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Department of Orthopaedics,Pediatric DivisionOffices of Dr. Sanjeev Sabharwal / Dr. Folorunsho Edobor-OsulaMR #:CPIToday’s Date:(Fecha de hoy)CONFIDENTIAL PATIENT INFORMATION(Información confidencial de pacientes)Patient’s Name: DOB: Age:(Last Name First) (Nombre del paciente)(Fecha de Nacimiento) (Edad)Address (Direccion): City: State: Zip:Phone #: (H) (W) (cell)(Casa #)(Trabajo #)(Celular #)Place of Birth (Lugar de nacimiento):Sex: Male / Female(circle one)Father’s Name (Nombre de padre):SS#Mother’s Name (Nombre de Madre):SS#Emergency Contact: Relationship: Tel#:(Contacto de Emergencia)(Relacion)(Telefono)INSURANCE INFORMATION(INFORMACIÓN DEL SEGURO)Primary Ins. (Segura Primario): Address (Direccion):Name of Insured: Relationship to patient:(Nombre del Asegurado)(Relación con el paciente)ID: Group #Secondary Ins. (Seguro Secundario): Address (Direccion):Name of Insured: Relationship to patient:(Nobre del Asegurado)(Relacion con el paciente)ID: Group #Are you covered by any other Health Insurance? Yes or NoEsta usted cubierto por otro seguro medicoSi or NoIf yes, please includeSign: Date:Revised – 1/30/15 JI

AUTOMOBILE OR OTHER ACCIDENT RELATED INJURIES(VEHÍCULOS u otro accidente Accidentes)Date of Accident: Location of Accident:(Fecha del Accidente:(Lugar Del accidente)How did accident occur:(Cómo se producen accidents)Automobile Insurance Co.:Address: Tel:(Direccion)( Telefono)Name of Adjuster: Claim #:(Nombre del Ajustador)(Reclamo)Attorney: Tel #:(Fiscal)(Telefono)Address:(Direccion)GUARANTEE TO PAYI understand that payment is expected at the time of services unless payment will be made directly by either aworker’s compensation or auto insurance carrier for the injuries sustained in an accident.I authorize and request payment of my medical benefits for treatment and /or surgery directly to the UniversityPhysician Associates, Department of Orthopeadics. I further authorize my attorney to pay directly any moniesdue to them on accounts the same to deduct from any settlement made on my behalf. I will direct my attorney topay the University Physician Associates, Department of Orthopeadics directly any outstanding balanceimmediately upon settlement or judgment in my case.I understand that any outstanding balance not covered or paid by my insurance will be my responsibility to pay.If my accounts are turned over to an attorney or collection agency to obtain payment, I shall be responsible for theattorney’s fee, court costs, and any other costs incurred by the collection agency.Legal Guardian/Patient’s Signature:(Firma del Paciente)Date:(Fecha de hoy)Copy of my signature shall have the same force and effect as the original.Revised – 1/30/15 JI

Patient’s Medical ProfilePediatric OrthopedicsSanjeev Sabharwal, MD, MPHFolorunsho Edobor-Osula, MD, MPHPatient’s name: Date:(Nombre del paciente)(Fecha de hoy)D.O.B: Age:(Fecha de Nacimiento)(Edad)What is the reason for today’s visit?(Cuál es el motivo de la visita de hoy?)When did this problem first start?(Cuando este problema se inicia por primera vez?)Since you 1st noticed the problem is it?(Ya que primero existe el problema, verdad?)Better Worse Unchanged(Bien)(Peor)(Sin cambios)Is there a family history for this problem?Yes(Hay antecedentes familiares de este problema) (si)No(no)Has this problem been treated previously?(Este problema ha sido tratado con anterioridad?)Please List all treating Doctors:(Anote todos los médicos que tratan a)Past Medical History (Historial Médico)Major illness (Enfermedad grave):YesNo Explain (Explique):Operations (Operaciones):YesNo Explain (Explique):Medications (Medicamentos):YesNo Explain (Explique):Allergies (Alergias):YesNo Explain (Explique):List any medications your child is allergic to:(Enumere los medicamentos que su hijo es alérgico a)Revised – 1/30/15 JI

Birth History (Nacimiento Historia)Birth Weight (Peso al nacer): lbs (Libras) oz.Premature:YesNoReason (Razon):Problems (Problemas):YesNoReason (Razon):Breech (Presentación de nalgas): YesNoReason (Razon):Caesarean (Cesárea):NoReason (Razon):YesNumber of pregnancies for mother:(Número de embarazos de la madreNumber or children:( Numero o ninos)Your child sat at age:(Su hijo se sentó a la edad)Your child spoke at age:(Su hijo entró a la edad de)Your child walked at age:(Su hijo habló a la edad de)Source of referral: Self Physician Other(Fuente de referencia: Auto)Do you have a family doctor or pediatrician who should get a copy of your child’s medical report?(Tiene usted un médico de familia o pediatra que debe obtener una copia del informe médico de su hijo?)Yes: No:Doctor’s name:(Nombre del medico)Doctor’s Address:(Dirección del medico)Doctor’s Phone #:(Teléfono del médico #)SIGNATURE OF PARENT OR GUARDIAN:(FIRMA DEL PADRE O TUTOR)Revised – 1/30/15 JI

tPLEASEDO M(Medicare#)ll(Medicaid4) l(Sponsor's SSN) IUA File 4) HEALTH PLANT.-.I BLKI(SSN or tD)2. PATIENT'SNAME (Last Name, First Name, MiddleInitial)NAME (Last Name, First Name, Middle Initial)7. INSUBED'SADDRESS(No., Street)5. PATIENT'SADDRESS(No., Street)z8. PATIENTSTATUSsinsre[-lIrvrarieol-lOther EPTime10, IS PATIENT'SCONDITIONBELATEDTO:11. INSURED'SPOLICYGFOUPOB FECANUMBERa, EMPLOYMENT?(CURBENTOR PREVIOUS)a. INSURED'SDATEOF BIRTHYYMMDDves[-lttl--l r.rotlozPLACE(SIaIe)b. AUTOACCIDENT?b. OTHEF INSURED'SDATE OF BIRTHSEXMi - " i " [---lvrst t -t T--Not ''ttc. OTHEFACCIDENT?tlzUJd, IS THEREANOTHEFHEALTHBENEFITPLAN?1Od.BESERVEDFOR LOCAL USE12. PATIENT'SOR AUTHORIZEDPERSON'SSIGNATUREI authorizethe releaseof any medicalor other informationnecessaryto processthis claim.I ds requestpaymentof governmentbonefitssithsr to mysellor to the partywho FRENT: / ILLNESSMM , DD , YYbnI ttt.lunv lAccioerity\PREGNANCY(LMP)ii15, IF PATIENTHAS HAD SAI\4EOR SIMILAFILLNESS.YYDDGIVE FIFST DATE MMtlPHYSICIAN17, NAMEOF REFERBINGOF OTHERSOURCE17a.l.D. NUMBEROF FEFERRINGPHYSICIANIlf yes, tetun to and completeitem 9 a-d.YES NOPERSON'SSIGNATUREI authorize13. INSURED'SOF AUTHORIZEDpaymentof medicalbenelitsto the undersignedphysicianor supplierforservicesdescribsdbelow.IDATESRELATEDTO CUFRENTSERVICES18, HOSPITALIZATIONMMDDYYMI\,4 DDYYFFo20, OUTSIOELAB?Miiro:i CHARGESz9 trolr ELIIfeo-:)u,EozIoEo-25. FEDERALTAX l.D. NUI/ BERSSN EIN31.SIGNATUREOF PHYSICIANOF SUPPLIERINCLUDINGDEGREESOR CREDENTIALS{l certifvthat lhe statementson the reverseirpplyt6 this bill and are madea part thereof.)SIGNED26. PATIENT'SACCOUNTNO.NAMEANDADDRESSOF FACILITYWHERESERVICESWERE(lf otherthan homeor oflice)RENDEREDNAME,PHYSICIAN'S,SUPPLIER'SBILLING& PHONE#DATE(APPROVEDBY AMA COUNCILON MEDICALSERVICE8/88)PLEASE PRINT ON TYPEAppFovED oM8.0938.0008FORM HCFA-1500(12-90),FORM RRBn500,(CHAMPUS)FORM 5

North Jersey Orthopaedic InstituteRutgers, The State University of New Jersey205 South Orange Ave C 1200Newark, NJ 07103Phone: 973-972-2151Fax: 973-972-2155Cancer CenterHackensack Medical PlazaOverlook Medical Arts CenterSaint Barnabas Medical CenterConsent for Treatment of a MinorConsentimiento para el tratamiento de un menorI hereby authorize Dr. , and whomever he maydesignate as assistant to provide all treatment he/she deemsnecessary. In order for this child to receive the best of care, I agree toprovide this office, to the best of my knowledge complete and accurateinformation regarding present complaint, past medical history,hospitalizations, medications, and any other prominent information onbehalf of the child being treated.It is my right to terminate treatment at any time; in which case weask that you inform your physician. This consent follows theguidelines of UMDNJ patient rights and privileges.Name of Child(Patient):Nombre del niño (paciente)Name of Parent orGuardian:(Nombre del Padre o Tutor)Signature: Date:(Firma)(Fecha)Witness:(Testigo)Revised 7/30/13 JI

North Jersey Orthopaedic InstituteRutgers, The State University of New Jersey205 South Orange Ave C 1200Newark, NJ 07103Phone: 973-972-2151Fax: 973-972-2155Cancer CenterHackensack Medical PlazaOverlook Medical Arts CenterSaint Barnabas Medical CenterAUTHORIZATION FOR RELEASE OF PATIENT RECORDSI authorize the offices of North Jersey Orthopaedic Institute(Patient name) (Nombre del paciente)To disclose to(Person to whom disclosure is made) (Persona a la que la divulgación se hace)My medical records to the following extent:(treatment dates, name of health care unit of UMDNJ in which treatment was provided, types of records to beexcluded, if any)For .(Purpose of disclosure) (Propósito de la divulgación)I understand that if my medical records contain information related to the history, diagnosisand/or treatment of any psychiatric problems, mental illness, drug abuse, alcoholism,sexually transmitted or communicable disease, AIDS, or test for infection with humanimmunodeficiency virus (HIV), that my signing this document authorizes University ofMedicine and Dentistry of New Jersey to release that information.I acknowledge and am aware that New Jersey has a statutory privilege accorded toconfidential communications between a patient and a licensed physician or psychologist andthat my signing this form waives this privilege.This consent may be revoked at any time by writing to – North Jersey Orthopaedic Institute, except to theextent that the North Jersey Orthopaedic Institute has already taken action in reliance on it. If notpreviously revoked, this consent will terminate upon .(Indicate date or an expiration event.)North Jersey Orthopaedic Institute will not make decisions concerning treatment, payment, enrollment oreligibility for benefits based on signing, refusing to sign or revoking this authorization.I acknowledge and understand that uses and disclosures of my health information authorized by thisdocument may be subject to redisclosure by the recipient and may not be protected by privacy andconfidentiality laws.Signature of patient or guardian: Date:(Firma del paciente o tutor)(Fecha)Revised 7/30/13 JI

North Jersey Orthopaedic InstituteRutgers, The State University of New Jersey205 South Orange Ave C 1200Newark, NJ 07103973-972-2151Fax 973-972-2155Cancer CenterHackensack Medical PlazaOverlook Medical Arts CenterSaint Barnabas Medical CenterNEW JERSEY MEDICAL SCHOOLACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICESWe keep a record of the health care services we provide for you. You may ask to see andcopy that record. You may also ask us to correct that record. We will not reveal yourrecord to others unless you direct us to do so, You are able to obtain more informationabout it by contacting our office Practice Administrator/Manager.Our Notice of Privacy Practices describes more in detail, how your health informationmay be used and revealed, and how you can obtain your information.*You May Refuse to Sign This Acknowledgement*I, , have received a copy of this Office’sNotice of Privacy Practice’s. (Aviso de la Práctica de Privacidad)Please Print Name (Por favor, Nombre Imprimir)Signature (Firma)Date ( Fecha)For Office Use Only (Sólo para uso official)We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practice, butacknowledgement could not be obtained because:[] Individual refused to sign[] An emergency situation prevented us from obtaining acknowledgement[] Other (please specify)Employee’s Signature and Date (Firma del Empleado y la fecha):

Cancer Center Hackensack Medical Plaza Overlook Medical Arts Center Saint Barnabas Medical Center Consent for Treatment of a Minor Consentimiento para el tratamiento de un menor I hereby authorize Dr._, and whomever he may designate as assistant to provide all treatment he/she deems necessary.