I-'rom:DI"I GOVIND PA TI::.L 43 2 697 6000 07/25/20,8 13:,2

PERMIAN GASTROENTEROLOGY, P.A. MRUNAL C. PATEL, M.D. GOVIND B. PATEL, M.D.

DIPLOMATE AMERICAN BOARD OF INTERNAl MEOICfNE AND GASTROENTEROLOGY

PRACTICF. LIMITED TO GASTROENTEROLOGY

REGISTRA TION FORM

Referred by : _______ _ Todays Date ______ _

PA TIENTS'S INFORMATION

Patient legal Name: First ________ M.l. __ last ______________ _

"'SI 1".007/0 18

Address _____ ______ City, _______ ,State ___ lip, ___ _

Telephone # ____________ Cell # _ _ _______ _

Date of Birth, ___ _ _ ___ _ Sex ___ Martial Status. ___ _ _

Social Security Number ____ _ _ _________ _

Full or Part Time Student _________ _

EMPLOYERS INFORMATION Employer Of (Circle one) Patient, Guarantor, Student EmploversName _______________________ _

Employer's Address Telephone' ____ _

City ___________ State ______ Iip _____ _

E/.'ERGENCY CONTACT (NEED TWO)

In case of emergency, please contact #11 _________________ _ Relationship to Patient _______ _ Phone number of Contact ____________ _

#2contact ______ ____________________ _

Relationship to Patient' _______ _ Phone number of Contact _ ___________ _

INFORMATION ON BACK

'214 ANDREWS HWY, STE, 203 MIDLAND, TEXAS 79703 TELEPHONE, (432) 697·1000 FAX, (432) 697·6000

f' r o "" ,O Fl a O VJN O Io'A fLL 4 3 2 6g 7 60 0 0 07 /26/ 2 016 ' 3 :12

T PERMIAN GASTROENTEROLOGY, P.A.

MRUNAL C. PATEL, M.D. GOVIND B. PATEL. M.D. DfPLO!".1ATEA.l,fERJCAN BOARD OF

INTERNAL MED1CINE AND GASTROENTEROLOGY PRACTICE UMITED TO GASTROENTEROLOGY

PRIMARY INSURANCE INFORMATION

Name of Insurance Company ___________________ _

Group Number _________ Policy#, ___________ _

SUBSCRIBER INFORMATION

Name ______________ _

Address __________________ Telephone. _____ _

Policyholder Date of Birth ______________ _

Policyholder Social Security 1# _____________ _

Policyholder Employer _______________ _

SECONDARY INSURANCE INFORMATION

Name of Insurance CompOlny' ____________________ _

Group Number _________ Policy#' ___________ _

Policyholder Name _______________________ _

Policyholder Date of Birth _______________ _

Policyholder Social Securitv# ______________ _

Employer Name __________________ _

ASSIGNMENT OF BENEFITS- REl£ASE OF MEDICAL INFORMATION

I ~lJest that pDyment olmy InslJlTlnc~ Ben~jits to be mad~ on my b~haJlto PERMIAN GASTROENTEROLOGY; P.A., for any services furnish~ me by PERMIAN GASTROENTEROLOGY, P.A.

"'5' P.0 071018

Signed _______________ Date __________ _

I outhorlu the release oj medical injormation jar the purpose 0/ processing my medical dalm. I understand that I am financially responsible jor any balonce not covered by my Insurance Carrier.

Signed _________________ Dare' ___________ _

4214 ANDREWS HWY. STE. 20) MIDLAND, TEXAS 79703 TELEPHONE, (432) 697·1000 FAX, (432) 697·6000

f' r o "" ,O Fl a O VJN O Io'A fLL 4 3 2 6g 7 60 0 0 07 /26/ 2 016 ' 3 :12

T PERMIAN GASTROENTEROLOGY, P.A.

MRUNAL C. PATEL, M.D. GOVIND B. PATEL. M.D. DfPLO!".1ATEA.l,fERJCAN BOARD OF

INTERNAL MED1CINE AND GASTROENTEROLOGY PRACTICE UMITED TO GASTROENTEROLOGY

PRIMARY INSURANCE INFORMATION

Name of Insurance Company ___________________ _

Group Number _________ Policy#, ___________ _

SUBSCRIBER INFORMATION

Name ______________ _

Address __________________ Telephone. _____ _

Policyholder Date of Birth ______________ _

Policyholder Social Security 1# _____________ _

Policyholder Employer _______________ _

SECONDARY INSURANCE INFORMATION

Name of Insurance CompOlny' ____________________ _

Group Number _________ Policy#' ___________ _

Policyholder Name _______________________ _

Policyholder Date of Birth _______________ _

Policyholder Social Securitv# ______________ _

Employer Name __________________ _

ASSIGNMENT OF BENEFITS- REl£ASE OF MEDICAL INFORMATION

I ~lJest that pDyment olmy InslJlTlnc~ Ben~jits to be mad~ on my b~haJlto PERMIAN GASTROENTEROLOGY; P.A., for any services furnish~ me by PERMIAN GASTROENTEROLOGY, P.A.

"'5' P.0 071018

Signed _______________ Date __________ _

I outhorlu the release oj medical injormation jar the purpose 0/ processing my medical dalm. I understand that I am financially responsible jor any balonce not covered by my Insurance Carrier.

Signed _________________ Dare' ___________ _

4214 ANDREWS HWY. STE. 20) MIDLAND, TEXAS 79703 TELEPHONE, (432) 697·1000 FAX, (432) 697·6000

I-'rom:DI"I GOVIND PA TI::.L 432 697 6000 07/25/20,8 13:,2

PERMIAN GASTROENTEROLOGY, P.A. MRUNAL C. PATEL, M.D. GOVIND B. PATEL, M.D.

DIPLOMATE AMERICAN BOARD OF INTERNAl MEOICfNE AND GASTROENTEROLOGY

PRAcnCF. LIMITED TO GASTROENTEROLOGY

Name: _____________ Date of Birth __________ _

OccupaUon : ________ _____________ _ _ ___ _

Orug~~~ ___________________________________________ __

Ust of aU mediaUons you take Indudini prescription & over-the'-Ounter medicines...

Medication Name & St~ngth How Many? How Often ? How lana have you taken tt?

Check any of these fUnesses you have ever had:

____ ,HJah 8100d P,..,ure Anemia -- _____ TlIvroNl Pn>bIenu

____ ,HoanAttad< ______ 81eedIre Tend."", _ ____ Breast Problems

___ Heart Disease ____ ,8Jood Transfusion _____ ,Mental Probtems

___ "18k Cholmorol ____ Pneumonia _____ Seizures

___ RheUmltit fever Tuberculosis _____ ,AnhrIWGoutt

____ ,Diabetes Emphysema _______ Psoriasis

_ ___ ,Strek" Diverticulosis _____ VenereaI OiseHe

___ Canc:er Hepatitis _______ HIV/AIDS

list be10w and OPERAnONS You have had YEAR

Your last COLON05COPY __________ ____ _

Your last FlEXI8lESIGMOJOOSCOPV :-====-=====-:=:-:-_ HAVE YOU SEEN ANY OTHER GASTROENTEROLOGIS'T IN THE AREA ,, _ ___ _

" ' S I 1",007/0 18

'214 ANDREWS HWY. STE. 203 MIDLAND, TEXAS 79703 TELEPHONE: (432) 697·1000 FAX: (432) 697·6000

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00"", __ ", ... ?' _______ ~jJ1UttI?------------

00"", __ 1>0\-" _____ Howmucl!? ___________ _

. . a""' ...... 4dng __ lid"", quiI? ________________ _

_ much did "'" _ prior 10 quIIing? __ ~ ______________ _

00 you .... any .teoo productt? YES NO

______ tJdillgl .. --u'clgeclgo~perdayb ,...

H "'" qui. _ lid ~.., (A kI_ for_ prior 10 qui

Hmo you ___ ~dnIga? YES NO

Have you evw tad • btIod trInIfuIIon? YES NO

Oo"",_...,_? YES NO

Ate any _ "'yow boctt pioIood? YES NO

Ateyou -.aIIy_? YES NO

FAlllLY HISTORY -a...,,01"-thlt. __ ,._

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_Cancer -. __ lItndol.........?' ___________ ------.:.-__

_ Mr ___ -pIoaespoc:ly, ________________ _

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Age 01 00aIh Couoo 0I1looIh ~r _______________________ ___

~,---~-----------~r ___________ _

9R.r' ______________ ~-

~,-------------~L _________ ~ ___ _

~L ___________ ~--

~L_~ ______ ~~ __ ~L ___________ _

No,., 1h/O,.. _Il0l tee«d./ """ _, h/ofw)' oM n "'" 11<".", In fII/o __ _ IMtwIn rrIU not'" ~ to any pIKSOtJ ex~""'" )'OU Mw.uthodzMJ It

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432 697 6000 07/25/2018 13:13

0 - GOVINO PATEL From: ... • .;".,:.r

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00 "'" _ """ .. ", ... 7 ______ --'- ~J>IIdI7------~-----00""'--.... _7 _____ --7 ___________ _ H"", IP'.'.oIci'll""""" _cild"", \PI? ___ '--___________ _

_ rnuchcld"",_p<Iorto~ __ ~ ______ __,__-------_

YES NO

_____ -" •• Vlli''' .... a ..... ' \lIgocigo NIpIpo/I:Nw per dtlyfor ,...

I"", qui, _ .., ""', qui? (AI'" _ ""_ prior to ....

Ha .. "'" __ .... dNgo7 YES NO

.... ""'_ ... __ 7 YES NO

00 "'" _.",, __ ~ YES NO

Ive."" _ tI,... body pionIOd'I YES NO

,.."", ....,-, YES NO

FAllLY IISTORY. Chod<."", __ • - _ ... --HlQlt-- __ HaaltT_ _81

_Concor . lyaa, whoIldnd"' _______ --__ -------

_~~.m. ... -~~r---~-----------

.Dr pd

~r ____________ _

~r_~ __________ ~ __ ---~r ___________ _

QW~.----~------~ ~L ____________________ _

~L _______ ~ ___ _

~L __________ ~--

~L_~ ______ ~ __ _ ~L ___________ __

Nolo: 1bJs". _tot:«d of your_ -,II1II, ""be"",,'" 11* _ ... _ ....... hereln will not be,.,.Nd 10 any peI80Tf UCI1Pt .."." you hive ~ It

F ~om:OR GO VIN D P ATEL 432 sa? 6000 0 7 / 25 / 20 1 8 13:1 3 H161 P .01S / 0 l 8

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INI'ORMA nON ABOUT YOV MAYBE IJSEIl AND DISCLOSED AND HOW YOV CAN GI!T ACCIISS TO THIS INFORMAnoN. PLEASBlEVIEW IT

CAllEl'ULLY.

This Notice of Privacy Prxticcs dc«ribe.s bow we 'ny cst aDd dilclose your prottd.td beallb informatioo (PHI) to carry 00( treatment, p&ymcAl or heaJ1b care openriom qro) ud for 0Iher purpose.$ !hal ~ permiUed or required by Jaw. II Wo describes y(Nt ripu to ICCCII and control your protected beIJth information. "P,.OklI;ted heahli iQ!ormation" is informatiorl about you, iDcludina; dc:mogrIphic iafomwio., that may identify you and that rdatcl 10 y_ past, prescot or future ph)'lica1 or mental heahb or CODditioo and related beaJdi cue 1Wn'ica.

I. U!g,M PlKfterruolProkd.e!lH .... Wtsw'iep

Utu ud ~otProtededB.ada W ..... tfm . Y OlD'" ~ bcafdI iafcnutiaD. tI:Iry he aed aDd diIclosed by your pbyricie. our office staff azw:I oCben outride of 011

office that are involved in )'OlD" ~ alId ~ for the ptIfpOSC of proYidill, beakb c:a:re senic:a to you, 10 pay yow bealch care bills, to support the openIioa 01 the pbyPcWl', pnCuoc, and any ocher use required by law .

Irai'Pralj We will use and dUc.loce your protccttd he&lth infonnation 10 provide, coon:Jinlte, or manqe your heIl!b alie and &IIy related servK:u. This iDCludeJ the c:oordiAatioD or .ma.nq:eme:nl of your bealth care,ntb I third party. For example, we woWd disclose your Pf'*dId bcaJth iaformatioa. u ~. to a houIe bcahh acwcy that provides can to )'00. For cnmple, your protecttJd heahh iaformatioo may be provided 10 • pbysjeillll to ...bom )'Ot.1 MW: bee!! refe.rred

. to usure dill the pbysiciaD has the oeoeaary iaform.moD to diapote « ttea1 you.

J!aymcmti Your protocted health iIlfurmation will be UJed, u needed. to obtain p&ymcnt far your health care services. For example, obtainin( app1)vaJ (or • hoqlital stay may n:quUe cha! your rtJevant protected health illformatioo be disckned 10 the beaJlh pluto obtaita approval for the bospitaJ ..:fmissioo.

BWtIaCll! Opeptiw; We may use 01 diJclose, u-Deeded, your protteted hc.ahh informarion in ardcc 10 support the bwiDcu activities o( your physician's prac:tia:. 1be.te activities inc:Nde. but are Dot limited 10. quality as.x.ssmtllt

acti.vitiu, employee review activities. training of mcdlcaI students, licuasing, and conductiDg Of ~ for other business activities: For ~~ ml¥ disclose yew prct:ceted-bcahb irUmmad"oli 10 mtdlCiJ iC600J iiiidt.Iils that lee

J*ieatl at our office. l:n Mlditioo.. we may usc. up.iD a:hecc .1 the rep:tm:ion desk 9rbere you will be asb:d 10 sip your name and iocticatc your physician. We may a1so call you by name irI the waitm, room when yOW" phys1c:Wi is ready to see you. We may usc or disclose )'OUt protec:Ied be.alth information, as ncc:e.ssary. to contact you to remind yOtJ of yOtlJ appointment

We may use or disclose your protected health information in the following siblatioos without your authorization. These situations include: as Required By Law, Public Health issues as reqtrired by law, 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: Milirary 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 detennine 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 reToM IbM: •• u.oriIatieD. at In)' timI:.. in wriliolo ucepI: to !be uleDI: that your pbysicillJl or lilt physiciaD's practice has takca MICtion in reliance on the tee or discktt~ indicated iIIlbc uchcrit.atioa.

YwrlUdats FolJowina is • stalemeltt of yow ri&tN; with respect to yoUr proIectod hcahh iafonnarion.

Yoa ban U.ericbtlolgupectyd"copy J91tprpSttttd_Ub ............. Undu fcdenll.w, howeWI', )'OUmayDCt inspecl or copy 1M roDowina rcc:ords; pI)'Cboct .... * notes; inI'mDItion compiled ill reuoaabk en';' i,.-;o. or, or IJIC. ia., • civil, crinDJW, or ~ ICtioo GI' JlI""""'O"na. and proCecIed beatth informa6on .... is iUbject 10 Jew _ prcbibils xcess 10 prok:C1r:d taIda infcrDllllioa.

9 l 0/ 9~Od ~ <;; ~ ..

In un 1M dIN" DQIIIl. 'Rtdiw "JIll'''''''''''' "7. """'-tiD. This IhemI you ay m us ~ 10 usC or dia:1osc.,. JNI1 of"fCM potcat:d lal1h b:IfotmMioII fur !he JMPCIIItS of ~ pI)'tI'ht or laJdarc operaI:ions,. You m.y aho requeat1bM lIlY part ofJOlf piACASd iahh iafoo ...... DOl be discJoted 10 ,""" DItnIber, or frieDds who r¥1 be iIrroI'fCd iI your '*' or for acttfic:atioa pwpoIOI. dCIcribcd iIIlhiI Notice of Princy PncOcca. Yom- mquest JDQIl scale the specifk ratrittion n:queAtId and 10 wbom you MDI the racricUoo to epplj.

Your physkiaD ia not required to ~ to • R.IlrictioB hi )'OIl may recpst 1f pbysiciIn believes it is i.a yow t.es. iDW'at 10 pemUl use and discklwte 01 )'OW ~ health iafcnnalioo. your proICClt.d beaJdl, informiltiOll .nJ ROt be rearicud· Yau !he. have die rip ~ IDe aDOthu HeaItbcwe Pinfe.i...a, .

5 rOw. by .... 5 7 ••• 1ft 11m .. 'dDt· I ,,,....,m r1' N ell .... k r= X."", .. "., ..... 7 em .eM ......... ~ ewa ifyoo hnc

YOI .., I)m Ate .... 'II IIm!W .'.'" 'JIM ...... t tt."",... H we dca)' your Rquest far ~ you hI'tt !be riJblto file •• ":merM of cfUlcJeemeM widl us ...t we may prepa ;; rebu~ to )'OIIJ ICMcmcDt and wiD provide you with • copy or ." M:h rebuaaI. • ..

We reserve !he ri&hl \0 cban&e the tams of tM ~ aDd will iAfmn)'Oll by nil of any dlenp. You then have the "PIt 10 object or withdraw as provided ill this DOtict.

CSIQrW ",

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights bave been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We wiD not ."tallals .Q!oj;l I9II for filing. complaint,

This GOIice wu publUhtd 'and becomes effective onIor before April14.ltt3,

We are required by law to maintain the privacy of, and provide individuals \lith, this notice of oue lega) duties and privacy pBCtkes with reapect (0 protected health information. If you bave any objecriODll0 this form, please ask to speak .... ilh our HIPAA CompJim:e OffICer in person or by phone at oUr Main PhoM Number,

Sigoa~uTe below is only acknowledgement that you h.ve received Ibis Notice of our Privacy Practices:

Print Name: __ .:;.... ____ ---''-.;gnatu .. ~ ______ 1)a .. '_ _ _'_ __

0009 Leg z:cv

07/25/2018 1 3:1 4

From:OR GOVIND PATEL

Yoa -1 ~ tWa ... __ at aD)' time. ia .. ririq. UCtpt to the eJ:teDI that your pb)'Aciu or !be pbya;aciu'l practice bas taktD III ICtion ia ntiaDoe on tbc lee or disclO5U"t iodicaled il.1hc aIIIhori%atioa.

YM run 1M .... II' , .... ,.,. ....... , tan Hp=p'Fy UDdcr1tdc:rallaw, howcwa,)'IXI1M)' lief

iDspcct or c:cpy Ibe foBcnrnDa: I'CICUdl; ~"" Dok:s; ibbiDiiIIIiuD compiled ill re. __ 1Ik _ntiripMio'M 01, or IDe ill, • civil. crimiatl. or .... j·.ttiw: a:doa c.. PI"> ........ i .. tad pClCaided IatItJ iDfuaiiMititM tMI is .... &0 1Iw dItI: probibils IiIXUs k) pr'*dcld __ iafCUDlQoo. .

Xtt ""At ricId .. ,... ........ ",......." tn. M , .... ThiI .... )'OG.,._ US.IO

we or d:isdoIe By ptrt of,.,.. JII1*II*I4....ad1 iIIri~ b tt. JIG'PC*S ~btlb;Ldlt. ~ or ....... e opa.oo.. Y OD .y ., R!IpIIIbII ""1*' 01 ~ JIft*IC*ed ~ iaIa...ao. DOl be divbod 10 .fIaiJy IIIaIlbcn or tiiCoda wbo..y be iIntohed is)'Om tire or b IOfitio II. ~. deIcribod iD 1bisNc6c:e ofPriwcy Pnt:b::a:. Yow 11:Cf'ICIl-swe the IpCdIic ~ req ,.1 d laid 10 ..... ,... waaI die I'CIIIric:tioa to ippIj.

Your phydc:ia illIOt reqaired 10 acn:e 10 •• CICIiccial" you IDIIQ' ~ Upbylic:iaft1ldit_ it is.)'OUr bell iDtt.rat to pucit .. aDd dilck:cn 0I)'CIUJ ......... IaICJl' ~:roar pr«*dod ~ infOlUlitioa ~ .,. be iutlkMd. You Ibea haw Ik riP. 10 _.,., ~ Ptc' 1_

~ ~t ~~ ~ ~.. . d:!!- 7 fl1!z kr * ... • or •• rx!:CA:4;,1, g:;;., "g:ar: • .. ...::.1IWIl if1C* line

Y-MJIJm*""' • ..,.,...'." ',..*W' n* 'Ife If ... '".. .... for """"""'t. you ~ die ri&k to file. ,7 .t 01 £=p-a willi • lid we ny JIRIIWe • rcbuIlallO ~ aNc:mMt ad wiD provide,.. 'IriIb. cop)' 01.., ... rebuIW. 7 ,·

Yo! len tit! ricltl "rw:ms • ..",rtIr "".' 'M "11m nt' '1Il'."J!K.'" 'cd", iPferndse .

We raer¥e tbc riJhC ID ~ die: ICfa of thb DOtice aDd will Worm you by IIIIil of uy c:banaa. You dIUI hive the nlht 10 object or withdraw II prol'i6cd ia dais DOdcc.

eve .... You may COmplain 70 US or 70 ibe SeaeIary of HcaJib and Human ~ if you believe your privacy righTS bave been violated by us. You may file a complaint wiib us by notifying our privacy conTacT of your complaint. We wlI! oot re!all'!e aQlnft 1011 for nunc a complA.nt.

This D«ice was publWlcd'anc! becomes etrcctive onItI bc(cnAtdll1.2tI3.

We are required by law 10 maintain the privacy of, and provide individual, with, this notice of our Jcpl dutie! and privacy pnctices: with respect to protcc:ted health infonutian, H)'OII have any objcctjOOs to this form. please uk 10 speak with our HIPAA CompJiance OffK:U in person or by phone II our Main Phone Number.

SilDl,ure below is Oflly acbowledgemenl thai you have n:ceived 1m, Notice of our Privecy Practices:

Print Name: __ ...::.. _____ --'-- Sjgnature'-_______ T)atc'--_-' __ _