PATIENT REGISTRATION FORM (eCW) PATIENT INFORMATION (Please p!int)

Patient's Legal Name: (Last) _ _ _ _____ ____.(First) ______________(MI) -------- ­

Preferred Full Name (if different from above): - - ---- - ------­

Address: ~----------------------------~----------------~­City, State, Zip: - ---- ----- - ---- ------------ - --- ----------- - ­Home Phone Number (landline): _ _ ______ ce11:______ _____ _ Work:

E-Ma~ Address: Date of Blrth: ------------ ­

Gender ldentity: O Female O Male 0Transgender Female to Male O Transgender Male to Female O Genderqueer O Choose not to disdose

O Additional Gender category not listed ---------- ­

Race: 0 American lndian/Alaska Native O Asían O NativeHawaiian/Pacifc lslander c O Black/African American O Wtute

O Hispanic O Chose not to disclose O Other not listed ---------- ­

Ethnicity: O Hispanic or Latino O Not H1spanic or Latino O Choose not to disclose

Preferred Language: O English O Spanish O ASL O Japanese O Mandarin O Korean O French O lndian: Hindi. Tamil, Gujarati etc

O Swahi!i O Russian O Arabic O VietnameseO Haitian Creole O Bosnial'YCroatian/Serbian/Serbo-Croatian

O Albanian O Burrnese O Tagalog O Farsi-lranian/Persian O Portuguese O Cambodian Oother not listed___

Patient Social Secuñty Number: ____ _ ___

RESPONSIBLE PAR!Y INFORMATION !lfnot selQ !ln!Qrrnation ysed for Rat1ent balance statements)

Responsible party: O Another patient O Guarantor O Self Check here if address and telephone information is same as patient O Responsible party name: (Last) ______________(First) (MI) _______

Date of birth: MM /DD__IYYYY Sex: 0 Female 0 Male

Responsible Party Social Security Number:_-______Phone number: ------ ­

Address; ___ _ _ _ ~----------------~--------------~--~-~----­City. State: _ _______ _ _______ZIP: - --- ----­

INSURANCE INFORMATION: Provide your insurance card(s) (primary. secondary, etc.) to the front desk at check-in.

EMERGENCY CONTACT INFORMATION

Emergency contact name: (Last) ___ ___ ______ ____ ___ _ (First) ___ _ ___ _ _ ______

Phone number:___ ___ ____ _________ ___ ___ ___ _ Do you have a living will? O Yes O No

Emergency contact relationship to patient:____ ___ __________________.O Guardian

Address_ __________________ ___ ___~----------------------­

City. State: ____ _ ___ _______,ZIP: --- ----- ­Home phone: Work hone: _________Ext. ___

GENERAL CONSENT FOR CARE ANO TREATMENT CONSENT

TO THE PATIENT: You have the light. as a patient, to be informed about your condition and the recommended surgical, medica! or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. Al this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evalualion necessary to identify lhe appropriate treatment and/or procedure for any identified condilion(s).

This consent provides us with your perrnission to perform reasonable and necessary medical examinations. testing and treatment. By signing below, you are lndicating lhat (1) you intend that lhis consent is continuing in natura even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at thls office Of' any olher satellite office under common O'Mlership. The consent will remain fully effeclive unlil it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss lhe treatment plan wilh your physician about the purpose. potential risks and benefits of any test ordered for you. lf you have any concems regarding any test or treatment recommend by your health care provider. we encourage you to ask questions. 1voluntarily request a physician, and/or mid-level provider (nurse practitioner, physician assístant. or clinical nurse specialist), and other heallh care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition whlch has brought me to seek care at this practica. 1understand that if additional testing, invasive or interventional procedures are recommended, 1will be asked toread and sign additional consent forms prior to the test(s) or procedure(s). 1certify that 1have read and fully understand lhe above statements and consent fully and voluntarily to ils contents.

Signature of patient or personal representative: _ _______ _____ __Date: - ----- - ------ - ----

Prlnted name of patlent or personal representative: ____ ___ _____ _ Relationship to palien!: - --- - ---- - - ­

Last Updated: May 2018

Kendall GME Program

Consent for Treatment and Paymeot Agreement 1 hercby authorize Kendall GME Program to use and/or disclose my health infonnation which specifically identifies me or which can reasonable be used to identify me to cany out my treatment, payment and healthcare operations.

Treatment includes but is not limited to: the administration and performance ofali treatments. the administration of any needcd anesthetics, the use of prescribed medication, the performance ofsuch procedures as may be deemed necessary or advisable in the treatment of this pati ent such as díagnostíc procedures, the taking and utilizatíon ofcultures and of other medically accepted Jaboratory tests, ali of which in the j udgment of the attending physician or their assigned designees may be considered medically necessary or advisable.

Payment includes but is not limited to: the authorization ofpayment directly to Kendall GME Program of benefits otherwise payable to me. 1 hereby acknowledge the release of my medica! records to third party insurers or authorized persons to whom disclosure is necessary to establish or collect a fee for the senrices provided, such as billing and collection services, insurance payers, auto accident insurers, or for work related injury to my employer or designee understand that 1 am tinancially responsible for charges not covered. 1 acknowledge that patient records may be stored electronícally and made available through computer networks.

Healthcare Operations ínc\ude but are not limited to: release of my medica! ínfonnation to any of my physicians and their oftices or insurance companies participating in my care or treatment and the quality of that care.

1 understand that this is given in advance of any specitic diagnosis or treatment and that these services are voluntary and that 1 have the right to refuse these services. 1 intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. This consent will remain in ful! force unless revoked in writing and will not affect any actions that were taken prior to receiving my revocation. A photocopy ofthis consent shall be considered as validas the original.

Patient and/or guarantor are responsible for charges incurred. lt is a courtesy for our office to file with your insurance; however, you are responsible for your co-pay and or percentage which the insurance is not responsible for on the day ofyour visit. lt is the patient's responsibility to obtain any necessary referral forms from your primary care physician when required. lfthe referral is not obtained before the visit, the patient is liable for payment in ful! on the date of service. lfwe are unable to obtain payment within a reasonable amount of time from the patient/guarantor we will place your account with a collection agency which will leave you liable for any additional charges incurred.

1 have fully read and understand the above payment pollcy. 1 agree to fornard to Kendall GME Program, all insurance or third party payments that 1 receive for services rendered to me lmmediately upon recelpt. Patlent lnitlal: ___ _ _

MEDICARE LIFETIME AUTHORIZATION 1 certify that the information given to me in applying for payment undcr Title XVII of the Social Security Act is correct. 1 authorize any holder of medica) infonnation about me to release to the Social Security Administration of its intermediaries or carriers any information needed for this or a related Medicare claim. 1 request that the payments ofauthorized benefits be paid on my behalf. 1 assign the benefits payable for servíces to the physician or organization fumishing the services or authorize such physician or organization to submit a claim to Medicare for payment

1 assign the beneflts payable for servlces to Kendall GME Program. Patient lnitial: _____

1 request this authorizatlon also apply to all other lnsurance. Patient lnitial: _ ___ _

1 acknowledge that 1 have been given Kendall GME Program Notice of Privacy Practices. 1 understand that if 1 have questions or complaints that 1 sbould contact the Facllity Prlvacy Official. Patlent lnltial: ---- ­

RELEASE OF MEDICAL INFORMATION I give pennission for my protected health information to be disclosed for purposes ofcommunicating results, findings and care decisions to the family members and others listed below. I understand that I may request individuals to leave the exam room at any time.

Name of Person who is Release info Allowed in ellam room Authorized to receive infonnation Cplease circle)

y N Cplease circle)

y N y N y N y N y N

*lfthe requestor/receiver of information is nota healthcare provider, the released information may no longer be protected from re­disclosure

I certify that 1 have read and fully understand the above statements and consent fully and voluntarily to its contents.

Date Patient Date of Birth ~----~~--~--~--~--~-~ ~-~--~--~-~~~-~--

Patient Signature

1 KENDALL GME PROGRAM

PATIENT HIPAA ACKNOWLEDGMENT AND CONSENT FORM

Patient Name (Printed): __ Date of Birth: --------- ­

Notice of Privacll Practice/clinlcs.

(PatienVRepresentative initials) 1 acknowledge that 1 have received the practice/clinic's Notice of Privacy, which describes the ways in which the practice/clinic may use and disclose my healthcare information for its treatment, payment, healthcare operation s and other described and permitted uses and disclosu res, 1understand that 1may contact the Privacy Officer desi gnated on the notice if 1have a question or complaint. 1understand that this information may be disclosed electron ically by the Provider and/or the Provider's business associates. To the extent permitted by law, 1consent to the use and disclosure of my information for the purposes described in the practice/clinic's Notice of Privacy.

Disclosures to Friends and/or Famllll Members

DO YOU WANT TO OESIGNATE A FAMI L Y MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MA'( DJSCUSS YOUR MEDI CAL CONDITION? IF YES, WHOM?" 1give permission for my Protected Health lnformation to be disclosed for purposes of communicating results,

members and others listed below: findinas and care decisions to the familv Na me Relationshi Contact Number ------!

1: 2: 3: Patient/Representative may revoke or modify this specific authorization and that revocation or modification must be in writing.

Consent for Photographing or Other Recording for Security and/or Health Care Operations / consent__ (PatienVRepresentative lnitials) to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice/clinic's health care operations purposes (e.g., quality improvement activities). 1understand that the facility retains the ownership rights to the images and/or recordings. 1will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. 1understand that these images and/or recordings will be securely stored and protected. lmages and/or recordings in which 1am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law. -OR­/ do not consent __ (PatienVRepresentative lnitials) to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice/clinic's health care operations purposes (e.g., quality improvement activities).

Consent to Email, Cellular Telephone, or Text Usage for Appointment Remlnders and Other Healthcare Communicatlons:

We want to stay connected wlth our patients. Patients in our practice/clinic may be contacted via email, calls to your cellular telephone (including prerecorded/artiflcial volee messages and/or calls from an automatic dialing device), and/or text messaging to confirm an appointment, to obtain feedback on your experience with our healthcare team, and to be provided general health reminders/information. lf at any time, you provide an email, cellular telephone number, address or text number below, you understand that you may get these communications from the Practice/clinic. You may opt out of these communications at any time (see next page).The practice/clinic does not charge for this service, but standard text messaging rates or cellular telephone minutes may apply as provided in your wireless plan (contact your carrier for pricing plans and details).

1authorize to receive text messages and/or cellular telephone calls for appointment reminders, feedback, and general health reminders/information and the cell phone number is----------- ­1authorize to receive email messages for appointment reminders and general health reminders/feedback/information and the email-that is_____________ _

-OR­1decline ___ (PatienV Representative lnitials) to receive communication via text. 1decline (PatienV Representativa lnitials) to receive communication via cellular telephone call. 1decline (PatienV Representative lnitials) to receive communication via email.

~pdated· Jan.uary_2Q_18-'l6-replacing..1220j6.._002t6....l028j_5_.Jl6J2:1..5. :t 1211.3 A photocopy of this consent shall be considered as valid as the origin_é!I.

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.r-Note: This clinic uses an Electronic Health Record that will update al/ your demographics and consents to the information that you just provided. Please note this information wíll a/so be updated for your convenience to al/ our afliliated clinics that share an electronic health record in which you have a relationship.

Release of lnformation.

1 hereby permit practice/clinic and the physicians or other health professionals involved in the inpa tient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations.

• Healthcare information regarding a prior service(s) at other HCA affiliated providers may be made available to subsequent HCA-affiliated providers to coordinate care. Healthcare information may be released to any person or entity liable for payment on the Patient's behalf in arder to verify coverage or payment questions, or for any other purpose related to benefit payment. Healthcare information may also be released to my employer's designee when the services delivered are related to a claim under worker's compensation.

• lf 1 am covered by Medicare or Medicaid, 1 authorize the release of healthcare information to the Social Security Administration or its intermediaries or carriers for payment of a Medicare claim or to the appropriate state agency for payment of a Medicaid claim. This information may include, without limitation, history and physical, emergency records, laboratory reports, operatíve reports, physician progress notes, nurse's notes, consultations, psychological and/or psychiatric reports, drug and alcohol treatment and discharge summary.

• Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information far quality improvement purposes; and such other purposes as may be permitted by law. 1 understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditíons and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIOS.

~ Prescrlption Order Plck-up. There may be times when you need a friend or family member to pick-up a prescription order (script) from your physician's office. In order for us to release a prescription to your family member or friend, we will need to have a record of their name. Prior to release of the script, your designee will need to present valid picture identification and sign for the prescription.

• /do want __ (Patient/Representative lnitials) to designate the following individual to pick up a prescription arder on my behalf:

o Name: Date:

º Name: Date: • Ido not want __ (Patient/ Representative lnitials) to designate anyone to pick-up my prescription order.

Patient/Parent/Guardian/Patient Representative Signature ----------Date:-----­

Patient/Parent/Guardlan/Patlent Representative Name (Printed) -------- ­

Patient Name (Printed): Date of Birth: --------- ­

Only lfyou have previous/y consented to rece/ve communication vía textlcel/ular telephone call/email and wish to remove the consent/Opt Out/Revocatlon of communications vla email andlor text or cellular telephone cal/. In other words, Ido not want my emall address or cell number to be used any /onqer for the above mentloned communlcatlons.

_/ hereby revoke my request to receive any future appointment reminders, feedback, and general health vía text. _/ hereby revoke my request to receive any future appointment reminders, feedback, and general health vía cellular telephone call. _I hereby revoke my request to receive any future appointment reminders, feedback, and general health vía !J!!!il.

Patient Name: ----------------------- ­

Patient/Patient Representative Signatura: _ ___ ___ ___ ___ ___ ___ _ _ Date: Time:

.__....,..-~ed~ary 2018 v6_r_epJaciag 122016, 0422l6.-10281-5,_Q6j2t5,-1j2l 13 -~-.J A photocopy of this consent shall be considered as va lid as the original.

KENDALL GME PROGRAM

PATIENT NAME.________________DATE OF BIRTH_____

PATIENT CONSENT FOR FINANCIAL COMMUNICATIONS

1. _____(,Patient or Guardlan lnitials)

Flnanclal A¡reement. }lo- 1 acknowledge, that as a courtesy, Kendall GME Program may bill my insurance company for services

provided to me. )- 1agree to pay for services that are not covered or covered charges not paid in full including, but not 11 mited

to any co-payment, co-insurance and/or deductible, or charges not covered by insurance. :¡;,.. 1understand that there Is a fee for returned checks.

2. _____(Patient or Guard~n lnltlals)

Third Party Collection. 1 acknowledge that KendaU GME Program may utilize the services of a third party business associate or affiliated entity asan extended business office ("EBO Servicer") for medical account billing and servicing.

3. _____(Patient or Guardian lnltials)

Assignment of Benefits. 1 hereby assign to Kendall GME Program any insurance or other third-party benefíts available for health care services provided to me. 1understand Kendall GME Program has the right to refuse or accept assignment of such benefits. lf these benefits are not assigned to Kendall GME Program, 1agree to forward all health insurance or third-party payments that 1receive for services rendered to me immediately upon receipt.

4. ______(Patlent or Guardlan lnitials)

Medicare Patient Certlflcation and Assignment of Benefit. 1certify that any information 1provide, if any, in applying for payment under Title XVIII ("Medicare") or Title XIX ("Medicaid") of the Social Security Act is correct. 1request payment of authorized benefits to be made on my behalf to Kendall GME Program by the Medicare or Medicaid program.

s. ______(Patlent or Guardian lnltials)

Consent to Telephone Calls for Financia! Communlcations. 1agree that. in order for Kendall GME Program, or Extended Business Office (EBO) Servicers and collection agents, to service my account orto collect any amounts 1 may owe, 1expressly agree and consent that Kendall GME Program or EBO Servicer and collection agents may contact me by telephone at any telephone number, without limitation of wireless, 1 have provided or Kendall GME Program or EBO Servicer and collection agents have obtained or, at any phone number forwarded or transferred from that number, regarding the services rendered, or my related financia! obligations. Methods of contact may include using pre-recordad/artificial voice messages and/or use of an automatic dialing device, as applicable.

6. ______(Patlent or Guardlan lnitials)

A photocopy of this consent shall be considered as valid as the original.

Patient/ Patient Representative Signature:

x______________________________~Date____~--

lf vou are not the Patient, please identify your Relationship to the Patient.

(Circle or mark relationship(s) from list below):

Spouse Guarantor Parent Healthcare Power of Attorney

Legal Guardian Other (please specify)_______________

--L Kendall GME Program ~--] CONTROLLED SUBSTANCE AGREEMENT

PATIENT NAME: --------------------DOB: ________

The purpose of this Agreement Is to enter a mutual contract regarding certain medicines (controlled substances) you will be taking or could be taking in the future. Prescription of controlled substances is strlctly monitored by state and federal law so strict accountability is necessary.

• 1 understand that thls Agreement is based on the trust and confldence necessary in a provider/patient relationship and that my provider will manage controlled substances based on this agreement. Pt. lnitials

• 1 understand that if 1 break thls Agreement, my provider will stop prescribing these controlled substances. Pt. initials

• 1agree to notlfy my provider of any and all controlled substances or prescriptions that 1 receive from other providers (effective from date of this agreement and ongoing). Such notification should occur within two (2) weeks, or sooner if 1have an encounter with my provider, following receipt of prescription. lf 1 fail to alert my provider 1understand1 may be discharged from the practice. Pt. initials

• 1 understand that someday my provider may recommend weaning me partially or totally from controlled substances if he/she determines that, in the long run, this is likely to be in my best interests. In such situations other medications or therapies will likely be suggested as part of my new treatment plan. 1agree to respect my provider's opinion in such circumstances and comply with the new treatment plan or discuss pursing other treatment venues. Pt. lnitials

• 1 understand that lf 1 am suspected of diverting or distributlng my controlled substances, my provider will lmmedlately cease prescrlblng these medications. In this case, my provider will be required to comply with local state and/or federal reporting requirements and investigation. Pt. initials

• 1 agree to consider to follow my provider's recommendation to seek psychiatric treatment, psychotherapy, psychological treatment or referra l to pain management specialist / addictionologist if my provider deems necessary. Pt initials

• lf the controlled substances are prescribed to treat paln symptoms, 1 agree to communicate fully and honestly with my provider about the character and intensity of my pain, the effect of the pain on my daily Ufe, and how well the medicine is helping to relieve the pain. Pt initials

• lfthe medication causes drowsiness, sedation, or dizziness, 1understand that 1must not drive a motor vehicle or operate machinery that could put my llfe or someone else's life in jeopardy. 1 also understand that my state may have regulations concerning driving while under the influence of drugs and accept responsibility fer adhering to those regutations. Pt. lnitials

Physician Services HCXI Group ll Page August 2016

Kendall GME Program

CONTROLLED SUBSTANCE AGREEMENT

• t understand the combination of opiates or pain medications with anti-anxiety medicatlons such as Valium or Xanax may lncrease the llkelihood of side effects such as stopplng breathing and/or abnormal heart rhythms which may result in injury or death. ___Pt. initials

• understand that controlled substances which 1 may be prescrlbed have potential risks and side effects, including the risk of addiction. An over-dosage with a controlled substance may cause injury or death. Other possible complications include, but are not limited to, constipation, difficulty with urination, fatigue, drowsiness, nausea, itching, stomach cramps, loss of appetite, confusion, sweating, flushing, depressed respiration, reduced sexual function, seizures, coma, and/or aspiration. Pt. lnitials

• 1 will not use any recreational mind-altering or illiclt (i.e. marijuana, cocaine, methamphetamine, etc.) substances. Avoid use of alcohol as 1 understand alcohol may accentuate or exacerbate side effects associated with legal CS. Pt. lnitials

• 1 will not share, sell or trade my medication with anyone nor will 1 take other individual's prescribed CS. Pt. lnitials

• 1 will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or anti-anxiety medicines from any other provider unless that provider is co-managing care with my current provider. ___.Pt. lnitials

• 1 will inform my provider of All current medications including herbs, vitamins, supplements, and over-the-counter · medications. 1 will provide an updated medication list during every visit. Pt. lnitials

• 1will not alter my medicine in any way or use any other administrative method other than what has been prescribed. Long-term agents (MS Contin, Oxycontin, etc.) must be taken whole and are not

allowed to be broken, chewed, crushed, injected and/or snorted. Potential toxicity

could occur dueto rapid absorption if taken inappropriately, which may lead to injury or death. ___Pt. lnitials

• 1 understand that suddenly stopping sorne medications (including opioids and

sedatives) can cause substantial discomfort including psychological distress, extreme

achiness and fatigue, nausea, trembling, etc. Pt. lnitials

Physician Services HCXI Group 2 1Page August 2016

1 Kendall GME Program

CONTROLLED SUBSTANCE AGREEMENT

• 1 understand the abruptly stopping chronic higher dose use of benzodiazepines can

cause serious risk to my health and that weaning instructions must be followed explicitly. Pt. lnitials

• l will avoid wlthdrawal symptoms by budgeting my pills, not taking more medicat ions

than prescribed, and keeping my appointments for refills. 1 understand that 'running

out' of medication is not grounds for insisting on an 'emergency or urgent

appointment' . Pt. initials

• 1will safeguard my controlled substances from loss or theft. Lost or stolen medicines will not be replaced. Pt. lnitials

• 1 agree that refllls of my prescriptions for controlled substance will be made only at the time of an offlce visit or during regular office hours. No refills will be available during evenings or on weekends. Pt. lnitials

• 1 agree that prescriptions for controlled substances will not be refilled earlier than the agreed upon renewal date. Pt. lnitials

• (Females Only) lf 1 plan to become pregnant or believe that 1 have become pregnant whlle taklng this/these medicatlon, 1 will immediately call my obstetric provlder and prescribing prescriber/providerto inform them. Pt. lnitials

1 agree to use _________________________Pharmacy,

Located at ·-------~----------------------~

Telephone number ________________,., for filling prescriptions foral/ of rny

controlled substance(s).

• lf 1 chose to have my medicatlons fllled by a new pharmacy not listed above, 1 will be required to signa new Controlled Substance Contract at my next appointment with my updated pharmacy information. Pt. lnitia ls

• 1 understand that changlng date, quantity, or strength of medicines or altering a prescription In anyway is againstthe law. Forged prescriptions and/orforged provider's

Physician Services H CXI Group August 2016

Kendall GME Program

CONTROLLED SUBSTANCE AGREEMENT signatures are also against the law. lf any of these instances occur, it will result in an immediate termination from this practice. Pt. lnitials

• 1 authorize the provider and my pharmacy to cooperate fully wlth any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the lnvestigation of any possible misuse, sale, or other diversion of my pain medicine or other controlled substances. lf requested, 1 authorize my provider to provide a copy of this Agreement to my pharmacy orto the requesting government agency. 1agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. Pt. lnitials

• 1 agree that 1 will submit to a blood or urine test if requested by my provider to determine my compliance with my program of controlled substance. Tests may include screens for illegal substances, and my cooperation is required. Refusal of such testing may subject me to an abrupt / rapid wean schedule in order for the medication to be discontinued or prompt termination from this practice. Pt. lnitials

• 1 agree that 1will use my medicine ata rate no greater than the prescribed rate and that use of my medicine at a greater rate will result in my being wlthout medication for a period of time and posslble termlnation of care. Pt. lnitials

• 1will bring all unused controlled substances to every office visit ___Pt. lnitials

• 1 understand that any serious misbehavior such as yelling, threatening, cursing, etc. will likely be cause for dismissal from the practice. Pt. lnitials

• 1 agree to follow the guidelines that have been fully e><plained to me. Ali of my questions and concerns regarding treatment have been adequately answered. A copy of this document has been given to me. Pt. lnitials

This agreement is entered into on this _____day of _________ ----- ­

Patient/Responsible party signature:

Date:------- Time: ___

Prescriber /provider signature:

Date:------- Time: ___

Medicatlon(s) prescribed

Physician Services HCKI Group 4 1Pa ge August 2016

HCA PHYSICIAN SERVICES

KENDALL GME PROGRAM

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)

Section A: Will the Protected Health Information (PHI) be created or used for research and include treatment of the patient? lfyes, complete the Authoriution for Research Form. lfno, proceed to Section B.

Section B: Required for all Authorizations for Release ofPID or Right to Access Patient Name: Birth Date: Social Security No. (optional) :

Patient's Address: Requestor's Name/Phone Number (if patient is not the requestor):

PHI Recipient Name: Address/City/State/Zip Phone Number: (_J Fax Number: ( )

PHI Sender Name: Address/City/State/Zip Phone Number: (_J Fax Number: ( )

This authorization will expire on the following: (Fill in the Date or the Event, but not both.) Date: Event: Purpose of Disclosure:

Is this request for psychotherapy notes? O Yes, then this is the only ítem you may request on this authorization. O No, then you may check as many items below as you need.

Description: Date(s) Description: Date(s) Description: Date(s}

D Ali PHI in record O Physician Orders U Demographics - ~

O History and Physical O Laboratory O Rehabilitation O Consult Report O lmaging/Radiology Services O Operative Report D Nursing Notes O Special Test/Therapy D Progress Notes D Medication Record O Itemized Bill/Claims

D Other: I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information. checkhere O

(lnitial) If not, applicable,

1 understand that: l. 1 may refuse to sign this authorization and my treatment will not be conditioned upon signature of this

authorization (except for non-health related services such as pre-employment testing, life insurance exams, or drug screenings}.

2. 1 may revoke this authorization at any time in writing, but if1 do, it will not ha ve any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.

3. lf the requester or receiver is nota health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.

4. I understand that 1 may see and obtain a copy the information described on this form, for a reasonable copy f ee, if l ask for it.

5. 1 will receive a copy of this form after 1 sign it.

Section C: Signatures

I have read the above and authorize the disclosure of the protected health information as stated. Signature of Patient/Guardian/Patient Representative: Date:

Print Name of Patient's Representative: Relationship to Patient:

FORMS 2013- AUTHORIZATION RELEASE OF PHI

First Point of Contact Screening

Patient Name --~-------~----~Please print full legal name

We are commítted to providing the safest environment for our patients and together we can prevent the spread of germs.

Please complete the questionnaire below. Ifyou answer yes to any of the questions, please be considera te ofothers and act appropriately such as covering your cough, washing your hands, and covering any open wounds.

For the protection ofour patients, we gladly supply and encourage the use of tissue, masks, hand sanitizer, and Band-Aids.

l . Do you ha ve any of the following symptoms?

Ifyes, please circle the symptoms you have now, or have had, over the past seven days?

• Fever • Night sweats • Sneezing or runny nose • Cough • severe headache • stiffneck • muscle or joint pain (circle one or both) • new rashes or open sores on your skin or in your mouth • redness, swelling, or discharge ofyour eyes (pink eye) • unexplained bleeding • vomiting or diarrhea

2. In the past three weeks, have you traveled outside the U.S.?

If yes, please list where: -------------------- ­

3. In the past three weeks have you had close contact with someone who has traveled outside the U.S.?

lf yes, please list where: - --- - - ---- - ----- -----

Tbank you for your help and support in caring for our patients and community.

YES NC

YES NC

YES NC

TO BE FILLEI> OUT B J' OFF/CE STA FF

Reviewed by:

Action taken: No action taken Isolate Cough 1 hand washing etiquette prO\ iJed Mask provided PM/ lead clinical notified

Thank you far trusting us with your healthcare /

Date

•