14
Amelia Intern. Mine Gerald eurford, MD Todd DeVane. MD Henry Rodeffer. et, Suite 202 • Fernandina Beach, FL 32034 • Phone (904) 77-4690 • Fax (904)277 Dear Patient, Welcome to Amelia Internal Medicine. Please review the information below to get an idea of what to expect during your initial appointment. WHAT TO EXPECT AT YOUR INITIAL VISIT: Please arrive 20 rginytes before your appointmenttime to allow for parking and navigation to 1250 South 18 th Street, Suite 202; the 2 nd floor of Baptist Medical Center Nassau. RECEPTION: Office Check-In: Update personal and health insurance InfOrmation- please present your driver's license or photo ID and your insurance card(s) at appointment time Provide Co-pay if required PHYSICIAN CONSULTATION: (40 MINUTES) Meet Medical Assistant for Vital Signs, Review Medications and Medical Records Initial Medical Assessment and Treatment Plan RECEPTION: Office Check - Out: Schedule recommended follow - up appointments) Complete requests for Medical Records to obtain previous medical records from other physicians or health care providers who are not affiliated with Amelia Internal Medicine. LAB VISIT: On site lab tests may be ordered and can be completed in the designated laboratory in office. Fasting labs may be required; depending on the time of your appointment will determine when labs are scheduled. The laboratory schedule offers Monday- Thursday appointments 7:20am - 3:20pm. We recommend that you drink plenty of plain water the morning of your appointment. This prepares you for any lab test that may be ordered. We are delighted to welcome you to Amelia Internal Medicine!

Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

  • Upload
    dophuc

  • View
    217

  • Download
    1

Embed Size (px)

Citation preview

Page 1: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

Amelia Intern. Mine Gerald eurford, MD Todd DeVane. MD Henry Rodeffer.

et, Suite 202 • Fernandina Beach, FL 32034 • Phone (904) 77-4690 • Fax (904)277

Dear Patient,

Welcome to Amelia Internal Medicine. Please review the information below to get an idea of what to

expect during your initial appointment.

WHAT TO EXPECT AT YOUR INITIAL VISIT:

Please arrive 20 rginytes before your appointmenttime to allow for parking and navigation to 1250

South 18 th Street, Suite 202; the 2 nd floor of Baptist Medical Center Nassau.

RECEPTION: Office Check-In:

• Update personal and health insurance InfOrmation- please present your driver's license or photo

ID and your insurance card(s) at appointment time

• Provide Co-pay if required

PHYSICIAN CONSULTATION: (40 MINUTES)

• Meet Medical Assistant for Vital Signs, Review Medications and Medical Records

• Initial Medical Assessment and Treatment Plan

RECEPTION: Office Check- Out:

• Schedule recommended follow -up appointments)

• Complete requests for Medical Records to obtain previous medical records from other

physicians or health care providers who are not affiliated with Amelia Internal Medicine.

LAB VISIT:

• On site lab tests may be ordered and can be completed in the designated laboratory in

office. Fasting labs may be required; depending on the time of your appointment will

determine when labs are scheduled. The laboratory schedule offers Monday- Thursday

appointments 7:20am - 3:20pm. We recommend that you drink plenty of plain water

the morning of your appointment. This prepares you for any lab test that may be

ordered.

We are delighted to welcome you to Amelia Internal Medicine!

Page 2: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

Amelia Internal Medicine 1250 South 18IP Street Suite 202 Fernandina Beach, Florida 32034

Phone: 904-2774690 Fax: 904-277-8487

PATIENT INFORMATION SHEET (ADULT) PATIENT NAME: LAST FIRST MIDDLE INITIAL

Mr. Mrs. Ms.

DATE OF BIRTH:

HOME ADDRESS'

CITY:

__.

STATE: ZIP CODE'

' MAILING ADDRESS DIFFERENTPROM SS):

CITY. STATE: ZIP CODE:

E-MAIL ADDRESS: RELIGION (OPTIONAL):

EMPLOYER: OCCUPATION: YEARS EMPLOYED:

HOME PHONE. BUS PHONE: CELL PHONE.

DRIVER'S LICENSE: SOC: SEC. NO: MAIDEN NAME:

SEX MARITAL STATUS;

OMOF 0 SINGLE 0 MARRIED 0 DIVORCED 0 WIDOWED

REFERRED BY.

HIGHEST LEVEL OF EDUCATION:

SPOUSE'S NAME. LAST FIRST. MIDDLE INITIAL DATE OF BIRTH. SOC. SEC. NO:

RACE, ETHNICITY:

PRIMARY INSURANCE CARRIER NAME:

INSURANCE

LANGUAGE:

POLICY ID#: GROUP $:

INSURED'S NAME: LAST FIRST MIDDLE INITIAL DATE OF BIRTH

EMPLOYER: PATIENT RELATIONSHIP TO INSURED: D SELF 0 SPOUSE 0 CHILD 0 OTHER

' SOCIAL SECURITY # OF INSURED: EMPLOYER PHONE.

SECONDARY INSURANCE CARRIER NAME: POLICY ID #: GROUP A

INSURED'S NAME: LAST FIRST MIDDLE INITIAL

' EMPLOYER: PATIENT RELATIONSHIP TO INSURED:

0 SELF 0 SPOUSE 0 CHILD 0 OTHER

Signature: Date:

Page 2 of 11

Page 3: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

I HEREBYAUTHORIZE PAYMENT DIRECTLY TO AMELIA INTERNAL MEDICINE, INC, FOR MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME UNDER THE TERMS OF MY INSURANCE.

DATE:

SIGNATURE: RESPONSIBLE PARTY IF MINOR

Anielie Internal Medicine 1250 South 18°' Street, Suite 202 Fernandina Search, Florida 32034

Phone: 904-277-4690 Fax 904-277-8487

PAYMENT AT TIME OF SERVICE

IT IS OUR OFFICE POLICY THAT PAYMENTS ARE DUE AT THE TIME OF SERVICE. IF WE HAVE A CONTRACT

WITH YOUR INSURANCE COMPANY, WE WILL FILE YOUR INSURANCE. HOWEVER, YOU ARE RESPONSIBLE

FOR ALL COPAYS, CO-INSURANCES, DEDUCTIBLES, AND NON-COVERED SERVICES AT THE TIME OF

SERVICE, A $35.00 FEE WILL BE CHARGED FOR NO-SHOW PROVIDER APPOINTMENTS AND A$75,00 FEE

WILL BE CHARGED FOR NO-SHOW THIRD PARTY CONTRACTED SERVICES.

I UNDERSTAND AND AGREE THAT, REGARDLESS OF MY INSURANCE STATUS, I AM ULTIMATELY

RESPONSIBLE FOR THE BALANCE OF MY ACCOUNT. FOR ANY UNPAID BALANCE AFTER 98 DAYS, I

UNDERSTAND THAT MY ACCOUNT WILL BE CHARGED MONTHLY INTEREST OF 1.5% (18% ANNUAL).

I CERTIFY THAT THE INFORMATION PROVIDED ON THE REVERSE SIDE OF THIS FORM IS TRUE AND

CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOTIFY YOU OF ANY CHANGES IN THIS INFORMATION.

A PHOTOSTATIC COPY OR OTHER REPRODUCTION OF THIS WILL BE AS VALID AS THE ORIGINAL.

DATE: SIGNATURE: RESPONSIBLE PARTY IF MINOR

AUTHORIZATION FOR ASSIGNMENT OF BENEFITS (YEAR 1)

I HEREBYAUTHORIZE PAYMENT DIRECTLY TO AMELIA INTERNAL MEDICINE, INC. FOR MEDICAL BENEFITS, IF AN OTHERWISE PAYABLE TO ME UNDER THE TERMS OF MY INSURANCE,

DATE: SIGNATURE: RESPONSIBLE PARTY IF MINOR

AUTHORI T ON FOR ASSIGNMENT OF BENEFITS (YEAR 2)

I HEREBY AUTHORIZE PAYMENT DIRECTLY TO AMELIA INTERNAL MEDICINE, INC FOR MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE TO ME UNDER THE TERMS OF MY INSURANCE.

DATE: SIGNATURE: RESPONSWEPAMY IF MINOR

AUTHORIZATION FOR ASSIGNMENT OF BENEFITS (YEAR 3)

Page 3 of 11

Page 4: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

Main reason for today's visit

Other Concerns:

Where were you receiving your health care before? In the past 2 weeks, have you been bothered by: Little interest or pleasure in doing things? El No 0 Yes

Feeling down, depressed or hopeless? 0 No 0 Yes

REVIEW OF SYMPTOMS: Please mark the box and/or circle any persistent symptoms you have had in the past few months. Read through every section and check "no problems" if none of the symptoms apply to you. List other concerns above.

General Unexplained weight loss / gain Unexplained fatigue / weakness

_Fall asleep during day when sitting Fever, chills No Problems

Skin _New or change in mole _Rash / itching

No Problems

Breast Breast lump / pain / nipple discharge No Problems

Ears/Naseahroat Nosebleeds, trouble swallowing Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems

Eyes Change in vision / eye pain / redness No Problems

Cardiovascular Chest pain / discomfort Palpitations (fast or irregular heart beat) No Problems

Respiratory Cough I wheeze Loud snoring / altered breathing during sleep Short of breath with exertion No Problems

Gastrointestinal Heartburn / reflux / indigestion Blood or change in bowel habits

_Constipation No Problems

Genitourinary Leaking urine Blood in urine Nighttime urination or increased frequency Discharge: penis or vagina Concern with sexual function No Problems

Musculoskeletal Neck pain Back pain

_Muscle / joint pain No Problems

Endocrine Heat or cold sensitivity No Problems

Hematologic/Lymphatic Swollen glands Easy bruising No Problems

Neurological Headache Memory loss Fainting Dizziness Numbness / tingling Unsteady gait Frequent falls No Problems

Allangicilmmune Hay fever / allergies Frequent infections No Problems

Psychiatric Anxiety / stress / initability

_Sleep problem Lack of concentration No Problems

Women only _Pre-menstrual symptoms (bloating

cramps, irritabiltiy) Problem with menstrual periods Hot flashes / night sweats No Problems

IMMUNIZATIONS: Check off any vaccinations you have had. Add year, if known. Check the box if you don't know the information. E Tetanus(Td) With Pertussis (Thep) Varicella (Chicken Pox) shot or - illness Pneumovax (pneumonia) Prevnar 13 Influenza (flu shot) Influenza (High dose) Hepatitis A Hepatitis B MMR Meningitis Zostavax (shingles) HPV

Amelia Internal Medicine 1250 South 18t! Street, Suite 202 FernanclinaSeach, Florida 32034

Phone: 904-2774690 Fax: 904-277-6487

NAME' DATE OF BIRTH: Date

Adult Health History for NEW Patients Your answers on this form will help your health care provider get an accurate history of your medical concerns and conditions.

Please complete all pages. If you cannot remember specific details please provide your best recall. If you are uncomfortable with any question, do not answer it. Thank you!

Page 4 of 11

Page 5: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

ysicians: • ease list a p ysicians t at you are current y seeing an. sta tet e reason or same.

Allergies or intolerance to medications in Jude type of reaction):

❑ NONE

HEALTH MAINTENANCE SCREENING TESTS:

Lipid (cholesterol) Sigmoidoscopy or Colonoscopy (circle one) Bone Density Test PSA Carotid Ultra Sound Echocardiogram EKG Physical

Date Abnormal? ❑ No ❑ DYes 0 No D Yes ❑ No ❑ Yes ❑ No DYes ❑ No 0 Yes ❑ No ❑ DYes ❑ No ❑ Yes ❑ No ❑ DYes

Date Polyp? Date Abnormal? Date Abnormal?

Date Abnormal? Date Abnormal?

Date Abnormal? Date

Women only: Mammogram Pap Smear

PERSONAL MEDICAL HISTORY: Do you have now (current)

Date Abnormal? ❑ No 0 Yes 0 No DYes

the following conditions? ❑ NONE Date Abnormal?

or have you had (past) any of

Condition Code Current Past Comments

Alcohol 1 Drug abuse F10.10/F10 129

Allergy (Hay Fever Anemia D64.9

Anxiety F41.1/F41,9

Arthritis (Rheumatoid) M06.9 Arthritis (Osteoarthritis) M19.90

Asthma J45.909

Bladder / Kidney Problems Blood Clot (leg) 182.409/182.403

Blood Clot (Iunq 126.99

Blood Transfusion 251.89

Breast Lump (benign) N63

Cancer Breast D49.3

Cancer Colon 018.9

Cancer Other Type C80,1

Cancer Ovarian 280.41

Cancer Prostate 061

Chicken Pox 801,9

Wort Polyp D12.6

Coronary Artery Disease 125.10

Depression F32.9 Diabetes (adult onset) E11.9

Diabetes (childhood onset) E10.9 Diverticulosis K57.30 Emphysema J43.8 Fralures (List broken bones) T14.8

Galtgodder Disease K80.20

Gastroesppliageal Reflux (Heartburn( RD) K21.9 Glaucorr H40.9 Gout M10.9

Page 5 of 11

Page 6: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

PERSONAL MEDICAL HISTORY:Continued:

Condition Code Current,. Past Comments

Gynecological Conditions (Endometriosis) Gynecological Conditions (Fibroids) 287.898 Gynecological Conditions (Other) Heart Attack 121.3 Hepatitis - Type A 815.9

Hepatitis - Type B 819.10

Hepatitis - Type C 817,10

Hepatitis - Other B19.9 High Blood Pressure 110 High Cholesteml E78,00

Hip Fracture S72.009A

Irritable Bowel Syndrome K58.9 Kidney Disease / Failure N19

Kidney Stones N20.0 ._ Liver Disease k76,9 Migraine Headaches G43.909

Osteoporosis M81.0 Pneumonia 18,9 Prostate (enlargement) N40.0 Prostate (nodules) N40.2 Seizure / Epilepsy R56.9

Skin Condition tEczema) Skin Condition (Psoriasis) L40.8 Skin Condition (Abrtt rmal Moles) D485 Sleep Apnea G47.30/G47.31

Stomach Ulcer 125.9 Stroke 163.50 Thyroid (Nodule) E04.1 Thyroid High (Overactive) / Hyperthyroidism E05.90

Thyroid Low(Underactive) / Hypothyroidism E03.9 Other (list Other (list) Other (list)

SURGICAL HISTORY - Please check off any procedure or surgeries. List any abnormal finding or complications. 0 NONE

Condition Facility Date Physician Comments

Abdominal Surgery Appendectomy (appendix removal) Back-Surgery (lumbar) Biopsy (location) Circle: Right Left Both

Breast B' ++ y Circle: Right Left Both

Coronay - ass Coronary Stent EGO (Stomach Endoscopy) Cataract Gallbladder Removal Circle: Lapatoscopic

Heart Surjery (other than coronary bypass )

Hip Chic Right Left Both

ysterectomy tote , includingovaries) C :Loparoscopic via l Abdominal

Hysterectomy (partial) Circle paroscopic Vii*al Abdominal

Knee Surgery circle: tht nett Both

Page 6 of 11

Page 7: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

SURGICAL HISTORY - Continued

Condition Facility Date Physician Comments

LEEP (Cervix Surgery) Neck Surgery Ovary Ligation ribbe(") Ovary Removal Circle: Right Left Both

Vasectomy Sigmoidoscopy Sinus Surgery Other (list) Other (list}

Adopted - Yes No (please circle) If yes and you do not know your family history skip this section and continue to next

page. (Other Health Issues)

FAMILY HISTORY - Indicate which rely e has had the following diseases (parents and siblings are the most important),

Disease [

Mot

her

I Fa

ther

Siste

r(%)

;Bro

ther

(s)

Mom

's M

om

Mom

's D

ad

E O M in -0 a Da

d's

Dad

Other Relative Comments

No significant history known Alcoholism / Drug use Alzheimers Asthma Autoimmune Disease Bleeding_or Clotting Disorder Cancer greast Cancer Colon Cancer Other Type Cancer Ovarian Cancer Prostate Colon Polyp Coronary Artery Disease (e.g. heart attadt, angina) Depression / Suicide / Anxiety Diabetes (childhood onset) Diabetes (adult onset) Emphysema (COPD) genetic Disorder (explain)

lemma Heart Disease (CHF) Heart Disease (Other) Hepatitis B or High Blood Pressure' - Hypertension High Cholesterol Hip Fracture Hypothyroidism / Thyroid Disease Kidney Disease Kidney Stones Macular Degeneration Migraine Headaches Osteoporosis Other (list)

Page 7 of 11

Page 8: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

OTHER HEALTH ISSUES:

Tobacco Use Exercise: Do you exercise regularly? ❑ Yes c No

Smoke cigarettes ❑ Never ❑ No 0 Yes What kind of exercise?

(if you never smoked please go to alcohol use queston now)

Quit date: How many years did you smoke?

Approximately how many packs a day did you smoke?

Current smoker: Packs/Day: # of years:

Other tobacco 0 Pipe 0 Cigar 0 Snuff ❑Chew

Alcohol Use

Do you drink alcohol? 0 No ❑ Yes

# of drinks/week: ❑ Beer ❑ Wine ❑ Liquor

Drug Use Do you use marijuana or recreational drugs? ❑ No ❑ Yes

Have you ever used needles to inject drugs? 0 No 0 Yes

Sexual Activity

Sexually involved currently: a No o Yes

Sexual partner(s) is/are/have been: 0 Male ❑ Female

Birth control method (circle below all that appy): ❑None needed

Condom, pill, diaphragm, vasectomy, other

How long (minutes)? How often?

Diet: How would you rate your diet? ❑ Good ❑ Fair ❑ Poor

Would you like advice on your diet? ❑ No 0Yes

Safety: Do you use a bike helmet? ❑ No bike ❑Yes

0 No

Do you use seatbelts consistently? ❑Yes

0 No

Does your home have a working smoke detector? ❑Yes 0No

If you have guns in your home, are they locked up?

0 Not applicable 0 Yes

0 No Is violence at home a concern for you? ❑ No

°Yes

Have you completed an Advance Directive for Health Care

(ADHC), Living Will, or POLST (Physician Orders for Life Sustaining

Therapy)? (Circle all that apply) 0 Yes 0140

WOMEN'S HEALTH HISTORY

Total number of pregnancies: Number of births:

Date (month/day if known) of last menstrual period if you are still menstruating:

Age at beginning of periods (menstruation):

Age at end of periods (menopause):

ADDITIONAL INFORMATION

THANK YOU FOR TAKING THE TIME TO COMPLETE YOUR MEDICAL HISTORY.

Page 8 of 11

Page 9: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

Page 9 of 11

Allergies or intolerance to medications (include type of reaction): o NONE

Amelia Internal Medicine 1250 South 18°' Street, Suite 202 Firnandina'Beach, Florida 32034

Phone: 904-277-4690 Fax: 904-277-8487

Patient Name: DOB: Date:

Name of :medicine, vitamin.

or supplement

Prescribed by (if a prescription

medicine)

Purpose How often to take it and when

Other questions or concerns

Example: Medicine ABC

Example: To help control

high blood pressure

Example: Once a day

in the morning

. .

Example: Dr. Who

Page 10: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

PATIENT SELF DETERMINATION ACT QUESTIONAIRE

Don't Lose Your Right To Decide! ,

You cannot remove all uncertainty about your future health care needs but by having an advance directive you can have the peace of mind that comes from making your wishes known in advance!

Declaration To Decline Life-Prolonging Procedu (Living Will)

El I have made a Living Will.

El I do NOT have a Living Will.

Health Care Surrogate

El I have designated a Health Care Surrogate.

n 1 have NOT designated a Health Care Surrogate.

Durable Power of Attorney

11 I have appointed a Durable Power of Attorney for health care decisions.

11 I have NOT appointed a Durable Power of Attorney for health care decisions.

Print Name

Signature of Patient or Representative Date

If you have any further questions, you can contact your family attorney, local hospital, or local medical association for additional information.

omnibus Budget Reconciliation Act of 1990 (Patent Self-Determination Act) Chapter 765, Florida Statutes Page 10 of 11

Page 11: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

HIPAA Notice of Privacy Practices Amelia Internal Medicine

1250 South 18th Street, Suite 202 Fernandina Beach, FL 32034

(904)277-4690

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

PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected Health Information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out of those activities. You may also choose to opt back in.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers' compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

Revised: 12/7/17

Page 12: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following are statements of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information (fees may apply) — Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information — This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket.

You have the right to request to receive confidential communications — You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information — If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures — You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach — We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Please sign the accompanying "Acknowledgment" form. Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices. Form provided by: HCSI — 801947-0183 — http://www.hcsiinc.com

Page 13: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

Acknowledgment of Receipt of Notice of Privacy Practices

I hereby acknowledge that I have received or have been given the opportunity to receive/review a copy of Amelia Internal Medicine's

Notice of Privacy Practices. By signing below I am "only" giving acknowledgment that I have received or have been given the opportunity to receive/review this organization's Notice of our Privacy Practices.

Patient Name (Type or Print)

Patient's Date of Birth

Signature of Patient or Parent/Legal Guardian Date Signed

Name of parent/legal guardian if signing for patient

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, however, acknowledgment could not be obtained because:

❑ Individual refused to sign

❑ Communications barriers prohibited obtaining acknowledgement

❑ An emergency situation prevented us from obtaining acknowledgement

❑ Other (please specify):

Notes:

Page 14: Amelia Intern. Mine - storage.googleapis.com · Frequent sore throat, hoarseness Hearing loss I ringing in ears No Problems Eyes Change in vision / eye pain / redness No Problems

Amelia Internal Medicine 1250 South 18'n Street, Suite 202 Femaricitrig Beach, Florida 32034

Phone: 904-277-4690 Fax: 904-277-8487

Amelia Internal Medicine Gerald Burford, MD Todd DeVane, MD Henry Rodeffer, MD

1250 South 18th Street, Suite 202 • Fernandina Beach, FL 32034 to Phone (904) 277-4690 • Fax (904) 277-8487

Patient Consent Agreement for Chronic Care Management Services

My physician, has recommended that I receive Chronic Care Management (CCM) services because I have been diagnosed with two or more chronic conditions, which are • expected to last at least twelve months, and place my health at risk of decline. I understand that CCM services include: 24/7 access to a member of my care team via phone or other non-face-face means; a designated practitioner or care team member with whom I am able to get successive routine appointments; systematic assessment of my health care needs; processes to ensure timely receipt of preventative care services; oversight of my medication regimen; a jointly created and comprehensive care plan that is congruent with my choices and values; management of care transitions across all of my providers and settings; coordination with home and comonaity based clinical service providers.

By signing this agreement, I consent to receive these services and agree to the following:

• My provider has explained to me the availability and the elements of the CCM services that are relevant for my condition(s).

I consent to receive CCM services from the provider listed above and/or any associates he/she nnay designate to assist in providing me with CCM services,

• I understand that I have the right to stop CCM . services at any time (effective at the end of a calendar month) with this provider and the effect of a revocation of this agreement. I may revoke this agreement verbally by calling (904)277-4690, Option S or in writing to Amelia Internal Medicine, Attn: CCM. After revocation of this agreement, I may opt to receive CCM services from another healthcare provider in the month following revocation of this agreement

• I understand my Insurance permits only one practitioner to furnish and be paid for these services during a calendar month.

• I understand that I will receive a written or electronic copy of my comprehensive care pla

• I authorize electronic communication of my medical information with other treating providers.

• My provider has explained to me any potential cost-sharing obligations that may apply when re services.

Patient Name: DOB:

iving CCM

Patient Signature:

Date:

Chronic Care Conditions:

Page 11 0111