Dates Revised: 5/7/2013

© 2013 Dr. Scott Fox

HEALTH HISTORY

All questions contained in this questionnaire are strictly confidential and willbecome part of your medical record.

Name: M(Last, First, M.I.) F DOB

MaritalStatus: Single Partnered Married Separated Divorced Widowed

Date of LastPrevious or Referring Doctor: Physical Exam:

PERSONAL HEALTH HISTORY

Childhood Illness: Measles Mumps Rubella Chicken Pox Rheumatic Fever Polio

Immunizations Tetanus Pneumonia

and Dates: Hepatitis Chicken Pox

Measles, Mumps, Rubella

List Any Medical Problems That Other Doctors Have Diagnosed:

Surgeries:

Year Reason Hospital

Other Hospitalizations:

Year Reason Hospital

Have you ever had a blood transfusion? .................................................................................. Yes No

Continued on Back Side

1

List Your Prescribed Drugs and Over-the-Counter Drugs, Such as Vitamins and Inhalers:

Name of Drug Strength Frequency Taken

Allergies to Medications:

Name of Drug Reaction You Had

HEALTH HABITS AND PERSONAL SAFETY

Exercise: Sedentary (No exercise) Mild Exercise (i.e., climb stairs, walk 3 blocks, golf)Occasional Vigorous Exercise (i.e., work or recreation less than 4x/week for 30 min.)Regular Vigorous Exercise (i.e., work or recreation 4x/week for 30 minutes)

Diet: Are you dieting? ..........................................................................................Yes NoIf yes, are you on a physician prescribed medical diet? ..................................Yes No# of meals you eat in an average day?

Rank Salt Intake Hi Med Low Rank Fat Intake Hi Med Low

Caffeine: None Coffee Tea Cola # of Cups/Cans Per Day?

All questions contained in this questionnaire will be kept strictly confidential.

Alcohol: Do you drink alcohol? .................................................................................Yes NoIf yes, what kind? How many drinks per week?

_____

Tobacco: Do you use tobacco? ................................................................................. Yes NoCigarettes - Pks/day Chew - #/day Pipe - #/dayCigars - #/day # of Years or Year Quit

All questions contained in this questionnaire will be kept strictly confidential.

Drugs: Do you currently use recreational or street drugs? ........................................Yes NoHave you ever given yourself street drugs with a needle? .............................Yes No

© 2007 Dr. Scott Fox 2

Hormonal Therapy: Are youIfYes,

Are youIfYes

Are youIfYes

Have youIf Yes

using Testosterone presently? ........................................................Yes Nohow much per weekon Estrogen treatment for Menopause? ...........................................Yes Nohow much

on Progesterone treatment for Menopause? ....................................Yes Nohow much

used any ANABOLIC STEROID beside the above ....................Yes Nowhich

Sex: Are you sexually active? ...............................................................................Yes NoIf yes, are you trying for a pregnancy? ............................................................Yes NoIf not trying for a pregnancy, list contraceptive or barrier method usedAny discomfort with intercourse? ..................................................................Yes No

Are you satisfied with your sexual functioning ...............................................Yes No

FAMILY HEALTH HISTORY

Age

Father

Age atDeath

Significant HealthProblems or Cause ofDeath Age

Children MF

AgeatDeath

Significant HealthProblems or Cause ofDeath

MotherMF

MBrothers

FandMF

MSisters F

MF

MF Grandparents (Mother’s Side)

MF Male

MF Female

MF Grandparents (Father’s Side)

MF Male

MF Female

Continued on Back Side

© 2007 Dr. Scott Fox 3

MENTAL HEALTH

Do you feel depressed? .................................................................................................................... Yes NoDo you have problems with eating or your appetite? ....................................................................... Yes NoDo you cry frequently? .................................................................................................................... Yes NoDo you have trouble sleeping? ......................................................................................................... Yes NoHave you ever been to a counselor? ................................................................................................ Yes No

WOMEN ONLY

Age at onset of menstruation: Date of last menstruation:Period every days. Heavy periods, irregularity, spotting, pain, or discharge? ....................... Yes NoNumber of pregnancies Number of live birthsAre you pregnant or breastfeeding? .................................................................................................. Yes NoHave you had a D&C, hysterectomy, or Cesarean section? .............................................................. Yes NoAny urinary tract, bladder, or kidney infections within the last year? ............................................... Yes NoAny blood in your urine? ................................................................................................................. Yes NoAny problems with control of urination? ......................................................................................... Yes NoAny hot flashes or sweating at night? .............................................................................................. Yes NoDo you have menstrual tension, pain, bloating,

irritability, or other symptoms at or around time of period? .................................................... Yes NoExperienced any recent breast tenderness, lumps, or nipple discharge? ........................................... Yes NoDate of last pap smear and rectal exam?

MEN ONLY

Do you usually get up to urinate during the night? ........................Yes No If yes, # of timesDo you feel pain or burning with urination? ................................................................................... Yes NoAny blood in your urine? ................................................................................................................. Yes NoDo you feel burning discharge from penis? ..................................................................................... Yes NoHas the force of your urination decreased? ...................................................................................... Yes NoHave you had any kidney, bladder, or prostate infections within the last 12 months? ..................... Yes NoDo you have any problems emptying your bladder completely? ..................................................... Yes NoAny difficulty with erection or ejaculation? .................................................................................... Yes NoAny testicle pain or swelling? .......................................................................................................... Yes NoDate of last prostate and rectal exam?

OTHER PROBLEMS

Check if you have, or have had, any symptoms in the following areas to a significant degree and brieflyexplain.

SkinHead/NeckEarsNoseThroatLungsChest/Heart

BackIntestinesBladderBowelsCirculation

Recent Changes In:Weight

Energy LevelAbility to Sleep

Other Pain/Discomfort:

© 2007 Dr. Scott Fox 4

Patient Goals

Dear Patient,

Hormone replacement in an individual with hormone deficiencies maylead to improvement of some medical conditions. The FoxWest practice ofInterventional Endocrinology does not directly address these overt medicalconditions but, only the underlying hormonal deficiency. During the past 10years, specific results have been so vast and unpredictable that we cannot claimor promises any potential benefits for those medical conditions. What we dorecommend is that once hormonal deficiencies are documented that you begin aprogram of hormone replacement (supplementation) for a period of 3 to 6months before deciding if there has been any appreciable benefits.

Treatment GoalsDecrease percent body fat Increase lean body mass.

Improve Muscle Strength Improve post exercise recoveryIncrease Libido Improve quality of SkinImprove upon erections Decrease frequency of colds

Improve on hair condition Increase physical energy.Improve memory Increase mental energy.Increase mental alertness Improve upon sleep.

Improve upon mood Improve on mild depressionDecrease Menopause symptoms

Name Date

©2009 FoxWest 34709 9th Ave S., Suite B200, Federal Way, Wa. 98003

ANDROPAUSE & MENOPAUSE QUESTIONARRAIRETestosterone deficiency as seen in both males and females has a pervasive effect on our entire being.Symptoms relative to brain function, sexual function, general metabolic condition andmusculoskeletal wellness are inextricable linked to a healthy level of Testosterone. In Anti-AgingMedicine, this age related decline in testosterone is known as Andropause. Replacement can make adifference in how old we feel and how well we perform in our life.

Name: Date:A Sexual Functions Males A Sexual Functions Female

Decreased early morning erections. Decreased Libido or sexual desiresDecreased Libido or sexual desires Reduction in vaginal sensation during intercourse.Decreased fullness of erection Failure to produce or diminished vaginal lubricationDecreased volume of ejaculate or semen Failure to achieve orgasmDecreased strength of orgasm or muscle contractions.

Difficulty in maintaining full erection

Difficulty in starting erection-or no erection

B Mental Functioning C Musculoskeletal ConditionsSpells of mental fatigue or inability to concentrate Body aches with or without joint and muscle painsTiredness in the afternoon or early evening. Decline in flexibility and mobility; increased stiffness.

Feeling burned out Decrease in muscle size, tone, and strengthDecrease in mental sharpness, attention, wit. Decrease in physical stamina.Change in creativity or spontaneous new ideas. Decrease in athletic performance.Decrease in initiative or desire to start new projects Prolonged recovery phase after exercise.

Decreased interest in hobbies or new activities. Back pain; neck pain

Decrease in competitiveness. Tendency to pull muscles or get leg crampsChange in memory function; increased forgetfulness. Development of Osteoporosis or Inflammatory

Arthritis

Feeling of depression; a sense that work, marriage, orrecreational activities have lost significance.

D Metabolic Changes E Physical ConditionsIncrease in total cholesterol or triglycerides Unexplained weight gain, more around the mid-driftIncrease in LDL cholesterol Increased fat distribution in breast or hip areasDecrease in HDL cholesterol Increased facial lines and weathering

Rise in blood sugar level or onset of diabetes Vertical lines on the upper lip. RhytidesChange in visual acuity.Decreased night vision.Ringing in the ears (Tinnitus)Increased symptoms of asthma or emphysemaOnset of new headaches.Shortness of breath with simple activities.Lightheadedness or dizzy spellsPoor circulation in the legs.Development of chest pain. or hardening of thearteries.

2013 © Dr. Scott Fox Swelling of the legs w/ or w/o increase in varicoseveins.

Progesterone Therapy Compliance

I, _________________________________________________________ , have beenadvised of the risks of hormone replacement therapy. I have chosen to pursue estrogenreplacement therapy and understand that taking progesterone is necessary when takingestrogen. I understand that if I don’t take my progesterone as prescribed, that I canexperience irregular vaginal bleeding, and I also increase my risk for uterine cancer.

Initial_____

Non-Pregnancy Disclosure

I, ___________________________________________________ have been counseled byDr. Fox and told the risks to developing fetuses with hormones. I will not attempt to

become pregnant for 6 months following therapy, and will utilize birth control measuresto avoid pregnancy. I understand that hormones can cause birth defects and gender

identity problems to developing fetuses. If I accidentally become pregnant I will contactDr. Fox immediately.

Initial______

Signature_________________________________________________________Date____________________

Gynecological and Obstetrical History

Name: Date:

Menstrual History (Menses = PeriodEvents Answers Comments

Onset of Period (Age)

Days between cycle (ave)

Days on menses (ave)

Date of Last Menses

Birth Control Pills? ( YES ) ( NO ) How Long?

Hormone Replacement? ( YES ) ( NO )

Number of Pregnancies

Number of Children

Number of Abortions

Breast Fed Children ( YES ) ( NO )

Last Pap Smear Normal – ( YES ) ( NO )

Ever an Abnormal Pap? ( YES ) ( NO )

Gynecologist’s Name

Last Mammography Normal – ( YES ) ( NO )

Breast Augmentation ( YES ) ( NO )

Fibrocystic Disease ( YES ) ( NO )

F a m i l y H i s t o r y o fB r e a s t C a n c e r ? ( YES ) ( NO ) _____________

Other Issues:

G:___P:___AB:___

FDA DisclosureDr. Fox has discussed hormone therapy with me and that compounded bio-identical hormones are notFDA approved. While they are compounded in FDA certified compounding pharmacies, the actualcompounded formulas are not FDA approved. Dr. Fox discussed multiple treatment optionsincluding topical creams, patches, pellets and oral preparations, both pharmaceutical andcompounded. I understand the WHI study doesn’t differentiate between pharmaceutical gradehormones and compounded hormones, and that their stance is that hormone replacement therapycan increase the risk for the following:Initial each:

____Breast Cancer____Uterine Cancer____Heart Attacks____Strokes____Blood clot

Signature___________________________________________________________________

Mammogram Informed Consent

Informed Refusal Form

My physician, Dr. Laurence S. Fox , has recommended thefollowing test/procedure/treatment: Mammogram

I understand the potential benefits of the test/procedure/treatment include:Early breast cancer detection

And the risks are: Radiation exposure to the breast, and failure to identifyearly cancer Despite my physician’s recommendation, I refuse to consent tothis medical treatment. I understand the following risks of my refusal. Theyinclude, but are not limited to: Failure to detect breast cancer

By signing this document, I acknowledge the potential benefits of such treatment andthe risks associated with it, as well as the probable risks of not following therecommended treatment, which I fully understand. In spite of this understanding, Irefuse to consent to this diagnostic procedure, but would like to proceed withhormone replacement therapy which can stimulate certain cancers.

Date Time Patient/Rep’s Signature________________ ______

Request for Release of Medical Documents

I, ____________________________________ authorize the release of the mostrecent

medical documents consisting of, but not limited to; Medical Chart Notes,

Physical Examination, Laboratory Reports, Consultation Reports, and X-

Ray Reports. As per regulations under the BOMQA - Consumer Affairs,

these records must be forwarded to the designated recipient (below) within

14 calendar days.

Patient’s Signature ________________________________Date

Printed Name: _____________________________________

Please send or fax my documents to:Facility Name/Doctor Dr. Scott Fox

Street Address 34618 11th Place South suite B100

City, State, Zip Federal Way, WA 98003

Fax Number 253-838-4145

Phone Number 253-336-4462

Family Medicine Clinic of Federal Way, LLC Vuthy Leng M.D. Laurence S. Fox D.O.

Board Certified Family Medicine

Name______________________________________________ DOB ______________ SSN _________________ First middle last

Gender: M or F (circle one) Marital status: single ___ married ___ divorced ___ widowed ___ separated ___

____________________________________________________________________________________________________________ Address Apt. # City State Zip

_____________________ ______________________ Insurance Information: Home Phone # cell phone #

________________________ Insurance name

________________________

_______________________ _______________________ _______________________ ID# / policy # Name of employer work phone # employer location (city& zip)

________________________

_______________________ _______________________ _______________________ Group # Name of spouse spouse employer spouse contact phone #

________________________ Subscriber name

______________________ _______________________ _______________________ Name of trusted contact contact phone # relationship ________________________ Person outside home Subscriber birth date

Secondary Insurance:

___________________________________________________ E-mail

________________________ Insurance name

________________________ ID# / policy #

________________________ Group #

_________________________ Subscriber name

_________________________ Subscriber birth date

I agree to the listed demographic information as being honest and accurate for the above named patient. I agree it is my responsibility to directly notify this office of any demographic changes. ______________________________________ __________________ Patient signature/ legal guardian Date ______________________________________ Printed name of legal guardian ________________________ Relationship to patient

If legal guardian

Office Policy Though our primary concern is your healthcare needs, we also need you to be aware of our office policy. It is our desire to have a mutually respectful relationship with our patients. In a sincere effort to maintain patient satisfaction, we work diligently to provide quality healthcare and hope we can avoid discrepancies. Communication with our office is crucial. If you have any billing concerns such as a change or a problem please call our billing office @ 253-336-4512

Printed patient name __________________________________________________

All co-pays are due at time of service. A $10 billing fee will be assessed for unpaid co-pays. Please do not badger the front desk with reasons for not furnishing your co-pay for this conduct is considered impolite and tacky, and deprives other patients of necessary interaction with our staff. If you do not have your co-pay at

time of visit simply accept the $10 billing fee on your next statement. Please note: Your unpaid copay amount, the billing fee, and your current visit copay total are due in full upon your next appointment.

Our no-show/broken appointment policy is as follows: Failure to cancel a scheduled appointment within 24 hours of the start of the day at 8am, no-showing (abandoning) a scheduled appointment, or arriving more than 30 minutes late to a scheduled appointment will result in a $25 service charge. Situations of repeat no-shows, late cancellations, late arrivals, and other forms of broken appointments will require a non-refundable $25 deposit for the upcoming appointment. We feel this $25 service charge is necessary as a broken appointment denies the opportunity of another patient being provided care. Anytime you are uncertain of your appointments, please call. We will be happy to verify them for you. Accounts 60 days past due without any record of payment will be delinquent until a payment is made. If we do not receive a payment toward your balance within 60 days you will be suspended from scheduling any

future appointments until a satisfactory payment toward your balance is established. Please note: In some cases, it is the discretion of the office staff to decide a minimum amount due before appointments can be resumed. Forms of payment accepted : cash, debit/credit cards, money orders, and money grams. Checks are not accepted. There is a $25 charge for each returned check due to insufficient funds. The combined amount of the written check amount and the $25 NSF fee is expected before future appointments are allowed. We do not bill for cash paying patients. We know our cash fee schedule is very reasonable as we understand a lack of insurance can complicate medical needs. The set cash amount is due at appointment check-in. If you do not have your payment at time of visit a $10 billing fee will be assessed. It is your responsibility to notify us of any demographic changes. If our office is trying to disclose information to you, and your contact information on file with us is incorrect we will hold the patient accountable for any unresolved balances, missed lab follow-ups, etc. that may incur. We will bill all workers compensation, Labor & Industries, and motor vehicle accident claims with a valid and open claim number. If at any time your claim is closed or denied you are required to pay cash or your private insurance will be billed. To expedite your claim processing and keep discrepancies at a minimum, please bring your incident information with you to your appointment or notify the office before your appointment. Failure to have this information available to us may result in paying out of pocket for the visit.

We participate with most insurance plans at the in-network PPO (preferred provider organization) status. If you have questions about your benefit detail for a service or procedure, let our staff know beforehand and we will inquire on your behalf. It is your responsibility to notify us of any changes in your insurance coverage. Please be aware of the current specifications for your insurance (co-pays, deductibles, etc.) Due to timely filing regulations administered by insurance companies, the sooner you communicate a change or problem the better. If a certain amount of time has elapsed for an outstanding claim requesting subscriber (patient) information the amount of the claim may become patient responsibility. In the event your insurance does not cover a service or procedure and the claim was submitted correctly you will be responsible for the charge. Legally, we are not permitted to re-submit claims with a new diagnosis or procedure code if the claim was accurately submitted then denied by your insurance company, as this is considered fraudulent and measures are taken against physicians including criminal indictments who code to accommodate coverage.

Please note: We do not accept DSHS, Molina, or any state issued health plan (all HMO’s included) We are a private practice facility with no affiliations with outside organizations. We are not recognized as an in-network preferred facility or provider, therefore we will maintain our out-of- network classification with these outside organizations. If you are covered under an HMO policy and seek care at our office, you will be responsible for the charges as stated in your HMO benefits plan. Same-day appointments are accepted on an urgent basis only for the acutely ill. Prescription refills of any kind are not emergencies and therefore not acceptable as reason for same-day appointment. Prescriptions are like money and may not be replaced if lost, stolen, misplaced, overused, or abused. All prescription refill requests require 24-48 hours advance notice. Please note: If you call on a Friday your prescription(s) will not be filled until Monday at the earliest, as our office is closed on weekends and this time does not count toward the 24-48 hour time frame.

I have read and understand the office policy

_______________________________________ Patient signature

_______________ date

Authorization to Release / Obtain Protected Medical Information

T # 253.336.4462

F # 253.838.4145

34618 11th Ave. S. # 100

Federal Way, WA 98003

PO Box 6015

Federal Way, WA 98063-6015

Family Medicine Clinic of Federal Way, LLC

I, _______________________________________ __________________ _______________________ , authorize Family Medicine Print name Birth Date SSN

Clinic of Federal Way to release / obtain confidential information to / from the following : _________________________________________ Person or Organization releasing / obtaining

Information to Release / Obtain ( check all that apply )

______ Complete Chart Notes ______ Operative Report(s) ______ Prescription History

______ ER Assessment / Evaluation ______ Lab / Radiology Report(s) ______ Diagnostic Films

______ Physician Orders ______ Respiratory Report(s) ______ Immunization Log

______ PT / OT Report(s) ______ Other: (Please specify) _________________________________________________

I understand that diagnostic and/or therapeutic information concerning Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syn-

drome (AIDS), sexually transmitted diseases, drug/alcohol abuse, or other health care information classified as protected may be communicated to

the individual or organization listed above on the basis of this authorization.

Purpose of Release / Obtain ( check all that apply )

______ To coordinate medical care ______ To obtain life insurance ______ To inform friend / relative of

treatment procedures

______ To meet terms of employment ______ To provide information for legal action

______ To transfer to another facility ______ Payment arrangement

______ Other : ( Please specify ) _____________________________________________________________________________

I understand that my records are protected under the Washington State Healthcare Information Act, HIPAA, and applicable federal laws and regula-

tions and cannot be disclosed without my written consent unless otherwise provided for in the statutes and/or regulations. I also understand that I

may revoke this authorization in writing at any time, except to the extent that action has already been taken to comply with. My signature below

indicates that I have read and understand this authorization and its terms.

________________________________________________ ____________________ Signature of Patient Date

Consent to Medical Care and Treatment

I authorized Dr. Vuthy Leng and/or Dr. Scott Fox, D.O. and such physicians, associates, assistants andother personnel of the Family Medicine Clinic of Federal Way chosen by him or her to perform thefollowing:

_______________________________________________________________________________________

[________ ] GENERAL RISKS AND COMPLICATIONS: I am satisfied with my understanding of the more commonrisks and complications of the treatment, which have been described and I have discussed with the doctor.

[ _______ ] SPECIFIC RISKS AND COMPLICATIONS: I am satisfied with my understanding of specific risks of thistreatment protocol/program as described by the doctor which included: Infection, scarring, bleeding,bruising, sepsis, subcutaneous calcification, keloid scar formation, discoloration, pain, regional painsyndrome.

[ _____ ] NO TREATMENT: I am satisfied with my understanding of the possible consequences, outcomes or risks if notreatment is rendered.

[ ________ ] SECOND OPINION: I have been offered the opportunity to seek a second opinion concerning the proposedtreatment from another physician.

OTHER QUESTIONS: I am satisfied with my understanding of the nature of the treatment and all ofmy additional questions about the treatment have been answered.

Signature:__________________________________ Date:_____________ Time ____________ AM/PM

Primary Physician:________________________________ Telephone#:

E-Prescribing Consent Form

Patient Name __________________________________________________________________________

Our office is pleased to announce that we have implemented ePrescribing and we are offering this feature to you. There are benefits to both providers and patients that participate in ePrescribing. ePrescribing software sends prescriptions over the internet to your pharmacy in a safe and secure way, which helps protect the privacy of your personal information. ePrescribing software also lets your doctor see important information like drug interactions and prescription History. Patient benefits : Eliminates the possibility of a blurred fax or interrupted transmittals, resulting in delays Reduces or eliminates phone calls and call-backs to pharmacies due to questions and clarifications Reduced possibility of medical errors Less chance of adverse reactions Convenience with fewer trips to the pharmacy for drop-offs and pick-ups A safer, faster, easier way to get your prescription(s) filled Patient Consent :

I agree that Family Medicine Clinic of Federal Way may request and use my prescription medication history from other health care providers, insurance payors, and third party benefit payors for treatment purposes. This consent form will be updated on an annual basis. I understand I am to notify Family Medicine Clinic of Federal Way if my pharmacy infor-mation changes.

Please provide our office with your pharmacy information

_____________________________________________

Pharmacy Name

_____________________________________________ Address

_____________________________ Phone #

_____________________________ Fax #

___________________________________________

Pharmacy Name ___________________________________________

Address ____________________________

Phone # ____________________________

Fax #

_______________________________________________________ ______________________

Patient Signature Date

Patient Portal User Agreement Guidelines

Family Medicine Clinic of Federal Way, LLC provides this site in partnership with e-MDs for the exclusive use of its established patients. The patient portal is designed to enhance patient/physician communications. All users must be established by a previous office visit. We strive to keep all of the information in your records correct and complete. Additionally, by using the patient portal, the user agrees to provide factual and correct information. E-MDs is our EMR software vendor and provider of this service. The data is stored at Family Medicine Clinic of Federal Way. The data is on HIPAA compliant VPN with high level encryption standards. While we believe the IT infra-structure and data are safe and secure, it does not guarantee unforeseen adverse events cannot occur. To the extent that it is possible, Family Medicine has undergone rigorous IT implementation and security standards exceeding indus-try recommendations. The patient portal is provided as a courtesy to our valued patients. While some offices charge for this conven-ience on an annual basis, we are focused on providing a high level of health care services. However, if abuse or negli-gent usage of the patient portal persists, we reserve the right at our own discretion to terminate patient portal offer-ing, suspend user access, or modify services offered through the patient portal. The information on the patient portal is maintained by Family Medicine Clinic of Federal Way, LLC at its physical facility—34618 11th Ave. Suite 100, Federal Way, WA 98003. For questions about this site, contact us di-rectly.

The patient portal provides the following services: * Medication re-fill requests * Communication of laboratory results from staff to patient * Review patient’s medical summary, medication list, treatment history, and visitation dates * Scheduling requests * Billing inquiries such as balance and eligibility ? The patient portal does not provide the following services: * Internet based diagnostic medical services * No internet based triage and treatment requests. Diagnosis can only be made and treatment rendered after the patient schedules a visit. * No emergency communications or services. Any emergent conditions should still be seen by Urgent Care facilities, Hospital ER, or 911. * No requests for narcotic pain medication will be accepted. * Requests for medication not being treated by the physician

If you are interested in using the Patient Portal please ask for our user agreement form

Notice of Privacy Practices Our pledge regarding medical information

The staff at Family Medicine Clinic of Federal Way respects your privacy. We understand that your

personal health information is very sensitive. We will not disclose your information to others unless you

tell us to do so, or unless the law authorizes or requires us to do so. The law protects the privacy of the

health information we create and obtain in providing our care and services to you. For example, your

protected health information includes your symptoms, test results, diagnoses, therapies, health

information from other providers, and billing and payment information related to these services. Federal

and state law allows us to use and disclose your protected health information for purposes of treatment

and health care operations.

This notice applies to the information and records we have about your health, health status, and the

health care you receive at this office. We are required by law to give you this notice. It will tell you the

ways you and we may use and disclose health information about you. It also describes your rights and

obligations regarding the use and disclosure of that information.

Examples

Dear Patient,

Due to a combination of increased workflow, patient volume, and an unacceptable

number of abandoned appointments and same day cancellations we have made a revision

to our office policy about walk-in appointments and no-shows.

Effective January 1, 2012 Family Medicine Clinic of Federal Way is instituting a no-

show/broken appointment policy. Failure to cancel a scheduled appointment within 24

hours of the start of the day at 9am, no-showing (abandoning) a scheduled appointment,

or arriving more than 30 minutes late to a scheduled appointment will result in a $25

service charge.

Situations of repeat no-shows, late cancellations, late arrivals, and other forms of broken

appointments will require a non-refundable $25 deposit for the upcoming appointment.

We feel this $25 service charge is necessary as a broken appointment denies the

opportunity of another patient being provided care. Please be aware this deposit is not

included in any insurance copayment amounts or payments toward an existing balance.

Our commitment to you and your health, we strive to provide timely, satisfying care. As

part of our commitment to your health care needs we will give you a reminder call for

your scheduled appointment at least 48 hours in advance using the telephone number(s)

on file. Anytime you are uncertain of your appointments, please call. We will be happy to

verify them for you.

Sincerely,

Family Medicine Staff

NON-COVERED SERVICES CONSENT FORMRequired for the following Insurances:

All Regence Oregon Products

All Regence Washington Products

Premera. Blue Cross (Washington)

Premera Lifewise (Washington)

Lifewise of Oregon

HMA

___________________________________________________________________(patient name),

Understand that the services listed below may not be considered

eligible for benefits (e.g., services may be determined to not be

medically necessary, non-covered or investigational) by my health

plan. I understand my health insurance coverage has certain

restrictions and limitations such as authorization requirements, and

non-covered services and/or supplies.

Service Requested:Hormone Evaluation Vitamin Testing

Approximate Cost: $

YOUR CHOICE— CheckOnlyOne

I choose to have the service listed above and have my insurance

billed, knowing the cost may be declined if not medically necessary

and I will be responsible for payment.

I choose to have the service and

pay for it today.

l I decline the service.

Signature_________________

Date

__________________