Patient Registration Form T Tr'1Q( THE UROLOGY CENIER

SOUTHERN CALIFORNIA

Innoative and Comprehensive Urological Care

Last Name First Ml LI Female Birth date Home Phone

L3 Male / /

Address Apt# City State Zip

Cell Phone Social Security: Marital Status

Drivers License: Li Single Li Married LI Divorced Li Separated LI Widowed

Occupation Employer Name! Address

City State Zip Work Phone LL

I— Emergency Contact Relationship Phone

LU

E-Mail Contact Preference 0

Li Home Phone Li Cell Phone

Referred to us! How did you hear about us?

LI Dr. Li Hospital: Li Insurance Plan:

Li Family/Friend Li Yellow Pages Li UCOSC Website Li Healthgrades.com

Li Inland Empire Magazine Li Other Website:

Primary Insurance- Name and Address Phone

2 Q Subscriber Name Subscriber # Group# Subs. DOB

Z. Patients Relationship to Subscriber: LI Self LI Spouse Li Child U Other

0 LL

If patient is a minor, person responsible for bill: Relationship:

Z u.j Responsible Party Social Security No: Responsible Party Birth Date:

Z Secondary Insurance- Name and Address Phone

cic

Subscriber Name Subscriber # Group# Subs. DOB

/1

Patients Relationship to Subscriber: LI Self LI Spouse LI Child LI Other

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize The Urology Center of Southern California Medical Group or insurance company to release any information required to process my claims.

Patient! Guardian Signature: Date

ucoscI THE UROLOGY CENTER'f SOUTHERN CALIFORNIA

1i1flOVatIvC and Comprehensive tJroIogieal Care

Patient Communication Consent Form

Patient Name (Last, First, Middle Initial):

Date of Birth:

I authorize The Urology Center of Southern California and medical staff to discuss my

healthcare information (which may include history, diagnosis, labs, test results,

treatment and other health information) with the contacts listed below.

Name Relationship to Patient Contact Information

By my signature below, I acknowledge that I have read and understand the information

provided on this consent form.

Patient Name:

Patient Signature: Date:

Acknowledgement of Receipt of the Notice of Privacy Practices

I hereby acknowledge that I have read and received a copy of the Notice of Privacy Practices, with an effective date of November 1, 2016. Patient Name:_____________________________ Date of Birth:_____________ Signed:_________________________________ Date:____________________

Telephone: __________________________________

Patient Address:_______________________________________________________________

If not signed by the patient, please indicate name and relationship: Name:____________________________

Parent or guardian of minor patient

Guardian or conservator of an incompetent patient

Other authorized personal representative:__________________

FOR INTERNAL USE ONLY

Our office has been unable to obtain a signed acknowledgement of receipt for the following reasons:

Patient was unable to sign

Patient / Personal representative refused to sign on _____/_____/_____

Date of Refusal

Other:_____________________________________________________________ 11/1/2016

Patient Partnership Plan

Dear Patient,

Welcome to our practice. We intend to provide you with the care and service that you expect and deserve.

Achieving your best possible health requires a “partnership” between you and your doctor. As our

“partner in health,” we ask you to help us in the following ways:

Schedule Visits with My Doctor for Routine Physical Exams and Other

Recommended Health Screenings

I understand that my doctor will explain to me which regular health screenings are appropriate for my

age, gender, and personal and family history. I understand I will need to complete these recommended

health screenings (mammogram, immunizations, pap smears etc). These health screenings are tests

that can help detect life-threatening diseases and conditions. If I visit my doctor only for treatment

of immediate problems and forget to arrange for regular health screenings, I put myself at risk of letting

serious health problems go undetected. I will schedule regular visits with my doctor to complete my

physical exam and to discuss these health screenings.

Keep Follow-up Appointments and Reschedule Missed Appointments

I understand that my doctor will want to know how my condition progresses after I leave the office.

Returning to my doctor on time gives him or her the chance to check my condition and my response to

treatment. During a follow-up appointment, my doctor might order tests, refer me to a specialist,

prescribe medication, or even discover and treat a serious health condition. If I miss an appointment and

don’t reschedule, I run the risk that my physician will not be able to detect and treat a serious health

condition. I will make every effort to reschedule missed appointments as soon as possible.

Call the Office When I Do Not Hear the Results of Labs and Other Tests

I understand that my physician’s goal is to report my lab and test results to me as soon aspossible.

However, if I do not hear from my physician’s office within the time specified, I will call the office for my

test results.

Inform My Doctor if I Decide Not to Follow His or Her Recommended

Treatment Plan

I understand that after examining me, my doctor may make certain recommendations based on what he

or she feels is best for my health. This might include prescribing medication, referring me to a specialist,

ordering labs and tests, or even asking me to return to the office within a certain period of time. I

understand that not following my treatment plan can have serious negative effects on my health. I will let

my doctor know whenever I decide not to follow his or her recommendations so that he or she may fully

inform me of any risks associated with my decision to delay or refuse treatment.

Thank you for your partnership. As our patient, you have the right to be informed about your health care.

We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have.

If you need more information about your health or condition, please ask. Patient Name: _______________________________ DOB: _________ ___________________________________________ ____________ Patient Signature Date ___________________________________________ ____________ Physician Signature Date 10/3/2016

Privacy Policy

This privacy policy discloses the privacy practices for https://patients.ucosc.com/patientportal/.

This privacy policy applies solely to information collected by this web site. It will notify you of the following:

What personally identifiable information is collected from you through the web site, how it is used and with whom it may be shared.

What choices are available to you regarding the use of your data. The security procedures in place to protect the misuse of your information. How you can correct any inaccuracies in the information.

Information Collection, Use, and Sharing We are the sole owners of the information collected on this site. We only have access to/collect

information that you voluntarily give us via email or other direct contact from you. We will not sell or rent this information to anyone. We will use your information to respond to you, regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request, e.g. make a payment for services. Unless you ask us not to, we may contact you via email in the future to tell you about specials, new products or services, or changes to this privacy policy. Your Access to and Control Over Information You may opt out of any future contacts from us at any time. You can do the following at any time by contacting us via the email address or phone number given on our website: • See what data we have about you, if any. • Change/correct any data we have about you. • Have us delete any data we have about you. • Express any concern you have about our use of your data. Security

We take precautions to protect your information. When you submit sensitive information via the website, your information is protected both online and offline. Wherever we collect sensitive information (such as credit card data), that information is encrypted and transmitted to us in a secure way. You can verify this by looking for a closed lock

icon at the bottom of your web browser, or looking for "https" at the beginning of the address of the web page. While we use encryption to protect sensitive information transmitted online, we also protect your

information offline. Only employees who need the information to perform a specific job (for example, billing or customer service) are granted access to personally identifiable information.

The computers/servers in which we store personally identifiable information are kept in a secure environment. Updates Our Privacy Policy may change from time to time and all updates will be posted on this page. If you feel that we are not abiding by this privacy policy, you should contact us

immediately via telephone at 951-735-2700 or invoices@ucosc.com.