PLEASE MARK (X) NEXT TO DOCUMENTS YOU HAVE: LIVING WILL POWER OF ATTORNEY DO NOT RESUSCITATE ORDER

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1 CAREFIRST FAMILY PRACTICE 3631 W BURLEIGH BLVD TAVARES FL P.(352) F.(352) PATIENT NAME ALLERGIES TO MEDICATIONS TODAY'S DATE: DOB Hospital Admissions-Indicate the year you were admitted and the reason. Do NOT include normal pregnancies. Year Illness/Operation Year Illness/Operation Medical History: Main Problems Mark (x) to indicate any of the following symptoms or diseases you have had. DECREASED HEARING BRONCHITIS NAUSEA/VOMITING CONTROL OF URINATION BACK PAIN WEAR BRACE RINGING IN EAR ASTHMA PEPTIC ULCERS KIDNEY STONES BONE FRACTURE HERPES EAR INFECTIONS SHORTNESS OF BREATH ABDOMINAL PAIN VENEREAL DISEASE FOOT PAIN CHLAMYDIA DIZZY SPELLS CHEST PAIN CHANGE IN BOWELS CHRONIC FATIGUE COLD NUMB FEET CHICKEN POX GLAUCOMA HIGH BLOOD PRESSURE DIARRHEA WEIGHT LOSS RASHES MUMPS FAILING VISION HEART MURMUR CONSTIPATION ANEMIA HIVES POLIO CATARACTS PALPITATIONS DIVERTICULITIS BRUISE EASILY PSORASIS MEASLES BLURRED VISION IRREGULAR PULSE BLOOD IN STOOL DIABETES TYPE1 TYPE2_ ECZEMA T.B EYE INFECTIONS FAINTING SPELLS HEMORRHOIDS THYROID DISEASE TROUBLE SLEEPING RHEUMATIC FEVER NOSE BLEEDS SWOLLEN ANKLES HERNIA SEIZURES NERVOUSNESS CANCER SINUSITIS LEG PAIN WALKING GALLBLADDER TROUBLE STROKE DEPRESSION TYPE OF CANCER: SORE THROAT VARICOSE VEINS JAUNDICE TREMOR MEMORY LOSS SOCIAL HISTORY HAYFEVER PHLEBITIS HEPATITIS NUMBNESS SENSATIONS MENTAL ILLNESS ALLERGIES LOSS OF APPETITE FREQUENT UTI'S HEADACHES MOODINESS HOARSENESS TROUBLE SWALLOWING PAINFUL URINATION ARTHRITIS PHOBIAS PNEUMONIA HEARTBURN BLOOD IN URINE GOUT HAIR LOSS DO YOU DRINK ALCOHOL? YES NO DO YOU USE CHEWING TOBACCO? YES NO HISTORY OF SUBSTANCE ABUSE? YES NO DO YOU SMOKE CIGARETTES? YES NO DO YOU SMOKE MARIJUANA? YES NO DO YOU DRINK COFFEE OR TEA? YES NO FEMALE PATIENTS: DATE OF LAST PAP TEST ARE YOU USING BIRTH CONTROL? DATE OF LAST MAMMOGRAM IF YES, TYPE: MEDICATION MENOPAUSE TUBAL LIGATION MENSTRUAL HISTORY AGE OF ONSET REGULAR IRREGULAR PAIN/CRAMPS FAMILY HISTORY: FATHER MOTHER BROTHER SISTER IMMUNUZATIONS:YEAR OF LAST INJECTION NUMBER OF PREGNANCIES LIVE BIRTHS MISCARRIAGES LIVING DECEASED CAUSE OF DEATH AGE CHRONIC HEALTH PROBLEMS FLU PNEUMO23 PREVNAR13 ZOSTER TETANUS PLEASE MARK (X) NEXT TO DOCUMENTS YOU HAVE: LIVING WILL POWER OF ATTORNEY DO NOT RESUSCITATE ORDER

2 Carefirst Family Practice PLEASE NOTE: IMPORTANT CHANGES IN PRESCRIPTION REFILLS As of January 1 st, 2017, we will ask that you refill prescriptions during office visits. This method is quickly becoming standard practice in family medicine. We are all concerned with the safe and correct use of medication. We want to ensure that you, our patient, have exactly the prescription you need, in the dose that is correct for you right now. It is important that you BRING ALL YOUR MEDICATIONS IN THE BOTTLE TO EVERY OFFICE VISIT, including VITAMINS & SUPPLEMENTS, so that we can be sure that all your medications can be taken together safely. Please bring all medications including ones written by other doctors. Please write down how often and how much you take over-thecounter drugs including Tylenol, Motrin, Cold Remedies etc. PLEASE DONT BRING MEDICINES THAT MUST BE KEPT COLD IN THE REFRIDGERTOR. INSTEAD, JUST BRING THE NAMES AND DOSES OF THOSE MEDICINES. All medications previously not documented as being prescribed by our doctors will require an office visit to fill. If you need a refill before your next appointment with the doctor, please contact the pharmacy and have them fax us a refill request. This excludes any CONTROLLED SUBSTANCES, those medications require an appointment with the doctor. On all faxed refill requests please allow up to 72 hours to complete. Thank you very much for your understanding. Our goal is always to provide you with the best possible health care.

3 Care First Family Practice Inc W. Burleigh Blvd Tavares, FL PATIENT INFORMATION please print Today's : Last Name First Name MI Home/Cell Phone Work Phone Street Address DOB Social Security Number City State Zip Code Sex Marital Status Drivers License Employer Name Occupation Student? Full Time Part Time If patient is a child, parent or guardians name Parent/Guardian's SS # Parent/Guardian's DOB Parent/Guardian's Employer, Address, & Phone Number SPOUSE INFORMATION Last Name First Name MI Home/Cell Phone Work Phone Street Address DOB Social Security Number City State Zip Code DOB Employer, Employer Address ADVANCE DIRECTIVE (FOR COMLIANCE WITH THE PATIENT SELF-DETERMINATION ACT) Have you executed an advance directive? YES NO If Yes, Is this directive in form of: Living Will A Durable Power of Attorney A Healthcare Surrogate Please let staff know if you would like a do not resuscitate order to be on file with our office. If you have any of the Advance Directives listed above the office will you need you to provide a copy to keep in your chart, on file. EMERGENCY INFORMATION Name (Not living with you) Relationship Phone Address (City, State, Zip Code) CONSENT FOR TREATMENT I HEREBY GIVE CONSENT TO CAREFIRST FAMILY PRACTICE INC. TO PROVIDE WHATEVER TREATMENT THEY MAY DEEM NECESSARY TO THE PATIENT ABOVE Patient (Responsible Party) Signature How did you learn of our practice?

4 Care First Family Practice W. Burleigh Blvd Tavares, FL FINANCIAL POLICY- please read carefully Basic Policy: Payment for service is due at the time service is provided in our office. Accounts that have balances more than 90 days past due will be turned over to a collection agency, with an additional $30.00 service fee, unless previous arrangements have been made. For Patients with Insurance: We bill contracted insurance carriers if proper and correct information is provided. Because of various time limits, insurance information must be filled out correctly the first time. If incorrect information is given, then the patient will be responsible for payment in FULL. Co-payments, Coinsurance, and/or Deductibles are due at the time of service. Medicare: Carefirst Family Practice Inc. accepts assignments on all Medicare claims. We will also bill the secondary insurance companies that we are contracted with for you. If no secondary insurance information is provided, patients will be responsible for Medicare deductible, followed by 20% of the Medicare allowable charge at the time of service. Any Co payments, Coinsurance, and/or Deductibles are due at the time of service. Non-Covered Services: Any service not paid by your existing insurance coverage will require payment in full at the time services are provided. These services are usually considered cosmetic and will be discussed prior to being performed. INSURANCE INFORMATION PRIMARY INSURANCE SECONDARY INSURANCE Insured's Name Insured's Name DOB SS # DOB SS # Insurance Name Insurance Name ID # Group # ID # Group # Claims Address Claims Address Employer Name Employer Name YOUR SIGNATURE WILL SERVE FOR ALL OF THE ABOVE AND FOLLOWING I authorize any holder of medical or other information about me to release to the Social Security Administration and Healthcare Financing Administration or its intermediaries or carrier and independent laboratories any information needed for this this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. AUTHORIZATION OF MEDICAL RELEASE AND PAYMENT: We only file insurance claims to plans in which we participate. If you are not covered by one of the insurance plans that we participate in, then payment is expected at the time of service. I authorize the release of medical information necessary to process claims and also authorize payment of medical benefits to the physician. If insurance does not pay, I will become financially responsible for payment in full. I permit a copy of these authorizations to be used in place of this original which is on file at the physician's office. NON-COVERED SERVICES LIFETIME SIGNATURE AUTHORIZTION FOR MEDIGAP: I request that payment of authorized Medigap benefits be made on my behalf to Carefirst Family Practice Inc. for any services furnished to me by Carefirst Family Practice Inc. I authorize any holder of medical information about me to be released to the above Medigap carrier any information needed to determine these benefits or the benefits payable for related services. I understand that I do not need to provide my supplemental insurer with information concerning this Medicare claim, because my signing this authorization will cause Medicare payment information to cross over automatically. Patient (Responsible Party) Signature

5 Carefirst Family Practice Inc W. Burleigh Blvd Tavares, FL Phone Number (352) Fax Number (352) Confidentiality Clause and Continuation of Care Authorization Please check here if you do not want our practice to discuss any patient information with anyone other than the patient. Please check here if you consent to leave information on your answering machine or voice mail Please check here if you consent to give information to any of the following person's listed: Name Relationship Phone Number I understand that if my doctor feels it is necessary to refer me out to a specialist or facility for further testing, that my Name, of Birth, Social Security Number, Insurance Information, Phone Number, Address, Diagnosis, and possible other health information will be given for the continuation of my care. Please Initial By signing this form, I understand and authorize all of the above. The information on this page MUST expire, please chose an expiration date. This date can be as little as one month, as much as six years. Please note, you may change this form at any time. Expiration

6 Hipaa Notice of Privacy Practices Carefirst Family Practice Inc W. Burleigh Blvd Tavares, FL P. (352) F. (352) This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review the information carefully. The Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operation (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 or 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 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, we would disclose your protected health information, as necessary, to a home health agency that provides care to you, For example your protected health information may be provided to a physician to who 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 activities, employee review activities, training of medical students, licensing, marketing and fund raising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients in 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. Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You make revoke this 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 Following is a statement of your rights with respect to your protected health information. You have the right to inspect and copy 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 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 that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional. You have the right to request to receive confidential communications 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. You may have the right to have your physician amend 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 change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and became effective April 14, 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. If you have any objections to this form, please ask to speak with our HIPAA compliance officer in person or by phone at our main phone number. Signature below is only acknowledgment that you have received this notice of our privacy practices: Print Name