WEST COAST VASCULAR PATIENT INFORMATION LAST FIRST MI BIRTHDATE SS# PHONE ADDRESS CITY ST ZIP EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT

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1 C. Shawn Skillern, M.D. Li Sheng Kong, M.D. Sydney S. Guo, M.D. Edward N. Li, M.D. Kevin M. Casey, M.D. Sara J. Runge, M.D. WEST COAST VASCULAR 100 North Brent Street, Suite 201 I Ventura, CA Solar Drive, Suite 202 I Oxnard, CA Oak Park Lane, Suite 102 I Santa Barbara, CA North Third Street I Lompoc, CA Phone: Fax: PATIENT INFORMATION LAST FIRST MI SEX M F BIRTHDATE SS# PHONE ADDRESS CITY ST ZIP EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT MARITAL STATUS: S M D W CELL PHONE LEAVE A MESSAGE AT YOUR: HOME CELL OFFICE / VOICE MAIL WHO IS YOUR PRIMARY CARE PHYSICIAN? WHO MAY WE THANK FOR REFERRING YOU? DO YOU HAVE AN ADVANCE DIRECTIVE? Yes No IF YES, PLEASE PROVIDE A COPY FOR OUR RECORDS AND SIGN WAIVER. EMERGENCY CONTACT: LAST FIRST RELATIONSHIP ADDRESS CITY ST ZIP HOME PHONE WORK/CELL PHONE INSURANCE: PRIMARY PLEASE COMPLETE ALL INSURANCE INFORMATION COVERING THE PATIENT NAME ID# GRP NO. INSURED NAME SS# BIRTHDATE CIRCLE RELATIONSHIP TO PATIENT: SELF SPOUSE CHILD OTHER INSURANCE: SECONDARY PLEASE COMPLETE ALL INSURANCE INFORMATION COVERING THE PATIENT NAME ID# GRP NO INSURED NAME SS# BIRTHDATE CIRCLE RELATIONSHIP TO PATIENT: SELF SPOUSE CHILD OTHER AUTHORIZATION I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, AND I CONSENT TO ANY MEDICAL OR SURGICAL TREATMENT RENDERED THE PATIENT UNDER THE GENERAL AND SPECIAL INSTRUCTIONS OF THE PHYSICIAN. SIGNED, PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE X DATE ASSIGNMENT OF INSURANCE BENEFITS AND AUTHORIZATION TO RELEASE INFORMATION RELATED TO MEDICAL SERVICES PROVIDED I, HEREBY, ASSIGN ALL BENEFITS TO CENTRAL COAST VASCULAR, INC. FOR SERVICES RENDERED TO ME OR SAID MINOR PATIENT. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME OR SAID MINOR TO RELEASE TO MY INSURANCE COMPANY ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES. I UNDERSTAND MY SIGNATURE REQUESTS THAT PAYMENT BE MADE TO CENTRAL COAST VASCULAR, INC. AND AUTHORIZE RELEASE OF MEDICAL INFORMATION NECESSARY TO PAY THE CLAIM. I HAVE GIVEN ALL MY INSURANCE INFORMATION FOR BILLING PURPOSES AND UNDERSTAND THE BILLING PROCEDURES. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES NOT COVERED BY MY INSURANCE INCLUDING BUT NOT LIMITED TO, CO-PAYMENTS, DEDUCTIBLES, AND NON-COVERED SERVICES. I ALSO AGREE TO COMPLETE ALL NECESSARY PAPERWORK IN ORDER FOR MY CLAIM TO BE PAID BY MY INSURANCE COMPANY AND ACCEPT FULL LIABILITY FOR ALL CHARGES IF PAYMENT IS NOT MADE ON MY BEHALF BY MY INSURANCE COMPANY. SIGNED, PATIENT, PARENT, GUARDIAN OR PERSONAL REPRESENTATIVE X DATE PLEASE PRINT NAME RELATIONSHIP

2 CONSENT TO RESUSCITATIVE MEASURES Patients have the right to participate in their own health care decisions and make Advanced Directives or to execute Power of Attorney that authorize another person to make decisions on their behalf, based on the patient s expressed wishes when the patient is unable to make decisions or to communicate decisions. This Company DOES NOT routinely perform HIGH RISK procedures, however, there are minimal risks associated with all procedures. Your physician will discuss the specifics of your procedure and answer questions associated with risk. This Company has a policy that resuscitative and/or stabilizing measures will be initiated and a transfer to an acute facility will ensue. Yes, I have an Advanced Directive, Living Will, or Healthcare Power of Attorney. I do accept this Center s policy. I do NOT accept this Center s policy and cancel my scheduled procedure. No, I do not have an Advanced Directive, Living Will, or Healthcare Power of Attorney. If you checked box YES to the question above, please provide a copy of that document so that it may be made a permanent part of your medical record at this facility. Patient signature or legally responsible person Date

3 C. Shawn Skillern, M.D. Li Sheng Kong, M.D. Edward N. Li, M.D. Sydney S. Guo, M.D. Kevin M. Casey, M.D. Sara J. Runge, M.D. I PATIENT, FAMILY & SOCIAL INFORMATION Patient Name: Date of Birth: Sex: M G F G Marital Status: M G S G D G W G If Married, Spouses State of Health: Primary Physician: Referred By: Reason for Referral: Who do you live with? List spouse, family members, and others who will be involved in your care: Name City Telephone List any allergies: Do you smoke? Yes G No G Quit G If smoking, how long? How many packs per day? If you have quit, how long ago? Do you drink alcohol? Yes G No G Quit G If yes, how many drinks per day? If you have quit, how long ago? Do you have any history of substance abuse or IV drug use? Yes G No G Have you completed a "Durable Power of Attorney for Healthcare", also known as an "Advanced Directive" or a "Living Will"? Yes G No G (If yes, please provide a copy for your medical record in our office). II FAMILY HISTORY Father: Living G Deceased G If deceased, at what age? Cause of Death Mother: Living G Deceased G If deceased, at what age? Cause of Death Brothers: Number Living Number Deceased If deceased, at what age? Cause of Death Sisters: Number Living Number Deceased If deceased, at what age? Cause of Death Children: Number Living Number Deceased If deceased, at what age? Cause of Death Check any disease which your father, mother, brothers, sisters, or children have experienced: G Heart Disease G Bleeding Disorders G Cancer G Other (list) G Kidney Disease G High Blood Pressure G Stroke G Other (list) G Diabetes G Seizures/epilepsy G Psychiatric problems G Other (list) G Alcoholism G Tuberculosis G Other (list)

4 III MEDICAL AND SURGICAL HISTORY Medical History List all serious conditions for which you have been treated by a doctor. Examples include, but are not limited to, anemia, diabetes, cancer, heart trouble, kidney disease, epilepsy, high blood pressure and hypercholesterolemia: Condition Date Treating Physician Surgical History List all operations below, and any significant complications related to the operations: Operation Date Significant Complications Diagnostic Tests List any recent diagnostic tests, including angiograms or x-rays: Name of Test/Xray Date Where Performed IV REVIEW OF SYSTEMS Please check any condition or symptoms you have experienced: G Diabetes if yes, controlled by insulin medication diet G Pain/weakness in legs/arms G Pacemaker If yes, date placed or revised G Numbness/tingling G Weight loss G Decreased hearing G Swelling in feet/legs G Dizziness/fainting G Fatigue G Sore throat G Abdominal pain G Headaches G Fever G Cough G Blood in stools G Stroke/CV/TIA G Poor healing G Wheezing G Constipation G Blood clots G Difficulty urinating G Chest pain G Diarrhea G Other G Bladder infection G Palpitations G Vomiting blood G Other G Bruise/bleed easily G Rapid heart beat G Back pain G Other G Blurred vision G Shortness of breath G Joint pain G Other Please attach a separate sheet to add any additional information you would like to bring to our attention 07/2015

5 MEDICATION LISTING NAME DATE ALLERGIES DATE OF BIRTH DIABETIC: YES NO PLEASE LIST YOUR CURRENT & OVER-THE-COUNTER MEDICATIONS, THE DOSAGE & FREQUENCY TAKEN: MEDICATIONS Dosage Frequency VITAMINS Dosage Frequency

6 West Coast Vascular HIPAA Privacy Rule of Patient Authorization Agreement Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations I,, (patient s name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment; A means of communication among the health professionals who may contribute to my healthcare; A source of information for applying my diagnosis and surgical information to my bill; A means by which a third-party payer can verify that services billed were actually provided; A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me. Privacy Rule of Patient Consent Agreement Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations I understand that: I have the right to review this facility s Notice of Information practices prior to signing this consent: This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I ve provided if requested; I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon. It is this facility s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction. Signature of Patient or Legal Representative Witness Printed Name of Patient or Legal Representative Witness Date:

7 HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement Form Acknowledgement of receipt of Information Practices Notice I,, (patient s name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that: I have the right to review this facility s Notice of Privacy Practices prior to signing this acknowledgement; this facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I ve provided if requested. Signature of Individual or Legal Representative Witness Printed Name of Individual or Legal Representative Witness Date FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because: Individual refused to sign Communication barrier prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other(please specify) Employee Date

8 West Coast Vascular PERSONAL REPRESENTATIVE AUTHORIZATION FOR MEDICAL RELEASE FORM I authorize this facility to speak to the following family members or my personal representative regarding All medical information, including but not limited to records pertaining to examinations, treatments, consultations, billing records, x-rays and reports, history, laboratory findings, admissions and discharge reports, treatment records, diagnosis and prognosis and records, nurse s and doctor s notes and any other non-medical information in my file. Only the following types of information: The above medical information shall only be released to the following persons: Family Member/Personal Representative Relationship I understand that I may terminate this Medical Authorization form. I must notify this facility in writing regarding termination and effective date. This authorization shall remain valid (check one) Until revoked in writing. Until, 20 I know that I am entitled to receive a copy of this agreement. Name Signature Signed this day of, 20

9 West Coast Vascular To All Patients: In order to bring our records into compliance with the Medicare Electronic Health Record Initiative Program, we need to update the following information for all of our patients. You will only be asked to complete this form one time. Thank you. GENDER Male Female RACE Please indicate your race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Decline to Report ETHNICITY Please indicate your ethnicity: Hispanic or Latino Not Hispanic or Latino Decline to Report PREFERRED LANGUAGE Please indicate your preferred language: English Spanish Other: Specify Decline to Report Print Name: Date of Birth:

10 CANCELLATION AND NO SHOW POLICY If you must cancel your appointment, please provide one business day notice. Those who do not provide such notice will be subject to a $75.00 cancellation fee for office visits, $ for both an ultrasound and office visit or $ for a procedure. We understand some circumstances are unavoidable and unexpected. Fees in this instance will be reviewed by the physicians and waived only with the physician s approval. Please sign below confirming you have read and understand our Cancellation and No Show Policy effective 2/1/2017. Date: Patient Name Patient Signature Confirm patient received policy: Date: Staff Signature

11 HOW DID YOU HEAR ABOUT US? Please let us know how you heard about West Coast Vascular. Circle one of the options below: Radio Formula 1400 A.M. La Primera 87.7 FM Conejo Chinese Cultural Association Magazine Our Website: WestCoastVascular.com Insurance Carrier Referring Physician Friends / Family Other Please Print Your Name