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Dear New Patient:
Welcome to our office! We are looking forward to meeting you at your scheduled appointment. Enclosed, you will
find forms related to your medical history, please complete the forms in advance and bring them with you to your
initial visit. In addition, please arrive 30 minutes prior to your appointment time, this will allow us to complete your
check-in promptly and enable you to see the doctor at your scheduled time.
Please also be sure to bring the following items with you:
• List or prescription bottles of all current medications
• Insurance and Prescription card(s)
• Current driver’s license or non-driver’s ID
• Referral form (if required by carrier)
• Prescription cards
• Method of payment (cash, check, AMEX, MC, VISA or Discover)
Please note the following information:
• We have a 24 hr. cancellation policy. Canceling an appointment with less than 24 hrs. notice may result
in a charge of $50.00.
• You will receive a reminder notification via email, text, or phone call two to four days prior to your
scheduled appointment.
If you have any questions prior to your visit, please feel free to contact us. We look forward to a meaningful
patient-physician-staff relationship.
Sincerely,
Arthritis & Rheumatism Associates, P.C.
Patient Name ______________________________________________________ Date _______________
Thank you for choosing Arthritis & Rheumatism Associates to assist you with your care. Please check the
primary source of how you heard about our practice to make the decision to visit:
_______My Primary Care Physician referred me (Name)_________________________________________
_______ Specialty physician referred me (Name) ______________________________________________
_______A friend or family told me about practice (Word of Mouth)
_______I was a former patient of practice
______Internet (Select One)
Google Search
Grading Sites'''''
'''''
Yelp
Online YPages'
Angie’s List
Facebook/Twitter'
______Advertisements (Select One)'
School PTA Directory
Washingtonian
Bethesda Magazine
Your Health Magazine'
Newspaper (Which) ________________________________________________________'
_______TV''''''
USA'9'''''''' ABC'7'''' Channel'8'News'''''''
Cable'
_______Radio
_______Community Event (Which)__________________________________________________________
Did you use the internet to research the practice prior to making a decision to schedule an
appointment?
________Yes _______No
Did your research influence your decision?
_________Yes _______No
5HYLVHG-201
Page 1 of 2
2730 University Blvd. West, Ste 310, Wheaton, MD 20902
14995 Shady Grove Road, Ste 250, Rockville, MD 20850
5454 Wisconsin Avenue, Ste 600, Chevy Chase, M
D 20815
18111
Pr
i
n
ce Philip Drive, Ste 323, Olney, MD 20832
71 Thomas Johnson Drive, Frederick MD 21702
2021 K Street, NW, Ste 300, Washington, D.C. 20006
8270 Willow Oaks Corporate Drive, Ste 150, Fairfax, VA 22031
Patient Registration
Call Center: 301-942-7600
PATIENT NAME LAST FIRST M
DATE OF BIRTH
BIRTH SEX
M F
HOME ADDRESS APT NO.
CITY
STATE
EMAIL ADDRESS:
HOME PHONE
CELL PHONE
PATIENT STATUS: SINGLE MARRIED OTHER :
PREFERRED PRONOUNS
HE, HIM, HIS
SHE, HER, HERS
THEY, THEM, THEIRS
ZE, HIR
DECLINED
OTHER
GENDER IDENTITY
M
F
MALE-TO-FEMALE
FEMALE-TO-MALE
GENDERQUEER
DECLINED
OTHER
SEXUAL ORIENTATION
HETEROSEXUAL/STRAIGHT
BISEXUAL
HOMOSEXUAL/LESBIAN/GAY
DECLINED
OTHER
RACE
ETHNICITY:
HISPANIC/LATINO
PREFFERED LANGUAGE
NON-HISPANIC/LATINO
FINANCIALLY RESPONSIBLE PARTY
PATIENT SPOUSE PARENT OTHER:
RESPONSIBLE PARTY’S NAME
CELL PHONE
RESPONSIBLE PARTY’S ADDRESS
HOME PHONE
DO YOU HAVE AN “ADVANCE MEDICALDIRECTIVE”?
MAY WE KEEP A COPYON FILE?
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Name
First Middle Last
Address
Relationship
Home Phone
Work Phone
PRIMARY INSURANCE COMPANY
POLICY/ID NO.
GRP. NO/SERV. CODE
PRIMARY INSURANCE COMPANY ADDRESS
Phone
Street Suite # City State Zip
Name of Policyholder Male Female Relationship
POLICYHOLDER’S DATE OF BIRTH
POLICYHOLDER’S ADDRESS
SECONDARY INSURANCE COMPANY
POLICY/ID NO.
GRP. NO/SERV. CODE
SECONDARY INSURANCE COMPANY ADDRESS
Phone
Street Suite # City State Zip
Name of Policyholder Male Female Relationship
POLICYHOLDER’S DATE OF BIRTH
POLICYHOLDER’S ADDRESS
IS THIS CONDITION RELATED TO: EMPLOYMENT AUTO OTHER ACCIDENT
ARA does not treat conditions related to Employment, Auto or Other Accident. Please contact the office at 301-942-7600.
For practice use only: MRN: DOS:
Page 2 of 2
PLEASE READ AND SIGN
Medicare Patients Only
“I request that payment of authorized Medicare benefits be made on my behalf to Arthritis & Rheumatism Associates,
P.C. for any services furnished to me by that physician or supplier. I authorize any holder of medical information
about me to release to the Health Care Financing Administration and its agents any information needed to determine
these benefits or the benefits payable for related services.”
Signature of policyholder or beneficiary Date
Other Insurance
I hereby authorize Arthritis & Rheumatism Associates, P.C. to apply for benefits on my behalf for covered
services rendered by Arthritis & Rheumatism Associates, P.C. and request that payments from
insurance company for covered services be made directly to Arthritis &
Rheumatism Associates, P.C. at their payment address.
Furthermore, I agree to designate Arthritis & Rheumatism Associates, P.C. to receive payment directly
from the above-named insurance company in the event I file a claim for benefits myself and to forward
within 15 business days any payments I may receive from the above-named insurance company for any
services rendered by Arthritis & Rheumatism Associates, P.C.
Signature of policy holder or beneficiary Date
I certify that the information I have reported with regard to my insurance coverage and benefits is correct
and further authorize the release of any necessary information, including protected health information, for
this or any related claim to any billing agent acting on behalf of Arthritis & Rheumatism Associates, P.C. I
permit a copy of this authorization to be used in place of the original and I understand that this
authorization may be revoked by me at any time by submitting a written revocation.
Signature of policy holder or beneficiary Date
Medigap Patients Only
“I request that payment of authorized Medigap benefits be made on my behalf to Arthritis & Rheumatism
Associates, P.C. for any services furnished to me by that provider of services or supplier. I authorize any
holder of Medicare information about me be released to
any information deeded to determine these benefits payable for related services.” (NAME OF MEDIGAP
INSURER)
Signature of policyholder or beneficiary Date
Revised 10/2021
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signature
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signature
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signature
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signature
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Patient Name: _
FINANCIAL POLICY STATEMENT
Welcome to Arthritis and Rheumatism Associates, P.C. (ARA). We are pleased to have you as a patient and we
are committed to providing you with the best medical care possible. In order to assist you in receiving the
maximum benefits allowable by your insurance, we ask that you read and sign this statement. We must
emphasize that as medical care providers, our relationship is with you and not your insurance carrier. As a
courtesy to you, we may file your claim; however you are responsible for charges incurred from the date services
are provided unless our contractual agreement with your carrier states otherwise. Because of the ongoing growth
and change in available health care plans, it is imperative that you understand your benefits and responsibilities
prior to being seen at ARA.
COST-SHARE
RESPONSIBILITY
Many insurance carriers require patients to share the cost of their medical services through copay, coinsurance,
or deductible.
Health insurance cost-share definitions are as follows:
Copay – a fixed dollar amount that a patient is required to pay per visit.
Coinsurance – a fixed percentage of the final dollar amount that patients are required to pay for a medical
service.
Deductible – a fixed dollar amount that patients are required to pay first before their insurance carrier begins
to pay for their medical service.
Patient cost-sharing is an integral part of the health insurance benefit plan for both federal and commercial
insurance carriers. As a patient, you are expected to understand your healthcare benefits and cost-share
amounts associated with your plan. ARA will make every attempt to collect all patient responsibility payments as
determined by your insurance. Your insurance should provide you with an explanation of benefit (EOB) after a
medical service claim is processed. All copayments are due at the time of service. Coinsurance, deductible, and
any outstanding balance will be billed to you.
MEDICARE PART B
ARA participates with Medicare and accepts assignment. We will file your claim and ask you to pay any deductible
you may owe plus your 20% coinsurance at the time of checkout. If you have a secondary insurance, we will file
the claim for you, and you will be billed for any remaining balance. In order to receive a non-covered supply or
service, you will be required to sign a Medicare waiver (Advance Beneficiary Notice or ABN) and pay in full. ARA
does not participate with any Medicare Advantage Plans, with the exception of Johns Hopkins Medicare
Advantage HMO and PPO. If you have a Medicare Advantage HMO plan, you will not have any out of network
benefits. If you are covered by a Medicare Advantage PPO plan that gives you out of network benefits, you may
have to pay any deductible and coinsurance payments due as determined by each individual Medicare Advantage
Plan.
CareFirst Blue Cross Blue Shield
ARA is a participating provider with CareFirst of the National Capital Area and CareFirst of Maryland. Our contract
with CareFirst includes all products: HMO (BlueChoice), Point of Service, Federal Employee, PPO, Blue Card,
National Account and Indemnity Plans. The HMO plan requires that you obtain a referral to see a specialist which
must be presented at check-in. Otherwise you will need to sign a waiver agreeing to pay for all services rendered.
Patient Name: _
PPO, POS and HMO Plans
Currently, ARA participates with Aetna HMO and PPO, CIGNA, Multiplan, PHCS and Priority Partners. All PPO
and HMO patients are required to pay their copayment at check-in. Those patients whose plan requires a referral
to see a specialist must present it at check-in or sign a waiver agreeing to pay for all services rendered. Those
using a POS benefit will be required to sign a referral waiver and to pay any deductible or coinsurance their plan
requires. ARA will be in violation of our contracts if we fail to collect amounts you are contractually obligated to
pay.
Worker’s Compensation
ARA does not accept new patients with work-related injuries who will be using Worker’s Compensation to cover
the cost of their care. In the event that an established patient’s visit is due to a work-related injury, the patient
must provide this office with complete billing information for the Worker’s Compensation carrier prior to treatment.
We will need: active claim number, carrier name, adjustor’s name, phone number and pre-authorization by the
insurance company for your care. If the case is being contested by an employer, then it will not qualify as a
worker’s compensation case until an independent medical examiner or the court rules. In this circumstance we
will bill the patient’s health insurance carrier. If a patient does not have health insurance, payment will be required
at the time of service.
Liability Cases/Auto Accidents
ARA will not bill the personal injury protection (PIP) portion of your auto insurance coverage. Physicians will treat
patients injured in personal injury or auto accident cases, but the patient’s own health insurance carrier will be
billed for all services rendered. In the event that a patient does not have health insurance (or their health
insurance denies the claim), payment will become the responsibility of the patient.
FMLA and Disability Forms
ARA physicians do not fill out FMLA forms nor do they provide disability assessments or supporting documents for
patients unless they have been seen for at least 6 visits and / or have been a patient of the practice for at least one
year. Even beyond this time frame, your physician may determine that it is more appropriate for your primary care
provider or other specialist to manage your disability application and forms. ARA physicians do not have the
experience or training to prepare disability documents from a legal perspective. If your physician provides disability
documents, the information used will be primarily based on objective information obtained from physical
examination, diagnostic studies, and laboratory findings which may not support a disability claim. You will also be
charged a $25 fee if your physician completes the disability documents. You may be better served if you discuss
with your attorney whether disability documents should be obtained from another specialist who performs disability
evaluations on a regular basis.
All Other Insurance (Including Secondary/Tertiary)
As a courtesy to you, ARA will file your primary insurance claim once, provided that we have complete insurance
information at the time of service. We do not file secondary or tertiary insurance claims unless we are contractually
obligated to do so. Depending on the carrier, you may be asked to pay your balance in full or pay any deductible or
copayment due. Any balances not paid by the patient’s insurance company/companies within 45 days will be
charged directly to the patient.
Self-Pay
ARA offers a self-pay rate to patients who have no health insurance or have non-participating health insurance. The
self-pay amount owed is expected to be paid in full at the time of service as ARA will not be submitting a claim to
an insurance carrier. Self-pay patients are responsible for ancillary service charges such as laboratory, radiology, or
any other services performed by ARA physicians on the date of service.
Non-Sufficient Funds (NSF) Policy
A $50 NSF fee will be added to any patient’s account that is returned by our bank for non-sufficient funds.
ARA Cancellation Policy
We request that cancellations or scheduling changes be made at least 24 hours in advance of your appointment.
We reserve an appointment time exclusively for you. Without proper notification we cannot reassign your time slot
to care for someone else. ARA has a missed appointment fee of $50.
Assistance
Our Business Office staff is available to assist you with any special concerns or questions. Please feel free to call
(301) 942-3126 for personal attention.
Responsibility
Failure to disclose a change in insurance coverage or failure to disclose another (primary, secondary, or tertiary)
insurance coverage will not absolve the patient of responsibility for all charges, and may also be grounds for
dismissal from the practice.
Patients are responsible for any outstanding balances. In the event a patient’s account is turned over (for
collections) or (to a third party), the patient will be responsible for any and all collection costs, interest, Attorney’s
fees and Court costs.
I have read, understand and agree to abide by the policies of ARA as stated in this document.
_ _
Signature
Date
_ _
Print Name
Revised September 2021
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Page 1 of 6
Date of first appointment:_____/_____/_____
Age: __________
Birthplace: _____________________
mm dd yyyy
Name: _____________________________________________________________________ Birthdate: _____/_____/_____
LAST FIRST MIDDLE MAIDEN mm dd yyyy
Birth Sex: F M
Referred by: (check one) ____Self ____Family ____Friend ____Physician ____Other Health Professional
Name of Person Making Referral: _________________________________________________________________________
Name of Primary Care Physician:__________________________________________________________________________
PRESENT PROBLEM DIAGNOSIS: __________________________________
Problem onset___________________________________________________________________________________________
Present symptoms _______________________________________________________________________________________
Severity 1-10 _________________
Location _______________________________________________________________________________________________
Pain quality_____________________________________________________________________________________________
Aggravated by __________________________________________________________________________________________
Relieved by ____________________________________________________________________________________________
Please shade all the locations of your pain over the past week on the body figures
Drug allergies: No Yes To what? __________________________________________________________
______________________________________________________________________________________________
Type of reaction: ________________________________________________________________________________
Patient History Form
For practice use only: MRN: _______________ DOS: _____________
Page 2
PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements)
Name of Drug
Dose
Number of
pills and
how often?
How long have
you taken this
medication?
Please check: Helped?
A Lot Some Not at all
1.
!
!
!
2.
!
!
!
3.
!
!
!
4.
!
!
!
5.
!
!
!
6.
!
!
!
7.
!
!
!
8.
!
!
!
9.
!
!
!
10.
!
!
!
PAST MEDICAL
HISTORY
Do you now or ever had: (check if “yes”)
!
Cancer
type
! Goiter
! Depression/Anxiety
! Nervous Breakdown
! High Blood Pressure
! Stroke
! Asthma
! Leukemia
! Rheumatic Fever
! Bleeding Tendency
! Alcoholism
! Epilepsy
SURGERIES:
!
Total knee replacement
! Total hip replacement
! Back Surgery
! Hysterectomy
! Prostate
!
Other
! Heart attack
! Angina
! Heart Failure
! Diabetes
! Stomach Ulcers
! Liver Problems
! Kidney Problems
! Osteoarthritis
! Gout
! Childhood Arthritis
! Psoriatic Arthritis
! Osteoporosis
! Thyroid Problems
! Lung Problems type
! Anemia
! Cholesterol
! HIV/AIDS
! Glaucoma
! Hepatitis
! Ankylosing Spondylitis
! Scleroderma
! Lupus or “SLE”
! Rheumatoid Arthritis
! Arthritis (unknown type)
! Colitis
! Psoriasis
! Tuberculosis
! Other significant
illnesses (please list)
Family History:
IF LIVING IF DECEASED
Age Health Age at death Cause
Father
Mother
Number
of
siblings
Number
living
Number
deceased
Sisters
Brothers
Number
of
children_ Number
living Number
deceased
List
ages
of
each
Daughters
Sons
Adopted
Page 3
At any time has a blood relative had any of the following? (give relationship)
Relative
Relationship
Relative
Relationship
Arthritis (unknown type)
Cancer
Osteoarthritis
Leukemia
Gout
Stroke
Childhood arthritis
Colitis
Lupus or “SLE”
Heart Disease
Rheumatoid Arthritis
High Blood Pressure
Ankylosing Spondylitis
Bleeding Tendency
Osteoporosis
Alcoholism
Psoriatic Arthritis
Asthma
Scleroderma
Epilepsy
Rheumatic Fever
Diabetes
Goiter
Other arthritis conditions:
SOCIAL HISTORY
Primary language spoken:
Education: (circle highest level attended)
Hand Dominance: Right Left
Grade School: 7 8 9 10 11 12 College: 1 2 3 4 Graduate School:
Occupation: Number of hours worked/average per week:
Employer: Retired
Date
Military Service: yes No Current status:
MARITAL STATUS: ! Never Married ! Married ! Divorced !Separated ! Widowed
Spouse/Significant Other:
!
Alive/Age
!
Deceased/Age
!
Major Illnesses
Do you smoke?
!
Yes
!
No
!
Past – How long ago?
Packs a day Number of years
Do you drink alcohol?
!
Yes
!
No Number per week
Has anyone ever told you to cut down on your drinking?
Do you drink caffeinated beverages? ! Yes ! No Type of Beverage
Do you use drugs for reasons that are not medical? ! Yes ! No
Cups/Glasses per day?
If yes, please list: _
Activity Level: !Sedentary
!Moderate
!Vigorous
Type of Exercise:
!
Aerobic
!
Golf
!
Jogging
!
Skiing
!
Swimming
!
Walking
!
Yoga
House Pets:
!
Yes
!
No Type:
Recent Travel: Out of State International
DIAGNOSTIC TESTS
MRI Scan CT Scan Biopsy
Date of last mammogram /_ /_ Date of last eye exam /_ /_ Date of last chest x-ray /_ /_
Date of last Tuberculosis test / /_ Date of last bone densitometry / /
Page 4
REVIEW OF
SYSTEMS
As you review the following list, please check any of those problems which have significantly affected you.
Constitutional
! Fatigue ! Fever ! Malaise ! Night sweats
! Recent weight gain ! Recent weight loss (amount)
(amount)
HEENT
! Eye dryness ! Eye pain ! Difficulty swallowing ! Nose bleeds
!
Redness of eyes ! VisualcChanges ! Dry mouth ! Hoarseness
Ears-Nose-Mouth-Throat
! Sores in mouth ! Loss of smell ! Loss of hearing
RESPIRATORY
! Shortness of breath ! Cough ! Coughing up blood ! Wheezing (asthma)
CARDIOVASCULAR
! Difficulty breathing at night ! Chest pain ! Swollen legs or feet ! Irregular heart beat
VASCULAR
! Cool extremity ! Ulcer ! Raynaud’s ! Thrombosis phlebitis
GASTROINTESTINAL
! Abdominal pain
! Jaundice
! Diarrhea
! Heartburn
! Vomiting
! Increasing constipation
! Nausea
GENITOURINARY
! Blood in stools
! Changes in stools
! Difficulty urinating ! Blood in urine ! Increased urinary frequency ! Urinary incontinence
REPRODUCTIVE
Female
! Vaginal discharge ! Breast discharge ! Vaginal dryness ! Sexual dysfunctions
! Irregular menses
Male
!
Penile discharge ! Sexual dysfunctions
ENDOCRINE
! Excessive thirst (Polydipsia) ! Abnormal sleep ! Goiter ! Tremors
! Hair changes
NEUROLOGICAL SYSTEM
! Gait disturbance ! Headaches ! Dizziness ! Memory loss
! Extremity numbness ! Seizures ! Vertigo
PSYCHIATRIC
! Depression ! Anxiety ! Insomnia
INTERGUMENTARY SKIN
! Sun sensitive (sun allergy) ! Hair loss ! Rash ! Hives
! Skin thickening
MUSCULOSKELETAL
! Back pain ! Joint pain ! Morning stiffness ! Joint swelling
! Muscle weakness ! Neck pain ! Muscle tenderness
Lasting how long: Minutes Hours
HEMATOLOGIC/LYMPHATIC
! Easy bruising ! Easy Bleeding ! Swollen Glands ! Anemia
ALLERGIC/IMMUNOLOGIC
! Asthma ! Seasonal allergies ! Food allergies ! Environmental allergies
Page 5
PAST MEDICATIONS
Name of Drug
Non-Steroidal/Anti-Inflammatory Drugs (NSAIDs)
Length of time
Please check: Helped?
A Lot Some Not at all
Reactions
Ansaid (flurbiprofen)
! ! !
Arthrotec (diclofenac + misoprostil)
! ! !
Aspirin (including coated aspirin)
! ! !
Celebrex (celecoxib)
! ! !
Clinoril (sulindac)
! ! !
Daypro (oxaprozin)
! ! !
Disalcid (salsalate)
! ! !
Dolobid (diflunisal)
! ! !
Feldene (piroxicam)
! ! !
Non-Steroidal/Anti-Inflammatory Drugs (NSAIDs)
Length of time
Please check: Helped?
A Lot Some Not at all
Reactions
Indocin (indomethacin)
! ! !
Lodine (etodolac)
! ! !
Meclomen (meclofenamate)
! ! !
Motrin/Rufen (ibuprofen)
! ! !
Nalfon (fenoprofen)
! ! !
Naprosyn (naproxen)
! ! !
Oruvail (ketoprofen)
! ! !
Tolectin (tolmetin)
! ! !
Trilisate (choline magnesium trisalicylate)
! ! !
Vioxx (rofecoxib)
! ! !
Voltaren (diclofenac)
! ! !
Other:
! ! !
Other:
! ! !
Other:
! ! !
Pain Relievers
Length of time
Please check: Helped?
A Lot Some Not at all
Reactions
Acetaminophen (Tylenol)
! ! !
Oxycodone, Percocet, Oxycontin
! ! !
Propoxyphene (Darvon/Darvocet)
! ! !
Other:
! ! !
Other:
! ! !
Disease Modifying Antirheumatic Drugs (DMARDS)
Length of time
Please check: Helped?
A Lot Some Not at all
Reactions
Gold Salts/pills (Myochrysine or Solganol)
! ! !
Hydroxychloroquine (Plaquinil)
! ! !
Penicillamine (Cuprimine or Depen)
! ! !
Methotrexate (Rheumatrex)
! ! !
Azathioprine (Imuran)
! ! !
Page 6
Sulfasalazine (Azulfidine)
! ! !
Cyclophosphamide (Cytoxan)
! ! !
Cyclosporine A (Sandimmune, Neoral or Gengraf)
! ! !
Etanercept (Enbrel)
! ! !
Infliximab (Remicade)
! ! !
Adalimumab (Humira)
! ! !
Rituximab (Rituxan)
! ! !
Abatacept (Orencia)
! ! !
Leflunimde (Arava)
! ! !
Other:
! ! !
Osteoporosis Medications
Length of time
Please check: Helped?
A Lot Some Not at all
Reactions
Estrogen (Premarin, etc.)
! ! !
Alendronate (Fosamax)
! ! !
Etidronate (Didronel)
! ! !
Raloxifene (Evista)
! ! !
Flouride
! ! !
Calcitronin injection or nasal (Miacalcin, Calcimar)
! ! !
Residronate (Actonel)
! ! !
Boniva
! ! !
Other:
! ! !
Gout Medications
Length of time
Please check: Helped?
A Lot Some Not at all
Reactions
Probenecid (Benemid)
! ! !
Colchicine
! ! !
Allopurinol (Zyloprim/Lopurin)
! ! !
Other:
! ! !
Other:
! ! !
Other Medications
Length of time
Please check: Helped?
A Lot Some Not at all
Reactions
Tamoxifen (Nolvadex)
! ! !
Tiludronate (Skelid)
! ! !
Cortisone/Prednisone
! ! !
Hyalgan/Synvisc injections
! ! !
Herbal or Nutritional Supplements
! ! !
Please list supplements:
Have you participated in any clinical trials for new medications? ! Yes ! No If yes, list:
Revised 1/2019
Patient Name: ________________________________________________ Date of Birth: ______ / ______ / ____________
Address: _____________________________________________________ City: __________________________________
State: ____________________ Zip Code: ____________________ Phone #: _____________________________________
I authorize Arthritis & Rheumatism Associates, P.C.
(ARAPC) to use/disclose the following information to:
Myself See additional designee(s) attached
___________________________________________
Name of Provider / Facility / Person(s)
___________________________________________
Address
___________________________________________
City / State / Zip Code
(_____) - _____ - ______ (_____) - _____ - _______
Phone Number Fax Number
I authorize Arthritis & Rheumatism Associates, P.C.
(ARAPC) to receive the following information from:
___________________________________________
Name of Provider / Facility / Person(s)
___________________________________________
Address
___________________________________________
City / State / Zip Code
(_____) - _____ - ______ (_____) - _____ - _______
Phone Number Fax Number
PURPOSE(S) FOR THIS REQUEST:
Referred to Outside Provider Changing Physicians Physician’s Request Personal Use
Insurance Purposes Legal Purposes Moving Employer’s Request
Other: __________________________________________________________________________________________
____ I understand that the person(s) (or practice) I am authorizing to use/disclose my protected health information may
charge a third party for doing so.
____ I understand that I may refuse to sign this authorization and that if I do, it will not affect my ability to obtain treatment,
payment, or eligibility for benefits and that I may inspect or copy any information used or disclosed under this
authorization. If I refuse to sign this form, the practice cannot use or disclose my protected health information for
purposes outside TPO. (Treatment, Payment, and healthcare Operations)
____ I understand that if the party receiving this information is not a healthcare provider or health plan subject to the federal
privacy regulations that the information described above may be re-disclosed and no longer protected by the privacy
regulations.
____ I understand that I may revoke this authorization in writing at any time except to the extent that the practice has acted
in reliance upon this authorization. My written revocation must be submitted to the Privacy Official at 2730 University
Boulevard West, Suite 310, Wheaton, MD 20902.
By signing this authorization it becomes effective immediately and will expire once the request has been completed. Every new request
thereafter will require a new authorization form to be completed, per our practice policy.
__________________________________________ ____________________________________
Signature of Patient or Personal Representative Date
__________________________________________ ____________________________________
Print Patient Name or Personal Representative Name Relationship to Patient
RECORDS TO BE RELEASED:
ARAPC Records ONLY Include Records from Outside Providers
Progress Notes: Most Recent From ________________ to ________________ All
Labs: Most Recent From ________________ to ________________ All
Radiology: Most Recent From ________________ to ________________ All
DEXA: Most Recent From ________________ to ________________ All
EMG: Most Recent From ________________ to ________________ All
Physical Therapy: Most Recent From ________________ to ________________ All
Other: _____________________________________________________________________________________________
Initials
Initials
Initials
Initials
MEDICAL RECORD
S RELEASE FORM
Revised 5/2021
2730 University Blvd. West, Ste 310, Wheaton, MD 20902 14995
Shady Grove Road, Ste 250, Rockville, MD 20850
5454 Wisconsin Avenue, Ste 600, Chevy Chase, MD 20815
18111 Prince Philip Drive, Ste 323, Olney, MD 20832
71 Thomas Johnson Drive, Frederick MD 21702
2021 K Street, NW, Ste 300, Washington, D.C. 20006
8270 Willow Oaks Corporate Drive, Ste 150, Fairfax, VA 22031
In the event you may have had lab work performed today and your lab work is normal, you will not hear
from our office--- your physician will discuss the results with you at the time of next office visit. We will
call you for any abnormal laboratory tests that require immediate attention; otherwise they will be
discussed at your next visit unless your physician has specifically asked you to call for results.
Remember, we will call you if any of your lab work requires immediate attention; otherwise, your results
will be discussed at your next visit. You can access your reports through the patient portal.
Revised 1/2019
HOW WE HANDLE LABATORY TEST RESULTS
How We Handle Prescription Refills
• If you have a prescription that needs to be refilled, please bring it to the attention of the medical assistant
or your physician at the time of your visit.
• ARA uses e-prescribing to deliver all prescription orders to your pharmacy. E-prescribing is a seamless
process that is accomplished through a few clicks in our electronic medical records system. It is strongly
encouraged by the Centers for Medicare and Medicaid and many commercial insurance companies
because it makes it much easier to track prescriptions and improves patient safety. Unfortunately,
technicians at some area pharmacies continue to rely on outdated fax technology to request authorization
for refills
– despite having the ability to send these requests to us through e-prescribing. We have informed most
area pharmacies that we do not accept faxed requests for refill authorizations.
• We kindly request that you remind your pharmacy to use the e-prescribing system if they
inform you that
they have not received a response to their faxed refill request from ARA.
Thank You,
The Physicians and Staff at ARA
In accordance with federal government privacy rules implemented through the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), in order for your physician or his/her
staff to discuss your medical and/or financial information with members of your family or other
individuals that you designate, we must obtain your authorization prior to doing so. In the
event of a critical episode, or if you are unable to give your authorization due to the severity
of your medical condition, the law stipulates that these rules may be waived.
_____ I DO authorize the Practice to release any or all information to the following individuals:
______________________________________
Name
______________________________________
Name
______________________________________
Name
______________________________________
Patient Signature
__________________________________
Relationship
__________________________________
Relationship
__________________________________
Relationship
__________________________________
Date
Revised 5/2021
AUTHORIZATION TO RELEASE INFORMATION TO
INDIVIDUALS/FAMILY MEMBERS
Acknowledgement of Receipt of Privacy Practices
I, have received a copy of Arthritis & Rheumatism
Associates Notice of Privacy Practices.
____ I have accepted electronic access of the Notice of Privacy Practices for Arthritis & Rheumatism
Associates.
Date
Print Name
Signature
OFFICE USE ONLY
On 20 we made a good faith attempt to obtain a written
acknowledgement of receipt of our NPP, but acknowledgement could not be obtained because of the
following reasons:
Patient refused to sign
Communication barriers prevented obtaining a receipt
An emergency prevented obtaining a receipt
Other: ______________________________________
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
This questionnaire includes information not available from blood tests, X-rays, or any source other
than you. Please try to answer each question. There are no right or wrong answers. Please answer
exactly as you think or feel. Thank you.

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UNABLE
ANY
SOME
MUCH
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OVER THE PAST WEEK
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






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
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


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                   
3. Patient Status
PAIN AS BAD AS
IT COULD BE
 


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  



 

3

4
4.5
5
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
 




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 0
 0
 

 
 □
 

 


 0
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