Gary E. Fink, M.D.
Gregory W. Niemer, M.D.
Alan N. Brown, M.D.
Colin C. Edgerton, M.D.
William M. Edwards, M.D.
Clarence W. Legerton III, M.D.
Jennifer K. Murphy, M.D.
Nicholas Holdgate, MD
Welcome to our practice!
We look forward to seeing you on this date: _________ at this time: _______ with
Dr._______________ at our West Ashley location.
We are delighted that you have chosen us for your medical needs. At Articularis Healthcare we
take great pride in the relationships that we establish with our patients and the ability to provide a
personalized approach to difficult problems.
As a patient of the Articularis Healthcare Group, Inc., we appreciate you following the guidelines of the
practice to help us maintain our goals. Please read through our policies carefully and call us with any
questions.
New patients:
Please arrive 15 minutes before your schedule appointment time with the completed
paperwork to allow for the registration process. Please do not mail paperwork.
• There is a $25 no-show and cancelation fee for all appointments not kept or not canceledwithin
72 hours prior to your appointment date, except for emergencies. A credit/debit card
number is required at the time of scheduling to secure all new patient appointments.
• Cash payments, deductibles and co-payments must be paid at the time of service.
Payments for medical services not covered by insurance plans are the patient's responsibility.
• We do not accept Medicaid as a secondary insurance to commercial plans.
• Self-Pay patients are required to bring $250 to their initial visit. Additional financial assistance is
available; please ask our Front Desk Receptionist for details.
Please bring attached forms, your photo ID and insurance cards to your visit.
Please be aware that if you arrive over 15 minutes late to your appointment you will be asked to
reschedule.
Phone (843) 572-4840
New Patient Dept. Phone (843) 572-4852
www.lowcountryrheumatology.com
Directions to the West Ashley Office
2291 Henry Tecklenburg Dr. Charleston, SC 29407
From Beaufort – Follow US-21N/Trask Pkwy and US-17N to Savage Rd in Charleston County. Turn
Left onto Savage Rd. Turn left on Henry Tecklenburg.
From Downtown Charleston – Take SC-30W to fielding connector and take Exit 1. Take
SC-61N to Henry Tecklenburg.
From Summerville - Get on I-26E in Berkeley County. Follow I-26E and I-526 to Paul Cantrell
Blvd. Take exit 11B from I-526W. Turn left on Magwood Dr. Take 1st cross street onto Henry
Tecklenburg.
Low Country Rheumatology, A Member of Articularis Healthcare, Inc.
Patient Information
Last Name First Name Middle Initial
Street Address Apt/Lot
City State Zip
SSN DOB Circle One:
Mr. Mrs. Ms.
Email Cell # Home #
Circle One:
Male Female
Marital Status
S M W D
Student
Yes No
Referring Physician Phone #
Primary Care Physician Phone #
Spouse Phone #
Emergency Contact Phone #
Primary Insurance Name Policy #
Policy Holder Name DOB
Group # Group Name
Secondary Insurance Policy #
Policy Holder Name DOB
Group # Group Name
Consent for treatment, payment and acknowledgement of receipt of notice of privacy practices: I request that payment under
the medical insurance program be made payable to Articularis Healthcare Group, Inc. I authorize disclosure of my personal
health information to carry out treatment, payment or health care procedures. I have received the privacy policy and notice of
information practices that provides a more complete description of information uses and disclosures. I agree to pay any and all
charges that exceed or not paid/covered by my insurance. In the event my account is turned over to a collection agency, I will
be billed the additional collection fees.
Patient/Guardian: Date:
Signature
Employment (Circle One):
Full-Time Part-time Retired Disabled
Low Country Rheumatology, A Member of Articularis Healthcare, Inc.
Health Questionnaire
Patient Name: _______________________________________________ Date of Birth: _________________
Reason for visit:________________________________________________________________________________
Preferred Pharmacy: _____________________________ Address: _________________________________________
City: __________________________ State: _______ Zip: ___________
Current medications: Please list name and strength.
1 / mg 8 / mg
2 / mg 9 / mg
3 / mg 10 / mg
4 / mg 11 / mg
5 / mg 12 / mg
6 / mg 13 / mg
7 / mg 14 / mg
Medications you have tried in the past for your arthritis condition.
1 3
2 4
1. 3.
2. 4.
Please indicate the history of arthritis or rheumatic disease in your family:
Father Mother Sibling
Rheumatoid Arthritis
Gout
Psoriasis
Lupus
Other:
Is your arthritis a result of an accident or trauma? Yes No
*We do not provide care for problems related to accidents for which there is ongoing litigation for Workman's
Compensation. Notify the office if you are unclear about your case.
*Disability forms will not be completed until you have received six months of established care from our practice.
1 6
2 7
3 8
Medication or Latex allergies: ___________________________________________________________________________
Prior Surgeries: _______________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever smoked cigarettes, or tobacco in other forms? Yes No
If yes, when you were smoking your heaviest, how many packs per day did you smoke, on average: ________
What year did you start smoking? __________ If you subsequently quit, what year did you quit? _________
Do Liquor you drink alcohol? Yes No If yes, please circle: Beer Wine
On average, how many drinks per week? ________
What other physicians care for you, now and in the past?
4 9
5 10
Medical History: Please list any diseases or illnesses you have now or have had previously.
Alan N. Brown, MD
Colin C. Edgerton, MD
William M. Edwards, MD
Gary E. Fink, MD
Nicholas Holdgate, MD
Clarence W. Legerton III, MD
Jennifer K. Murphy, MD
Gregory W. Niemer, MD
Authorization to Release/Obtain Medical Records
Patient Name: DOB:
Previous Name (if applicable): SSN:
* This authorization expires ONE year from the date of signature*
Method of disclosure:
I authorize Articularis Healthcare to release my medical records to:
Name:
Fax #:
I authorize Articularis Healthcare to obtain my medical records from:
Name:
Fax #:
Health Information to disclose:
ALL health information
Healthcare information relating to the following:
Treatment, Condition, or Dates:
I understand I have the right to refuse to sign thisform, and that I may revoke my authorization at any
time (except to the extent that the information has already been released). When myinformation is
disclosed, the federal HIPAA Privacy Rule may no longer protect it. This authorization will
automatically expire one (1) year from the date of thisrequest or on the following requested date:
Patient Signature: Date:
Witness Signature: Date:
Articularis Healthcare Group, Inc.
2001 2nd Avenue, Suite 201, Summerville, SC 29486 / 1165 Chuck Dawley Mt. Pleasant, SC 29464 / 2291 Henry Tecklenburg Dr., Charleston, SC 29414
Alan N. Brown, MD
Colin C. Edgerton, MD
William M. Edwards, MD
Gary E. Fink, MD
Nicholas Holdgate, MD
Clarence W. Legerton III, MD
Jennifer K. Murphy, MD
Gregory W. Niemer, MD
Medical Information Release Form (HIPAA Release Form)
I understand that Articularis Healthcare Group, Inc. maintains my personal records, medical history,
symptoms, examinations, and test results as a part of my healthcare. This information is not to be
given to any other person without my permission. Therefore, this is a written consent to authorize
release of my medical information.
RELEASE OF INFORMATION
I authorize the release of information including the diagnosis, records, laboratory values, prescribed medications,
treatment plan, examination rendered, and claims information. This information may be released to:
Spouse:
Child(ren):
Other:
Check if okay to leave detailed health information on voicemail
Information is NOT to be released to anyone
Patient Signature: Date:
Witness Signature: Date:
Articularis Healthcare Group, Inc.
2001 2nd Avenue, Suite 201, Summerville, SC 29486 / 1165 Chuck Dawley Mt. Pleasant, SC 29464 / 2291 Henry Tecklenburg Dr., Charleston, SC 29414
Low Country Rheumatology, a Member of Articularis Healthcare Group, Inc.
Scheduling Policy
We are committed to providing our patients with the best possible medical care and minimizing administrative costs.
Please read through this policy thoroughly. If you have any questions, please call our Front Desk prior to your
visit.
New Patients
• A credit/debit card is required to be on file to schedule a and reserve a new patient
appointment.
o A $25 fee will be charged to the card on file for all new patient appointments that are
canceled less than 72 hours prior to the scheduled appointment date.
• If you care unable to keep your appointment, kindly call our office at least 72 hours prior to your
appointment time. We will work with you to reschedule you to a more convenient time.
• We do NOT accept Medicaid as a secondary insurance.
• Self-pay patients are required to bring a payment in the amount of $250 to their initial visit,
which will be collected prior to being seen by the physician. Additional financial assistance is
available after the first visit; please ask the Front Desk Receptionist for details.
• A physician will review the medical records of all Medicaid and self-referral patients
before being scheduled.
Follow-up Appointments
• Established patients with a balance greater than $100 must clear the outstanding balance with
the billing department before scheduling any future appointments. Payment plans can be
arranged if necessary.
• Any patient who no-shows or cancels 2 appointments without giving a 72-hour notice
will receive a discharge warning letter in the mail.
• If a patient cancels or no-shows 3 times in a calendar year they will be discharged from the practice.
• It is the patient's responsibility to keep up with their appointment times. We send automated
calls/text message appointment reminders as a courtesy.
• It is the patient's responsibility to obtain any referral needed for a Blue Choice/Tricare Prime
insurance for their office visit.
Patient/Guardian Signature: _____________________________________________ Date: ___________________
Low Country Rheumatology, a Member of Articularis Healthcare Group, Inc.
Patient Financial Policy
We are committed to providing our patients with the best possible medical care and minimizing administrative costs.
Please read through this policy thoroughly. If you have any questions, please call our Billing Department prior
to your visit.
• We will no longer send paper statements in the mail; statements can be viewed online through our
Patient Portal.
• We will collect payments at the time of service based on the patient's insurance allowable amounts,
deductible, co-payment, and any portion of charges as specified by the plan at the time of visit.
o Payment for professional services can be made with cash, check, credit, or Care Credit.
o Patients that carry a balance after insurance is processed will receive a statement via Patient
Portal.
• Statements must be paid within 30 days upon receipt via Patient Portal, over the phone, by
mail, or in person.
• Patients that do not pay their first statement within 30 days will be required to store a credit,
debit, HSA card or account on file.
o Payment plans are available to those whose services rendered total greater than $200 after the
new patient appointment. A credit, debit, HSA card, or bank account is required to be on file
for all payment plans. For balances greater than $200, 1/3 of the balance will be drafted on the
1st day of each of the next 3 consecutive months.
• We do not have access to the patient's credit/debit/HSA/bank information. It is stored and
encrypted by a certified company that is compliant with all federal privacy laws as well as
the Payment Card Industry Data Security Standards (PCI DSS). Additionally, each of our
offices are PCI DSS compliant.
• As the owner of the insurance policy, the patient is solely responsible for the policies regarding their
plan, to provide us with current insurance information, to notify us with any changes to insurance
coverage, and to bring his/her insurance card to each visit. If we do not have the correct insurance
information, the patient is responsible for the bill.
• If the patient believes the insurance denied or processed the claim in error, please call us immediately.
• If the patient pays more than they are responsible for before insurance is processed, we will apply the
credit to the patient's account and it may be used at the next visit or receive a refund of the
overpayment.
• Our Billing Department will submit a claim for services rendered for patients who are beneficiaries of
insurance companies our practice participates with. All necessary insurance information, including
any forms, must be completed by the patient prior to leaving the office. If a patient has insurance in
which we do not participate, our office will file the claim upon request; however, payment in full is
expected at the time of service.
• If the patient's insurance company requests additional information from the patient, it is important to
reply to their requests in a timely manner. If the insurance company does not pay the claim in 45
days, the balance is billed to and becomes the responsibility of the patient.
• Financial assistance is available for qualified patients. If a patient feels that he or she may qualify for
assistance, the Front Desk Receptionist should be notified. Patients who do not have insurance are
expected to pay for professional services at the time of service unless prior arrangements have been
made with us.
Patient/Guardian Signature: ________________________________ Date: _______________
Low Country Rheumatology, a Member of Articularis Healthcare Group, Inc.
Prescription Refill Policy
Refill requests will only be accepted if the following appropriate criteria have been met:
• Your prescription can only be discussed with a physician, nurse, or medical assistant.
• The requested medication must have been ordered previously by an Articularis
Healthcare Group, Inc. physician.
• Physicians will not accept refill requests after hours or on the weekends (Friday-Sunday).
• Refill requests will be submitted to your pharmacy. Please allow 24 hours for this process. You
may call our offices only after you have spoken with your pharmacy.
o We do not accept refill requests from pharmacies.
• All narcotic refill requests will take 48 hours to process. You may pick up your prescription at
our office no sooner than 48 hours after it was called in.
• The patient has been seen by the physician in the last 6 months or it is documented that the
physician has order a 1 year follow up.
• A patient requesting DMARDS must have had the required blood work within the last 6 – 8
weeks. The nurse may arrange for the patient to get blood work completed if necessary.
• The patient has kept the last scheduled appointment or has been rescheduled for a date within
the next 4 weeks.
• All prescriptions will be written for periods no longer than your next scheduled appointment.
• If a patient misses their appointment and calls in for a prescription, the nurse may only
authorize enough medication to meet the patient's dosing requirement until the next scheduled
appointment. If possible, patients may be worked in within 1 week.
• No further refills can be authorized unless the next scheduled appointment is kept.
Patient/Guardian Signature: _____________________________________________ Date: ___________________
Multi-Dimensional Health Assessment Questionnaire (R808-NP2)
This questionnaire includes information not available from blood tests, X-rays, or any source other
than you. Please try to answer each question, even if you do not think it is related to you at this
time. Try to complete as much as you can yourself, but if you need help, please ask. There are no
right or wrong answers. Please answer exactly as you think or feel. Thank you.
1. Please check (√) the ONE best answer for your abilities at this time: FOR OFFICE
USE ONLY
.a-j FN (0-10):
1=0.3
2=0.7
3=1.0
4=1.3
5=1.7
6=2.0
7=2.3
8=2.7
9=3.0
0=3.3
1=3.7
12=4.0
3=4.3
4=4.7
5=5.0
16=5.3
17=5.7
18=6.0
19=6.3
20=6.7
21=7.0
22=7.3
23=7.7
24=8.0
25=8.3
26=8.7
27=9.0
28=9.3
29=9.7
30=10
.PN (0-10):
2. How much pain have you had because of your condition OVER THE PAST WEEK?
Please indicate below how severe your pain has been: 4.PTGL (0-10):
NO
PAIN
{ {
0 0.5
{
1.0
{
1.5
{
2.0
{
2.5
{
3.0
{
3.5
{
4.0
{
4.5
{
5.0
{
5.5
{
6.0
{
6.5
{
7.0
{
7.5
{
8.0
{
8.5
{
9.0
{ {
9.5 10
PAIN AS BAD AS
IT COULD BE
RAPID 3 (0-30)
3. Please place a check (√) in the appropriate spot to indicate the amount of pain you
are having today in each of the joint areas listed below:
None Mild Moderate Severe None Mild Moderate Severe Cat:
HS = >12
MS = 6.1-12
LS = 3.1-6
R = <3
4. Considering all the ways in which illness and health conditions may affect you at this
time, please indicate below how you are doing:
VERY
WELL
{ {
0 0.5
{
1.0
{
1.5
{
2.0
{
2.5
{
3.0
{
3.5
{
4.0
{
4.5
{
5.0
{
5.5
{
6.0
{
6.5
{
7.0
{
7.5
{
8.0
{
8.5
{
9.0
{ {
9.5 10
VERY
POORLY
Please turn to the other side
Copyright: Health Report Services, Telephone 615-479-5303, E-mail tedpincus@gmail.com
OVER THE LAST WEEK, were you able to:
Without
ANY
Difficulty
With
SOME
Difficulty
With
MUCH
Difficulty
UNABLE 1 To Do
a. Dress yourself, including tying shoelaces and
doing buttons? 0 1 2 3
b. Get in and out of bed? 0 1 2 3
c. Lift a full cup or glass to your mouth? 0 1 2 3
d. Walk outdoors on flat ground? 0 1 2 3
e. Wash and dry your entire body? 0 1 2 3
f. Bend down to pick up clothing from the floor? 0 1 2 3
g. Turn regular faucets on and off? 0 1 2 3 1
h. Get in and out of a car, bus, train, or airplane? 0 1 2 3 1
i. Walk two miles or three kilometers, if you wish? 0 1 2 3 1
j. Participate in recreational activities and sports
as you would like, if you wish? 0 1 2
1
3 1
k. Get a good night's sleep? 0 1.1 2.2 3.3 2
l. Deal with feelings of anxiety or being nervous? 0 1.1 2.2 3.3
m.Deal with feelings of depression or feeling blue? 0 1.1 2.2 3.3
a. LEFT FINGERS □ 0 □ 1 □ 2 □ 3 i. RIGHT FINGERS □ 0 □ 1 □ 2 □ 3
b. LEFT WRIST □ 0 □ 1 □ 2 □ 3 j. RIGHT WRIST □ 0 □ 1 □ 2 □ 3
c. LEFT ELBOW □ 0 □ 1 □ 2 □ 3 k. RIGHT ELBOW □ 0 □ 1 □ 2 □ 3
d. LEFT SHOULDER 0 1 2 3 l. RIGHT SHOULDER 0 1 2 3
e. LEFT HIP □ 0 □ 1 □ 2 □ 3 m. RIGHT HIP □ 0 □ 1 □ 2 □ 3
f. LEFT KNEE □ 0 □ 1 □ 2 □ 3 n. RIGHT KNEE □ 0 □ 1 □ 2 □ 3
g. LEFT ANKLE □ 0 □ 1 □ 2 □ 3 o. RIGHT ANKLE □ 0 □ 1 □ 2 □ 3
h. LEFT TOES □ 0 □ 1 □ 2 □ 3 p. RIGHT TOES □ 0 □ 1 □ 2 □ 3
q. NECK □ 0 □ 1 □ 2 □ 3 r. BACK □ 0 □ 1 □ 2 □ 3
5. Please check (√) if you have experienced any of the following over the last month:
Fever Lump in your throat
Weight gain (>10 lbs) Cough
Paralysis of arms or legs
Numbness or tingling of arms or legs
Weight loss (>10 lbs)
Feeling sickly
Headaches
Unusual fatigue
Swollen glands
Loss of appetite
Skin rash or hives
Shortness of breath
Wheezing
Pain in the chest
Heart pounding (palpitations)
Trouble swallowing
Heartburn or stomach gas
Stomach pain or cramps
Fainting spells
Swelling of hands
Swelling of ankles
Swelling in other joints
Joint pain
Back pain
Neck pain
Unusual bruising or bleeding Nausea Use of drugs not sold in stores
Other skin problems
Loss of hair
Dry eyes
Other eye problems
Problems with hearing
Vomiting
Constipation
Diarrhea
Dark or bloody stools
Problems with urination
Smoking cigarettes
More than 2 alcoholic drinks per day
Depression - feeling blue
Anxiety - feeling nervous
Problems with thinking
Ringing in the ears Gynecological (female) problems Problems with memory
Stuffy nose
Sores in the mouth
Dizziness
Losing your balance
Problems with sleeping
Sexual problems
Dry mouth Muscle pain, aches, or cramps Burning in sex organs
Problems with smell or taste Muscle weakness Problems with social activities
Please check (√) here if you have had none of the above over thelast month: .
6. When you awakened in the morning OVER THE LAST WEEK, did you feel stiff? No Yes
If "No," please go to Item 7. If "Yes," please indicate the numberof minutes , or hours
until you are as limber as you will be for the day.
7. How do you feel TODAY compared to ONE WEEK AGO? Please check only one.
Much Better Better the Same Worse Much Worse
8. How often do you exercise aerobically (sweating, increased heart rate, shortness of breath) for at least
one-half hour (30 minutes)? Please check only one.
� 3 or more times a week 1-2 times per month
� 1-2 timesper week Do not exercise regularly Cannot exercise due to disability/ handicap
9. How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST WEEK?
FATIGUE IS
NO PROBLEM
{ { { { { { { { { { { { { { { { { { { { {
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10
FATIGUE IS A
MAJOR PROBLEM
10. Over the last 6 months have you had: [Please check (√)]
No Yes An operation or new illness No Yes Change(s) of arthritis or other medication
No Yes Medical emergency or stay overnight in hospital No Yes Change(s) of address
No Yes A fall, broken bone, or other accident or trauma No Yes Change(s) of marital status
No Yes An important new symptom or medical problem No Yes Change job or work duties, quit work, retired
No Yes Side effect(s) of any medication or drug No Yes Change of medical insurance, Medicare, etc.
No Yes Smoke cigarettes regularly No Yes Change of primary care or other doctor
Please explain any "Yes" answer below, or indicate any other health matter that affects you:
SEX: Female, Male ETHNIC GROUP: Asian, Black, Hispanic, White, Other
Your Occupation
Work Status: Full-time, Part-time Disabled
□ Homemaker, Self-Employed, Retired,
□ Seeking w ork, Other
Please circle the number of years of school you have completed:
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18 19 20
Please write your weight: lbs. height: inches
Your Name Date of Birth Today's Date
Page 2 of 2 Thank you for completing this questionnaire to help keep track of yourmedical care. R808NP2
FOR OFFICE USE ONLY: I have reviewed the questionnaire responses.
Date: Signature
5. ROS:
FOR OFFICE
USE ONLY
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