memory complaints is a best practice, can

assist in ruling in or ruling out a diagnosis, and establishes a baseline for follow up.

Reason for referral for Neurocognitive Testing: (Check one or more):

o Detection of CNS disease via quantitative assessment of neurocognitive abilities

o Assist in differential diagnosis of psychogenic vs neurogenic syndrome

o Obtain objective measurement of subjective complaint of cognitive dysfunction

o Quantify cognitive deficits to determine rate of disease recovery/progression

o Assess neurocognitive function to aid in development of rehabilitation strategies

o Assess response to medication/treatment changes

o Assess atypical symptoms involving mental status

phone: 888.416.0004  email: info@braincheck.com  web: braincheck.com 

INTAKE SCREENER (ENGLISH) 

Do you have problems with any of the following: Yes | No 

1. My memory is a lot worse than 10 years ago

2. My memory is worse than other people my age

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3. My family tells me they notice my memory is getting worse

4. Everyday life is much harder because of my memory problems

5. I often lose things around the house, like keys or my phone

6. I have trouble finding the right word for things

7. People tell me I tell the same stories over and over

8. I often forget things that somebody just told me

9.� I’ve missed appointments or meetings that I should have remembered

10. I’ve gotten lost when driving in familiar locations

11. I sometimes have difficulty recognizing people I should know

12. I sometimes forget names of family or close friends

13. Difficulty finding the right word in conversation

14. Maintaining focus on a specific task for extended periods

15. Difficulty following multi-step directions, such as a recipe

phone: 888.416.0004  email: info@braincheck.com  web: braincheck.com 

FINANCIALPOLICY

We are committed to providing you with the best possible care. • We will provide you with the most appropriate care in the most time-efficient fashion. • We will treat you with respect and professionalism • We will always do our best to keep your scheduled appointment and to minimize any wait time you may

incur. However, due to circumstances beyond our control, there may be times that we must reschedule your appointment with short notice.

• In order to give you as much notice as possible, we request a phone contact so that we can reach you in person during the day, such as a business number or cell phone.

If you have any questions regarding this information, please don’t hesitate to ask us. We are here to help you. General Information

• In order to treat you effectively and efficiently and within HIPPA guidelines, we require a registration form and several other forms be complete by you.

• We are sorry, but due to high fax volume we are NOT able to accept any of the following documents via fax. Without the completed documents, films, tests, and referral, if appropriate, you will NOT be seen by the doctor and your appointment will be RESCHEDULED.

1. Referral, if required by your insurance 2. Active valid insurance card 3. Photo ID 4. MRI films, and reports, CT scan films and reports, bone scan reports 5. EMG reports 6. Primary doctor’s notes, other specialists’ notes (orthopedic surgeon, neurologist, psychiatrist,

rheumatologist, etc.) 7. List of current medications

We expect that you have an understanding of your responsibilities under your insurance contract with respect to referral and preauthorization requirements, as well as your deductible, copay, coinsurance and coverage limits. In order to achieve your maximum allowable benefits, we need your assistance and your understanding of our Financial Policy. If you have insurance coverage with one of the plans which we do participate with, we will bill your insurance company along the guidelines of our contract. However, we require that all co-pays are paid at the time of service. If you have an insurance which we do not participate with, you will be provided with an Out of Network Contract. Returned checks will be subject to an additional $39 service fee. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. Please realize that your insurance is a contract between you, your employer and the insurance company. We are not a part to that contract. While filing of insurance claims is a courtesy we extend to our patients, all charges are the responsibility of the patient from the date the services are rendered. You will be required to show a copy of your insurance card at each time of service. If you do not have your insurance information or we are unable to verify your coverage, you will be required to pay for the services rendered each visit until we are able to verify coverage. If your insurance coverage terminates or changes, you are responsible for notifying us of this change immediately so that we can assist you in receiving your maximum reimbursement.

Please help us serve you better by keeping your scheduled appointments. There is a NO SHOW FEE for all appointments that are not cancelled within 48 hours of your appointment. Please be sure to get the staff members name, date and time that you spoke with them when cancelling an appointment. I have read the Financial Policy. I understand and agree to this Financial Policy. I guarantee payment of all claims submitted to my insurance on my behalf. I further agree to pay any attorney fees, court costs and related collection agency fees incurred. ______________________________________ __________________________________ PATIENT NAME PATIENT SIGNATURE ______________________________________ _________________________________ RESPONSIBLE PARTY SIGNATURE (If not patient) DATE

AUTHORIZATION AND CONSENT I request that payment of authorized Medicare Benefits be made on my behalf to Renewus for any services furnished to me by Renewus. I authorize any holder of medical information about me to be released to Renewus and its agents, this includes any information needed to determine these benefits or the benefits payable to related services. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment. I request that payment of authorized Medigap Benefits be made on my behalf to Renewus for any services furnished me by Renewus. I authorize any holder of medical information about me to release to my insurance carrier any information needed to determine these benefits payable for related services. AUTHORIZATION to release information and payment request. I certify that the service(s) covered by this claim has been received and I request that payment for these services be made on my behalf. I authorize any holder of medical or other information about me to release to the Division of Medical Assistance and Health Services or its authorized agents any information needed for this or related claim. ASSIGNMENT OF INSURANCE BENEFITS : I irrevocably assign all payments to Renewus for medical insurance benefits including any Major Medical Benefits otherwise payable to me under the terms of my policy but not to exceed the balance due to Renewus for services performed during this period of treatment. In making this assignment, I understand and agree that I am financially responsible to the above party for charges not paid under this insurance policy. I permit a copy of this authorization to be used in place of the original. RELEASE OF INFORMATION : Renewus may disclose any or all parts of the clinical record to me, my insurance company(s) or employer(s) for purposes of satisfying charges billed by Renewus. I further understand that is may be necessary for Renewus to contact my past or present employer(s) in regards to this claim. This authorization does not cover 3rd party liability claims. GUARANTEE OF ACCOUNT: Renewus, for and in consideration of services rendered by Renewus to the below named patient, the undersigned (jointly and severally, if more than one) guarantees payment of all charges incurred for said patient in accordance with the policy of payment of such bills. There will also be a 35% collection fee and reasonable attorney fees, if your account goes to a collection agency. THE UNDERSIGNED CERTIFIES THAT EACH HAS READ AND UNDERSTANDS THE ABOVE TERMS AND CONDITIONS . ___________________________________ __________________________________ ____________ Patient’s Name Patient Signature Date __________________________________________________________________ Responsible Party Signature (if not patient)

AuthorizationtoDiscussMedicalInformation

I,__________________________,herebyauthorizeyoutouseordiscussthespecificinformationdescribed

below,onlyforthepurposeandpartiesalsodescribedbelow.

Pleaseselectthespecificinformationpermittedtobediscussed:

o Appointmentdates/Time

o Medications

o LabTest/Resultso SummaryofMedicalRecords

o CarePlano Diagnosis

PatientName:_______________________________D.O.B.:___________________________

InformationpermittedtobegiventoNAME(S)-______________________________________________

Relationshiptopatient:________________________________________________________________

Address:_____________________________________________________________________________

Phone:_______________________________________________________________________________

*Multiplenamesmaybeaddedifyousochoose*

Thusauthorizationshallremainineffectfromthedatesignedbelowuntil(pleasecheckone):

o SpecificDate:______________o NOEXPIRATIONDATE

IunderstandthatImayrevokethisauthorizationbycontactingyouroffice,attentionAdministrator.ThisauthorizationisgivingRenewustherighttodiscussmymedicalinformationwiththeoneormorepeoplelistedabove.Informationusedordisclosedpursuanttotheauthorizationmaybesubjecttore-disclosurebytherecipientandnolongerbeprotectedbyHIPPA.PatientSignature:_________________________________________Date:______________

AuthorizationtoReleaseMedicalRecordsOutgoing

Iherebyauthorize:

Renewus

1400Route70East2ndfloor

CherryHillNJ08034

Phone:(888)985-2727

Fax:(856)375-2419

Toreleasemedicalrecordsanddatapertainingto:

PatientName: SSN/MRN:

DateofBirth: PhoneNumber:

StreetAddress: City/State/Zip:

Tothefollowingphysician/facility:

Physican/Facility:_____________________________________________________________

Address:____________________________________City/State/Zip:______________________________

Phone/Fax:______________________________________________________________

SelecttheMOSTRECENTrecordstobereleased:

o Labs:__________________________________o Radiology/Imaging:________________________________________

o H&P/OfficeNotes:____________________________________o Medication:________________________________________________

o Other:_______________________________________________

Patient/GuardianSignature:________________________________________Date:_______________