6401 Poplar Avenue, Suite 195Memphis, Tennessee 38119P 901-866-8547 | F 901-302-2547

Physician Order FormPatient name: ____________________________________________________

Date of birth: _____________________________________________________

Medical Record #: ________________________________________________

Diagnosis: __________________________________________________________________________________________________________________________

Research: ___________________________________________________________________________________________________________________________

Rx: __________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

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RetuRn appointment

❏ Office Visit ❏ Treatment ❏ Lab ❏ Diagnostics ❏ CSMD

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

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Referrals: ___________________________________________________________________________________________________________________________

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ULTRASOUND

❏ Abdominal

❏ Lower Extremity ❏ Upper Extremity

❏ R ❏ L ❏ Bilat ❏ R ❏ L ❏ Bilat

DATE:

LaBS❏ ABO Blood Group❏ Activated Protein C ❏ Anticardiolipin Ab lgG❏ Anticardiolipin Ab lgM Qn ❏ Anticardiolipin Ab lg G/M ❏ AT III Func/Immuno ❏ ADAMTS 13 Activity ❏ Antiparietal Cell Ab ❏ Antithrombin Activity❏ Beta-2Glyco Ab lgG❏ Beta-2Glyco Ab lgM ❏ Beta-2Glyco Ab lg G/M❏ Bilirubin, Direct ❏ CBC ❏ CD4/CD8 Ratio ❏ CEA ❏ CMP ❏ Coombs Direct❏ Cortisol❏ CRP ❏ Donath-Landsteiner ❏ AD-Dimer ❏ (EPO) Serum❏ Euglobulin Lysis❏ Factor II ❏ Factor V ❏ Factor V Leiden ❏ Factor V R2 DNA Anal❏ Factor VII❏ Factor VIII

❏ Factor VIII Assay ❏ Factor VIII Inhibitor ❏ Factor IX ❏ Factor X ❏ Factor XI ❏ Factor XII ❏ Factor XIII ❏ Ferritin ❏ Fibrinogen❏ Folate/RBC❏ Folic Acid ❏ Free Lt Chain❏ Haptoglobin ❏ HCV Reflex ❏ HCV RNA, PCR Qual ❏ Hemosiderin, Urine ❏ Hep B Ag ❏ Hep C Ab❏ Heparin Anti-Xa❏ Hepatitis Panel ❏ HIV 1/0/2Ag/Ab w/Rfl ❏ HLA DR 15 ❏ Homocysteine❏ lgG, Subclasses (1-4)❏ lgA, Qn, Serum ❏ lgE, Total ❏ lgG, Qn, Serum ❏ lg G/A/M/E❏ Inhibitor Panel_____________________________

❏ Intrinsic Factor Ab❏ Iron/TIBC ❏ LDH❏ PARIS ❏ Plasminogen ❏ PFA ❏ Plt Agg W/ADP, Epi, Collagen ❏ Plt Agg W/Ristocetin ❏ PNH❏ POC Urine❏ Protein C ❏ Protein C-Functional ❏ Protein S ❏ Protein S-Functional ❏ PT Fragment It2 MoAb ❏ Ptt Mixing ❏ Quant Ristocetin ❏ Reptilase Time❏ Sed Rate❏ SIEP ❏ Soluable Transferrin ❏ SPEP ❏ Thrombin Time❏ Vitamin B6❏ Vitamin B12 ❏ VW Factor ❏ VW Mulittimers ❏ VW Profile❏ UIEP❏ UPEP

❏ Other

__________________________________

__________________________________

__________________________________

__________________________________

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Provider Signature:

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Date:

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Registration Form

98100 - 4/17

PATIENT NAME (LAST, FIRST, MIDDLE INITIAL) SEX DATE OF BIRTH MARITAL STATUS RACE SOCIAL SECURITY NUMBER

PATIENT ADDRESS CITY STATE ZIP CODE PATIENT PHONE NUMBER

PATIENT EMPLOYER OCCUPATION & DEPARTMENT

EMPLOYER ADDRESS CITY STATE ZIP CODE WORK PHONE NUMBER

PRIMARY CARE PHYSICIAN ADDRESS CITY/STATE/ZIP PHONE NUMBER

SPOUSE OR GUARDIAN (LAST, FIRST, MIDDLE INITIAL) DATE OF BIRTH RELATIONSHIP TO PATIENT SOCIAL SECURITY NUMBER

SPOUSE OR GUARDIAN ADDRESS CITY STATE ZIP CODE SPOUSE OR GUARDIAN PHONE NUMBER

SPOUSE OR GUARDIAN EMPLOYER WORK PHONE NUMBER SPOUSE OR GUARDIAN EMPLOYER ADDRESS CITY STATE ZIP CODE

GUARANTOR NAME (LAST, FIRST, MIDDLE INITIAL) PATIENT RELATIONSHIP TO GUARANTOR GUARANTOR SS NUMBER

GUARANTOR ADDRESS CITY STATE ZIP CODE GUARANTOR PHONE NUMBER

GUARANTOR EMPLOYER DEPARTMENT

GUARANTOR EMPLOYER ADDRESS CITY STATE ZIP CODE WORK PHONE NUMBER

SUBSCRIBER NAME EXPIRATION DATE RELATIONSHIP TO INSURED

PRIMARY INSURANCE COMPANY ADDRESS CITY STATE ZIP CODE .

PRIMARY INSURED NAME GROUP NUMBER POLICY #, ID #, OR CERTIFICATE # EFFECTIVE DATE . SECONDARY INSURANCE COMPANY ADDRESS CITY STATE ZIP CODE RELATIONSHIP TO INSURED SECONDARY INSURED NAME GROUP NUMBER POLICY #, ID #, OR CERTIFICATE # EFFECTIVE DATE . DO YOU HAVE MEDICARE? MEDICARE NUMBER STATE DO YOU HAVE MEDICAID? MEDICAID NUMBER STATE

IS THIS VISIT RELATED TO AN ACCIDENT DATE OF INJURY

REFERRING PHYSICIAN NAME ADDRESS CITY STATE ZIP CODE PHONE NUMBER

WHO MAY WE NOTIFY IN CASE OF EMERGENCY? RELATIONSHIP PHONE NUMBER

/ /( )

( ) EXT.

❏ SPOUSE ❏ GUARDIAN ❏ PARENT

( ) EXT.

❏ SELF

❏ SPOUSE

❏ CHILD

❏ OTHER

❏ SELF❏ SPOUSE❏ CHILD❏ OTHER INS. #

❏ YES ❏ NO

PATIENT RESPONSIBILITIES: I understand that as the patient, parent, or guardian, I am legally responsible for payment of all charges relating to my care.Patient and/or guarantor(s) agree to pay reasonable attorney’s fee and cost of collection if patient’s account is placed in the hands of an attorney for handling.

PATIENT’S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII or XIX of the Social Security Act, or under other insurance coverage, is correct. I authorize any holder of medical or other information about me to release to S.S.A. or its intermediaries or carriers and/or the State in which I reside or its Fiscal Agents, or the insurance company or its representatives, any information needed for this or a related Medicare/Medicaid claim, or other insurance claim. In consideration of services rendered, I transfer and assign to University Clinical Health any payment which may become due to me for medical and/or surgical services under policies applicable to me or my dependent.

______________________________________________ ___________________________________________ ____________________________________________Patient signature (signature by mark must be witnessed) Guarantor signature Witness signature

❏ WORK ❏ HOME

❏ AUTO ❏ JOB RELATED

FSC # __________ IC # ____________INS. # ___________________

❏ YES ❏ NO

❏ SELF ❏ DEP CHILD❏ SPOUSE ❏ STUDENT ❏ OTHER

( ) EXT.

( )

( )

( )

FOR OFFICE USE ONLY: PLEASE COMPLETE CHART NO: MRN: DATE OF APPOINTMENT: CLINIC: DOCTOR:

PATIENT INFORMATION

BILLING INFORMATION /GUARANTOR

INSURANCE INFORMATION

PLEASE PRESENT INSURANCE CARD(S) TO RECEPTIONIST FOR PHOTOCOPYING

/ /

SPOUSE / GUARDIAN / NEXT OF KIN INFORMATION

6401 Poplar Avenue, Suite 195Memphis, Tennessee 38119P 901-866-8547 | F 901-302-2547

Review of SystemsPlease answer ALL questions.

ACM - 131357 - 9/16

1407 Union Avenue, Suite 700Memphis, Tennessee 38104-3641901-866-8864

Have you experienced any of the following in the last 6 months?

Date: ______________________________________________________

CONSTITUTIONAL ❍ All NoNo Yes❍ ❍ Good general health lately❍ ❍ Recent weight change ❍ ❍ Fever❍ ❍ Fatigue❍ ❍ Headaches

EYES ❍ All NoNo Yes❍ ❍ Eye disease or injury❍ ❍ Wear glasses/contact lens ❍ ❍ Blurred or double vision❍ ❍ Glaucoma

ENT ❍ All NoNo Yes❍ ❍ Hearing loss ❍ ❍ Ringing in the ears❍ ❍ Earaches or drainage❍ ❍ Sinus problems ❍ ❍ Nose bleeds ❍ ❍ Mouth sores❍ ❍ Bleeding gums❍ ❍ Bad breath or bad taste ❍ ❍ Sore throat or voice change❍ ❍ Swollen glands in neck

CARDIOVASCULAR ❍ All NoNo Yes❍ ❍ Heart trouble❍ ❍ Chest pains ❍ ❍ Sudden heart beat changes❍ ❍ Swelling of feet, ankles or hands

RESPIRATORY ❍ All NoNo Yes❍ ❍ Frequent coughing❍ ❍ Spitting up blood ❍ ❍ Shortness of breath ❍ ❍ Asthma or wheezing

GASTROINTESTINAL ❍ All NoNo Yes❍ ❍ Loss of appetite❍ ❍ Change in bowel movements❍ ❍ Nausea or vomiting ❍ ❍ Frequent diarrhea ❍ ❍ Painful bowel movements or constipation ❍ ❍ Blood in stool ❍ ❍ Stomach pain

GENITOURINARY ❍ All NoNo Yes❍ ❍ Frequent urination❍ ❍ Burning or painful urination❍ ❍ Blood in urine ❍ ❍ Change of force of strain when urinating ❍ ❍ Incontinence or dribbling❍ ❍ Kidney stones❍ ❍ Male - testicle pain ❍ ❍ Female - pain with periods❍ ❍ Female - irregular periods ❍ ❍ Female - vaginal discharge❍ ❍ Female - # pregnancies _________ ❍ ❍ Female - # miscarriages _________Female - date of last pap smear __________❍ ❍ Female - findings of last pap smear ❍ Normal ❍ Abnormal

MUSCULOSKELETAL ❍ All NoNo Yes❍ ❍ Joint pain❍ ❍ Joint stiffness or swelling❍ ❍ Weakness of muscles or joints❍ ❍ Muscle pain or cramps❍ ❍ Back pain ❍ ❍ Cold extremities❍ ❍ Difficulty in walking

SKIN ❍ All NoNo Yes❍ ❍ Rash or itching❍ ❍ Change in skin color ❍ ❍ Change ill hair or nails ❍ ❍ Varicose veins ❍ ❍ Breast pain❍ ❍ Breast lump ❍ ❍ Breast discharge

NEUROLOGICAL ❍ All NoNo Yes❍ ❍ Frequent or recurring headaches Light headed or dizzy❍ ❍ Convulsions or seizures❍ ❍ Numbness or tingling sensations ❍ ❍ Tremors ❍ ❍ Paralysis❍ ❍ Stroke

PSYCHIATRIC ❍ All NoNo Yes❍ ❍ Memory loss or confusion ❍ ❍ Nervousness❍ ❍ Depression❍ ❍ Sleep problems

METABOLIC / ENDOCRINE ❍ All NoNo Yes❍ ❍ Glandular or hormone problem ❍ ❍ Thyroid disease ❍ ❍ Excessive thirst or urination ❍ ❍ Heat or cold intolerance ❍ ❍ Dry skin ❍ ❍ Change in hat or glove size

HEMATOLOGIC / LYMPHATIC ❍ All NoNo Yes❍ ❍ Slow to heal after cuts ❍ ❍ Easily bruise or bleed❍ ❍ Anemia❍ ❍ Phlebitis ❍ ❍ Past transfusion❍ ❍ Enlarged glands

Please list your 3 chief complaints for today’s visit.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Patient Signature: ___________________________________

Provider Signature: ____________________________________

MRN

CHART NO

NAME

DOB Patient stamp above

Patient Choice –University Clinical Health Bleeding Disorder Program made this policy to make sure you understand that you have many rights. You have the right to choose your bleeding disorder care doctors, clotting factor products (after talking with your doctor), and pharmacies. Please know that the staff does not practice medicine and does not support any single pharmacy, factor product or treatment plan.

There are several types of pharmacies. These include pharmacies run by Hemophilia Treatment Centers (HTCs), hospital pharmacies, non-profit pharmacies, and for-profit home health care agencies. These pharmacies can provide patients with clotting factor products and supplies. HTC staff will not limit your choice; but, your insurance company may limit your choice.

Provider Choice - Patients have a right to take part in their medical care and treatment. Patients also have a right to choose from whom they wish to buy these services. HTCs that receive government money exist in the region. These HTCs must provide care and services that meet the clinical standards to receive federal government funds. HTCs offer a skilled team of doctors, nurses, social work-ers, physical therapists and others. These teams have experience in caring for people with hemophilia and other bleeding disorders. A list of federally funded HTCs may be found on the Centers for Disease Control and Prevention (CDC) website https://www2a.cdc.gov/ncbddd/htcweb/Dir_Report/Dir_Search.asp.

Treatment Product Choice – The HTC doctor will talk with you about your type of bleeding disorder and bleeding history. He or she will also talk about the safety and general cost of the products available to treat your bleeding disorder. Together, you and your doctor will decide on a product and treatment plan. The HTC will tell you and your family about new products so that you can make good choices.

Delivery of Clotting Factor Products – You are free to make your decision about which pharmacy you will use to buy your treat-ment product. These choices include (but are not limited to) an HTC pharmacy, a hospital pharmacy, a non-profit pharmacy, or a commercial (for-profit) home care company. Patients are not required to purchase their factor from the HTC.

Patient Rights and Consumer Information - HTC staff will give patients a copy of the National Hemophilia Foundation’s (NHF) “Consumer Bill of Rights and Responsibilities" during a yearly visit. See the NHF website at www.hemophilia.org for more information.

I/we have received the above information. I/we have been given choice of a treatment center, a product, and a pharmacy/home health care agency. This form will be kept in my medical record.

__________________________________________________________________ _____________________________________Name (Printed) Relationship to Patient

__________________________________________________________________ _____________________________________Signature Date

Patient Choice Policy6401 Poplar Avenue, Suite 195Memphis, Tennessee 38119P 901-866-8547 | F 901-302-2547

11/16

Health Information Management - Medical Records1407 Union Avenue, Suite 700

Memphis, Tennessee 38104-3600901-866-8400 • Fax: 901-302-2400

MRN

Name

DOB

Patient stamp or label above Consent and Agreement

Part I. Medical Treatment Consent: I (the undersigned, and/or the parent or legal guardian) consent to the administration of reasonable and necessary services in connection with treatment of the above-mentioned patient at University Clinical Health (UCH). This consent includes, but is not limited to, labora-tory procedures, medication administration, infusions, procedures, and/or services rendered to a patient by members of the medical staff, their representatives, and/or associates, and employees under the instruction of the physician. I acknowledge that no guarantees have been made to me as to the results of treatments or examination in the clinic.

Part II. Release of Information, Assignment of Insurance Benefits, and Financial Agreement: Release of Information: I hereby authorize UCH and any physician who has rendered services to release any and all information pertaining to my (or the patient’s) treatment to enable the collection of benefits for the services rendered. The authorization includes release of information to insurance companies or healthcare providers, in whole or in part, for payment in exchange for services rendered, whether such payment is in exchange for services rendered by UCH or by the physicians. Release of Information is also authorized to any providers for follow-up medical care. A copy of UCH’s Request for Restrictions Form must be submitted in writing to terminate this agreement.

Assignment of Benefits: I hereby authorize and assign payment directly to UCH for benefits, including secondary benefits, due to me for medical services. I understand that I am financially responsible for charges not covered by any insurance or medical benefit payor. I further acknowledge that any benefits, when received by and paid to UCH will be credited to my account in accordance with this assignment.

Financial Agreement: I understand and agree that I am financially responsible to UCH, and/or physician for any charges not covered by the authorization below or charges not covered by insurance.

I agree that in order to collect any amounts I may owe for services provided by UCH, UCH or its designee may contact me via telephone at any telephone number associated with my account, including wireless telephone numbers, which could result in cellular charges. We may also contact you by sending text messages or e-mails, using any e-mail address you provided to us. Methods to contact may include using pre-recorded/artificial voice messages and or use of an automatic dialing device, as applicable.

I/We have read this disclosure and agree that UCH and/or its designee for collecting any amounts I may owe UCH may contact me as described above.

In addition, with respect to future treatments at UCH, this document is ongoing in nature and will remain in effect until revoked by me in writing.

080314 - 12/15 - Scan to Consent White copy - Clinic, Yellow copy - Patient

*If Personal Representative, the patient is unable to sign because (check one): ❑ Minor ❑ Incompetent❑ Other (explain): ___________________________________________________________________________________________

I hereby give permission to receive services and treatment by my physician (and/or associates) at UCH I authorize the release of in-formation including protected health information as needed to file for payment for services incurred. I fully understand my Financial Responsibility for services rendered at UCH.

Signature of Patient or Personal Representative*

Date

Printed Name of Patient or Personal Representative*

*Relationship to Patient (if Personal Representative)

For Office Use Only: Date received ____________________ Received by: _________________________ Check if applicable: ❑ Patient refused to sign Consent and Agreement (explain):__________________________

Dear Patient,

Thank you for choosing University Clinical Health (UCH). Each time you visit one of our health care providers, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. The doctors and staff of UCH use and maintain this and other health information related to the care you receive from us.

The attached version of our full Notice of Privacy Practices contains information to help you understand what is in your medical record and how your health information is used. This lets you better understand who, what, when, where, and why others may have access to your health information. It also helps you ensure the correctness of such information.

Please keep the full Notice and take it home with you. You may read it now or later. In either case, let us know if you have any questions after reviewing it. If you did not receive the full Notice, please ask the front desk staff person for a copy.

Please sign below to show that you received UCH’s full Notice:

Signature of Patient or Personal Representative* Printed Name of Patient or Personal Representative*

Date *Relationship to Patient (if Personal Representative)

*If Personal Representative, the patient is unable to sign because (check one):

❑ Minor ❑ Incompetent ❑ Other (explain): ___________________________________________________

Date received: _____________________________ Patient MRN: ____________________________

Received by (employee name): __________________________________________________________

❑ (Check if applicable) Patient refused to sign acknowledging receipt of the full Notice (explain):

____________________________________________________________________________________

____________________________________________________________________________________

For Office Use Only

Health Information Management - Medical Records1407 Union Avenue, Suite 700Memphis, Tennessee 38104-3600901-866-8400 • Fax: 901-302-2400

Summary ofNotice of Privacy Practices

030188 - 2/16 White - Medical Record | Yellow - Patient

UNDERSTANDING YOUR MEDICAL RECORD/HEALTH INFORMATION

Each time you visit University Clincal Health (UCH) a record of your visit is made. It usually includes information about your symptoms, examination, test results, diagnoses, treatment, and a plan for future care and treatment. This information is often called your “medical record.” This information and other information relating to your care are referred to in this Notice as “Health Information.”

The Health Information contained in your medical record is useful for many reasons. For example, this information: • Servesasabasisforplanningyourcareandtreatment • Provides a means of communication among the many health care professionals who are part of your care • Describesthecareyoureceive • Allowsyou,yourinsurancecompanyorotherthird-partypayertomakesurethattheservicesbilledwereprovidedtoyou • Allowshealthcareprofessionalsandorganizationsinvolvedinyourcaretoconducttreatment,payment,andhealthcare

operations • Containsinformationwewillneedtocontactyouaboutappointmentreminders,treatment

alternatives,orotherhealth-relatedbenefitsUnderstanding what is in your record and how your Health Information is used helps you to understand who, what, when,

where, and why others may access your Health Information and to make sure that it is correct. This, in turn, allows you to make better decisions about its use and disclosure.

YOUR HEALTH INFORMATION

EventhoughyourHealthInformationatourofficesbelongstoUCH,youhavecertainrightsrelatingtothisinformation.Asapatient, you generally have the right to: • RequestacopyorsummaryofyourHealthInformationortoinspectit • RequestanamendmenttoyourHealthInformationifyoufeelthereisanerror • RequestarestrictiononusesanddisclosuresofyourHealthInformationfortreatment,paymentorhealthcareoperations.Youalso

havetherighttorequestalimitontheHealthInformationwediscloseaboutyoutosomeoneinvolvedinyourcareorthepaymentforyourcare,likeafamilymemberorafriend.Wewillinformyouofourdecisiononyourrequest.RequestsshouldbesubmittedinwritingtoourPrivacyOfficerwhoseaddressislistedattheendofthisnotice.Unlessotherwiserequiredbylaw,wemustcomplywitharequestfromyounottodiscloseyourHealthInformationtoahealthplan,ifthepurposeforthedisclosureisnotrelatedtotreatment,andthehealthcareitemsorservicestowhichtheinformationapplies(suchasagenetictest)havebeenpaidforout-of-pocketandinfull;otherwise,wearenotrequiredtoagreetoyourrequest.Ifwedoagree,wewillcomplywithyourrequestunlessthe information is needed to provide you emergency treatment. Except for restrictions that we must comply with relating to health plans, we may terminate our agreement to a restriction at any time by notifying you in writing, but our termination will only apply to information created or received after we sent you the notice of termination, unless you agree to make the termination retroactive.

• Obtainanaccountingofwhenandwithwhomwehave sharedordisclosedyourHealth Information for some typesofdisclosures(afeewillbechargedtofulfillrepeatedrequestsforsuchaccountings)

• RequestthatwecommunicatewithyouaboutyourHealthInformationinaparticularwayoratacertainlocation • ObtainapapercopyofourNoticeofPrivacyPractices • RevokeapreviousauthorizationtocertainusesanddisclosuresofyourHealthInformationbyus,exceptwhereactionshave

alreadybeentakenbyusrelatingtothatauthorizationorwheretheauthorizationwasobtainedasaconditionofobtaininginsurance coverage, and other law provides the insurer with the right to contest a claim under the policy or the policy itself.

• FileacomplaintifyoubelievethatyourprivacyrightshavebeenviolatedAnyrequestsorquestionsabouttherightslistedaboveshouldbedirectedto:PrivacyOfficer,

University Clinical Health, at1407UnionAvenue,Suite700,Memphis,TN38104-3673, (901)866-8105,Fax:(901)302-2105.Youmayalsocallourconfidentialcompliancehotlineat901-866-8992.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

TO THIS INFORMATION. PLEASE READ IT CAREFULLY.

Notice of Privacy PracticesHealth Information Management - Medical Records1407 Union Avenue, Suite 700Memphis, Tennessee 38104-3600901-866-8400 • Fax: 901-302-2400

OUR RESPONSIBILITIES

UCHisrequiredto: • ProtecttheprivacyofyourHealthInformation • ProvideyouwithacopyofthisNoticedescribingourprivacypoliciesandlegalduties • AbidebythetermsofourcurrentNotice • Notifyyouifweareunabletoagreeto,ortocomplywith,yourrequestfor:accessorchangestoyourHealthInformation,

anaccountingofdisclosuresofyourHealthInformation,restrictionsondisclosuresofyourHealthInformation,confidentialcommunicationswithyouaboutyourHealthInformation,oryourrevocationofyourauthorization

• AccommodatereasonablerequeststocommunicatewithyouaboutyourHealthInformationinaparticularwayoratacertainlocation • NotifyyoufollowingabreachofyourunsecuredHealthInformation • ObtainwrittenauthorizationfromyouforanytypesofusesanddisclosuresnotmentionedinthisNotice.Youmayrevokeany

authorizationyouhavegivenusatanytimebysendingaletterto:UCHPrivacyOfficerat1407UnionAvenue,Suite700,Memphis,TN38104-3673.RevocationswillnotbeeffectivetotheextentweusedanddisclosedyourHealthInformationinrelianceontheauthorizationpriortoreceivingyourrevocationorwheretheauthorizationwasobtainedasaconditionofobtaininginsurancecoverage, and other law provides the insurer with the right to contest a claim under the policy or the policy itself.

We reserve the right to change our Notice and our privacy practices and to make the new provisions effective for all Health Information we keep. Should our privacy practices change, we will post our revised Notice at all of our clinics and on our website at www.univerityclinicalhealth.com.AnupdatedversionmayalsobeprovidedatyourrequestduringareturnvisittoUCHorfromourPrivacyOfficer.

WewillnotuseordiscloseyourHealthInformationwithoutobtainingyourauthorization,exceptasdescribedinthisNoticeorasotherwiserequiredorpermittedbylaw(forexample,inemergencytreatmentsituations).

Althoughotherhealthcareprovidersmayprovidetreatmenttoyou(forexample,hospitalsorotherphysiciangroups),wearenotjointly managed with or owned by such providers. They will have their own policies and procedures for handling your Health Information.

WAYS WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION

UnderTennesseelaw,wemaynotdivulgeyourname,address,orotheridentifyinginformationexceptfor(a)statutorilyrequiredreportingtohealthorgovernmentauthorities,(b)respondingtoasubpoenaorcourtorder,(c)respondingtoarequestforinformationauthorizedbystateorfederallaw;and(d)allowingaccessbyinsurancecompaniesorotherpayersforutilizationreview,casemanagement, peer review or other administrative functions. Within these parameters, the following categories describe some of the ways in which we may use and disclose your Health Information:

1. Treatment. We will use your Health Information to treat you. For example, information obtained by a nurse, physician, or other member of your UCH health care team will be recorded in your record and used to determine your course of treatment.

Some of our clinics may keep your Health Information in an electronic medical record (EMR), and this Health Information may be sharedacrossourclinicsfortreatment.EMRsmaybeequippedwithpatientportals,whichallowsomepatientsorthosepersonstheyauthorizetoaccesscertainportionsoftheirrecord,paystatementsonline,andviewopenaccounts.Patientportalswillbegoverned by separate documents and may be deactivated by UCH in its discretion.

ExceptwhererestrictedbyapplicablelaworwhereUCHhasapprovedyourwrittenrequesttothecontrary,UCHmayalsoprovidecopies of your Health Information to other health care providers who care for you.

WemayshareyourHealthInformationwiththeMidSoutheHealthAllianceinacommunity-widehealthinformationsysteminwhichsomehealthcareprovidersmayaccessyourHealthInformationwhentreatingyou.Asapatient,youhavetherighttonotshareyourHealthInformationintheAlliance.Thisiscalled“OptingOut.”However,ifyouchoosetooptout,healthcareprovidersmay not have access to Health Information that may be important and useful in making choices about your medical care.

AnyquestionsaboutEMRs,thepatientportals,ortheAllianceshouldbedirectedtoourPrivacyOfficerat(901)866-8105.

2.Payment. We will use and disclose your Health Information to bill and collect payment for the services you receive from us. For example,wemaycontactyourhealthinsurertocertifythatyouareeligibleforbenefits,includingtherangeofbenefits.Wemayalso provide your insurer with details regarding your treatment or to obtain payment from third parties that may be responsible forsuchcosts,suchasfamilymembers.Also,wemayuseyourHealthInformationtobillyoudirectly.

3. Health Care Operations. We will use your Health Information in our business operations. For example, we may use your Health Informationtoevaluatethequalityofcareyoureceivefromus,totrainresidents,studentsorotherhealthcareprofessionals,andto make business plans for our practice. However, we will limit the use and disclosure of your medical records, images, videos orpicturesintendedtobeusedforappropriatemedicaleducationalpurposes,evenifyourinformationhasbeende-identified.

4. Vendors. Some of our services are provided by outside vendors. For example, we might use a copy service to make copies of patient records for us. We may disclose Health Information to our vendors so that they can perform the job we have asked them to do. To protect your Health Information, werequirethesevendorstoagreeinwritingtokeepyourHealthInformationsafeusingmanyofthesamestandardsthatwearerequiredtoobserve.

5.Organized Health Care Arrangements. We may participate in arrangements with other health care entities to conduct joint health care-relatedactivities(forexample,qualityassurance,utilizationreview).Inthesearrangements,yourHealthInformationmaybe shared between the participants for treatment, payment, and certain operations purposes. Participants in these arrangements remain separate entities from each other and will have their own policies and procedures for handling your Health Information.

6. Appointment Reminders & Treatment Alternatives. We will use your Health Information to remind you of an appointment ortotellyouabouttreatmentalternativesandotherhealth-relatedbenefitsorservices.

7. Communication with Family and Others/Notification. We may disclose to a family member or other relative, close personal friend, or other person you identify, Health Information that is relevant to that person’s involvement in your care or payment for your care. We mayalsodiscloseyourHealthInformationtodisasterreliefauthoritiessothatyourfamilycanbenotifiedofyourlocationandcondition.Ifyouwouldliketorequestarestrictiononsuchdisclosures,pleasecontactourPrivacyOfficerat(901)866-8105.

8.Persons under the Age of 18. Goodmedicalpractice,paymentrequirements,orstatelawmaymakeitnecessarytotellyourparents or guardian about your visit or provide them with all or part of your Health Information. This does not apply if you are or have been married or have by court order or otherwise been freed from the care, custody and control of your parents.

9. Limited Data Sets and De-identified Information. In some instances where we use or disclose information for purposes of research, public health, health care operations, or other activities, certain information (names, social security numbers, etc.) will be removed to help protect your identity.

10. Research. We may use or disclose your Health Information for research purposes in certain circumstances. For example, whenyouhaveprovidedawrittenauthorization,foractivitiespreparatorytoresearch,and/orwhenaresearchprotocolhasbeendesigned and approved by an Institutional Review Board (IRB) or privacy committee (for example, the IRB for The University of Tennessee Health Science Center or an IRB at Methodist Healthcare Foundation).

11. Deceased Patients. We may release Health Information to coroners, medical examiners or funeral directors to permit them to carryouttheirduties,orotherwisewiththeapprovalofanauthorizedrepresentativeforthedeceasedpatient.

12. Organ or Tissue Donation. WemaydiscloseyourHealthInformationtoorganizationsthathandleorgan,eyeortissueprocurementor transplantation, including organ donation banks, as necessary to facilitate organ, eye or tissue donation and transplantation. 13. News Gathering Activities.Amemberofyourhealthcareteammaycontactyouoroneofyourfamilymemberstodiscusswhether or not you want to participate in a media or news story. For example, a reporter working on a story about a new therapy may ask whether any of our patients undergoing that therapy would be willing to be interviewed. In such a case, we might contact youtoaskwhetheryouwouldbewillingtobeinterviewedandaskforyourauthorizationinwritingbeforegivingthereporteryour name.

14. Fundraising. Someone from The University of Tennessee Health Science Center or another business associate of UCH may wish to contactyouaspartofafund-raisingeffortonourbehalf.Wemayuse,ordisclosetoabusinessassociateorTheUniversityofTennesseeHealth Science Center, the following information to contact you for our fundraising activities: your name, address, other contact information, age, gender and date of birth, the department(s) where you received services, your treating physician, your outcome information, your healthinsurancestatus,andthedatesyoureceivedservices.Youhavetherighttooptoutofreceivingourfundraisingcommunications.Ifyouoptoutofreceivingfundraisingcommunications,youcanalwayschoosetooptbackinwithrespecttospecificcampaignsorasktobecontactedforourfundraisingeffortsbycallingusat(901)866-8105. We do not condition treating you on your choice of whether to receive fundraising communications.

15.Food and Drug Administration (FDA). We may disclose your Health Information to a person subject to the jurisdiction of theFDA,forpublichealthpurposesrelatedtothequality,safety,andeffectivenessofFDA-regulatedproductsandactivities(forexample,relatingtoadverseeventswithrespecttofoodorsupplements,productsandproductdefectsorpost-marketingsurveillanceinformation to enable product recall, repair or replacement of regulated items).

16. Workers Compensation. We may disclose your Health Information to comply with laws relating to workers compensation or other similar programs established by law.

17. Public Health. WemaydiscloseyourHealthInformation,asprovidedbylaw,topublichealthofficialsorlegalauthoritieschargedwith improving health or preventing or controlling disease, injury, or disability.

18.Military Service. WemayuseordiscloseyourHealthInformationifyouareintheArmedForcesforactivitiesdeemednecessaryto assure proper execution of military missions, provided certain conditions are met. If you are a member of a foreign military force, we may use your Health Information or disclose it to your appropriate foreign military authority for activities deemed necessary to assure proper execution of military missions, provided certain conditions are met.

19. National Security and Intelligence Activities.WemaydiscloseyourHealthInformationtoauthorizedfederalofficialsfortheconductoflawfulintelligence,counter-intelligence,andothernationalsecurityactivitiesauthorizedbytheNationalSecurityActandimplementingauthority.WemayalsodiscloseyourHealthInformationtoauthorizedfederalofficialsfortheprotectionofthePresidentorotherpersons,or for certain federal investigations.

20.Correctional Institutions/Law Enforcement Custodians. Should you be an inmate of a correctional institution or be in the lawfulcustodyofalawenforcementofficial,wemaydiscloseyourHealthInformationtotheinstitutionortheofficialifnecessaryfor your health, the health and safety of other inmates or law enforcement, and the safety of the institution at which you reside.

21.Required by Law.WemayuseordiscloseyourHealthInformationtotheextentthattheuseordisclosureisrequiredbylaw.Theuseordisclosurewillbemadeincompliancewiththelawandwillbelimitedtotherelevantrequirementsofthelaw.Ifrequiredbylaw,youwillbenotifiedofanysuchusesordisclosures.

22.Child Abuse and Neglect. We may disclose your Health Information for public health activities and purposes to a public healthauthorityorothergovernmentalauthoritythatisauthorizedbylawtoreceivereportsofchildabuseorneglect.

23.Other Abuse and Neglect. We may disclose your Health Information if we believe that you have been a victim of abuse, neglectordomesticviolencetothegovernmentalentityoragencyauthorizedtoreceivesuchinformation.Inthiscase,ifyoudonotagreetothedisclosure,thedisclosurewillbemadeconsistentwiththerequirementsofapplicablefederalandstatelaws,andonlyifrequiredorauthorizedbylaw.

24.Communicable diseases. We may disclose your Health Information for public health activities and purposes to a person who may beatriskofcontractingorspreadingadisease,ifsuchdisclosureisauthorizedbylaw.

25. Workplace Health Surveillance. We may disclose your Health Information for public health activities and purposes to your employer, for the purposes of conducting an evaluation of medical surveillance of the workplace or for the purposes of evaluating whetheryourhaveawork-relatedillnessorinjury.

26. Health Oversight Activities. WemaydiscloseyourHealthInformationtoahealthoversightagencyforactivitiesauthorizedbylaw,such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee thehealthcaresystem,governmentbenefitprograms,othergovernmentregulatoryprogramsandentitiessubjecttothecivilrightslaws.

27. Judicial and Administrative Proceedings. We may use or disclose your Health Information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal, or in certain conditions in response to a subpoena,discoveryrequestorotherlawfulprocessnotaccompaniedbyanorderofacourtoradministrativetribunal,subjectto any applicable privileges.

28. Law Enforcement. WemaydiscloseyourHealthInformationforalawenforcementpurposetoalawenforcementofficialifcertain conditions are met.

29. Averting a Threat. We may, consistent with applicable law and standards of ethical conduct, use or disclose your Health Information if we believe that the use or disclosure is necessary to prevent or lessen a serious threat to the health or safety of a person or the public; provided that, if a disclosure is made, it must be to a person(s) reasonably able to prevent or lessen the threat. We may also use or disclose your Health Information if we believe that the use or disclosure is necessary for law enforcement authorities to identify or apprehend an individual who: (i) admits to participation in a violent crime that we reasonably believe caused serious physical harm to the victim, or (ii) appears to have escaped from a correctional institution or lawful custody.

30. Certain Uses and Disclosures for which an Authorization is Required. Certain uses and disclosures by us of your medical informationrequirethatweobtainyourpriorwrittenauthorization.Theseinclude: a.PsychotherapyNotes.IfPsychotherapyNotesarecreatedforyourtreatment,wemustobtainyourpriorwrittenauthorizationbeforeusingordisclosingthem,except(1)ifthecreatorofthosenotesneedstouseordisclosethemfortreatment,(2)foruseordisclosureinourownsupervisedtrainingprogramsinmentalhealth,or(3)foruseordisclosureinconnectionwithourdefenseofaproceedingbroughtby you. “Psychotherapy Notes” means notes recorded (in any medium) by a health care provider who is a mental health professional documentingoranalyzingthecontentsofconversationduringaprivatecounselingsessionoragroup,joint,orfamilycounselingsessionand that are separated from the rest of the individual’s medical record. “Psychotherapy Notes” excludes medication prescription and monitoring,counselingsessionstartandstoptimes,themodalitiesandfrequenciesoftreatmentfurnished,resultsofclinicaltests,andany summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. b.Marketing.IfweuseordiscloseyourHealthInformationformarketingpurposes,wemustfirstobtainyourwrittenauthorizationtodoso,exceptifthecommunicationisface-to-facebyustoyou,orisapromotionalgiftofnominalvalue. c. Sale of your medical information. If a disclosure of your Health Information would constitute a sale of it, we must firstobtainyourwrittenauthorizationtodoso.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

Ifyouhavequestionsorwouldlikeadditionalinformation,youmaycontactourPrivacyOfficerat(901)866-8105. Communications may also be sent by mail addressed to: UCHPrivacyOfficer,1407UnionAvenue,Suite700,Memphis,TN38104-3673. Youmayalsocallourconfidentialcompliancehotlineat901-866-8992.Ifyoubelieveyourprivacyrightshavebeenviolated,pleasefileacomplaintwiththePrivacyOfficer,aslistedabove,orwiththeSecretaryoftheU.S.DepartmentofHealthandHumanServices.Therewillbenoretaliationforfilingacomplaint.

THE POLICIES IN THIS NOTICE BECAME EFFECTIVE ON: September 23, 2013Earlier versions: April 14, 2003

*If Personal Representative, the patient is unable to sign because (check one):

❑ Minor ❑ Incompetent ❑ Other (explain): _____________________________________________________________________

Date received ____________________❑ All complete ❑ Proof of I.D. ❑ Signed copy to patient

Received by (employee name): ______________________________________ Clinic Name: ________________________________

Completed by (employee name): _____________________________________ Clinic Name: ________________________________

For Office Use Only

Signature of Patient or Personal Representative*

Date

Printed Name of Patient or Personal Representative*

*Relationship to Patient (if Personal Representative)

Authorization to Obtain, Use, and/or Disclose Health Information

Patient MRN

Name

DOBPatient stamp above - for HIM use only

UTMG 070584 - 1/16 WhiTe CoPY - MediCal ReCoRd, YelloW CoPY - PaTienT

Please PRINT or TYPE and return completed form to the above address.Patient Name: _______________________________________________________________________________________________

Address: ___________________________________________________________________________________________________

City:___________________________________________________ State: __________ ZIP: ________________________________

Date of Birth: ___ / ____ / ______ Social Security Number: ____________________ Phone Number: __________________________

1. I authorize UCH to obtain and/or disclose a copy of the health information described below (Please check ❑To be obtained from or ❑To be disclosed to):

_______________________________________________________________________________________________________

Mailing Address: _________________________________________________________________________________________

City_________________________________________________State: ________ZIP: __________________________________ 1(a). Information to be released: ❑ Complete medical record ❑ Laboratory results ❑ Progress notes ❑ Immunization record ❑ Other (specify) _____________________________________________________________________ 1(b). Purpose or need for the information is (optional) ____________________________________________________________

2. I understand that the information in my health record may include information relating to a sexually transmitted disease, acquired im-munodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

3. I understand that I can revoke this authorization at any time by sending my written request to: UCH Health Information Management Department at 1407 Union Avenue, Suite 700, Memphis, TN 38104-3600. Such written revocation will be effective only after receipt and processing by UCH. If I revoke this authorization, the information described above may no longer be used or disclosed for the purposes described in this authorization. I understand that the revocation will not apply to information that has already been obtained, used and/or disclosed under this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

4. Unless revoked, this authorization will expire on the following date, event or condition: ____________________________________If I fail to specify an expiration date, event, or condition, this authorization will automatically expire in six (6) months from the date of my request.

5. I understand that a disclosure of information under this authorization carries with it the potential for re-disclosure by the recipient and that the informa-tion may no longer be protected by federal confidentiality rules. If I have questions about the uses and disclosures of my health information at UCH, I can contact: UCH Privacy Officer at 1407 Union Avenue, Suite 700, Memphis, TN 38104-3673, Phone: (901) 866-8105, Fax: (901) 302-2105. I understand that I can refuse to sign this authorization. I need not sign this authorization in order to obtain treatment, payment, or health plan enrollment or eligibility.

6. I understand that I can refuse to sign this authorization. I need not sign this authorization in order to obtain treatment, payment, or health plan enrollment or eligibility.

Health Information Management - Medical Records1407 Union Avenue, Suite 700

Memphis, Tennessee 38104-3600901-866-8400 • Fax: 901-302-2400

*If Personal Representative, the patient is unable to sign because (check one):

❑ Minor ❑ Incompetent ❑ Other (explain): _________________________________________________

Date received ____________________❑ All complete ❑ Proof of I.D. ❑ Signed copy to patient

Received by (employee name): ______________________________________ Title: __________________

Completed by (employee name): ____________________________________ Title: __________________

For Office Use Only

Signature of Patient or Personal Representative*

Date

Printed Name of Patient or Personal Representative*

*Relationship to Patient (if Personal Representative)

Family and Friends Release Agreement

UTMG 070230 - 2/16

Please PRINT or TYPE and return completed form to the above address.

Dear Patient:Please use this form to provide us with written permission to disclose confidential information (such as lab results, test results, prescription information) to a specific individual (such as a spouse, family member, or close personal friend).

Patient Name: ____________________________________________________________________________________

Address: ________________________________________________________________________________________

City:___________________________________________________ State: __________ ZIP: _____________________

Date of Birth: _______ / ________ / ____________ Phone Number: ________________________________________

1. I authorize UTMG to disclose confidential information relating to my care as specified in Section 2 below:2. I authorize disclosure of my information to (check all that apply):

❑ Spouse ❑ Family member (specify relationship) ❑ Other (specify relationship)

Name: ____________________________________________________________________________________

Relationship: ______________________________________________________________________________

Address ___________________________________________________________________________________

City:_________________________________________________State: ________ZIP: ____________________

Telephone: ________________________________________________________________________________ 3. I understand that I can revoke this authorization at any time by sending my written request to: the UTMG Privacy Officer at 1407 Union Avenue, Suite 700, Memphis, TN 38104-3673; (901) 866-8105. Such written revocation will be effective only after receipt and processing by UTMG. I understand that the revocation will not apply to information that has already been used or released under this agreement.

4. I understand that I can refuse to sign this agreement. If I have questions about this agreement or uses and disclosures of my health information at UTMG, I can contact: UTMG Privacy Officer at 1407 Union Avenue, Suite 700, Memphis, TN 38104-3673, Phone: (901) 866-8105, Fax: (901) 302-2105.

Expiration Date (six months after date of signing)

Health Information Management - Medical Records1407 Union Avenue, Suite 700Memphis, Tennessee 38104-3600901-866-8400 • Fax: 901-302-2400