Name: Patient relation to Guarantor:

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Percival Foster
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1 Patient Infrmatin (Please print) Full Legal Name: Last First Middle Date f Birth: SS#: Mnth/Day/Cmplete Year Primary Care Physician: Preferred Name: Sex: Male Female Ethnicity: Hispanic/Latin Nn-Hispanic/Nn-Latin Refuse/Decline Preferred Pharmacy Name: Phne Number: Marital Status: Single Married Divrced Widwed Life Partner Legally Separated Race: Caucasian (white) American Indian African American (black) Hispanic Biracial Asian Oriental Other Unknwn Hme Address: City:_ State: Zip: Mail t Address: City:_ State: Zip: Cunty: Hme Phne: ( ) Cell Phne: ( ) Preferred language: Veteran: Yes N Unknwn Religin: Guarantr Infrmatin (If guarantr is Self, skip t Emergency Cntact) Parent/guardian presenting minr child fr treatment will be listed as the guarantr. If 18 r lder, patient will be listed as guarantr and des nt have t cmplete this sectin. The guarantr will be respnsible fr any balance due. Name: Patient relatin t Guarantr: Last First Middle Hme Phne: ( ) Date f Birth: SS#: Cell Phne: ( ) Hme Address: City: State: Zip: Cuntry: Mail t Address (if different): City: State: Zip: Cuntry: Emergency Cntact (Pediatric Patients please list smene ther than parent(s)/guardian) Primary Cntact Name: Hme Phne: ( ) Patient Relatin t Emergency Cntact Cell Phne: ( ) Secndary Cntact Name: Hme Phne: ( ) Patient Relatin t Emergency Cntact Cell Phne: ( ) Emplyment Patient Emplyer: Wrk Phne: Ext: Address: City:_ State: Zip: Emplyment Status: Full-Time Part-Time Self Emplyed Active Military Student Full Time Student Part-Time Retired Date Disabled Nt Emplyed Unknwn (Pediatric Patients Only) Parent/Guardian & Immediate Family Infrmatin Mther (If the address, phne numbers and emplyer infrmatin is the same as guarantr, please indicate same.) Full Name: Nickname: Last First Middle Date f Birth: SS#: Mnth / Day / Cmplete Year Hme Address: City:_ State: Zip: (if different frm patient) Hme Phne: Cell Phne: ( ) Emplyer: Wrk Phne: ( ) Ext: Father (If the address, phne numbers and emplyer infrmatin is the same as guarantr, please indicate same.) Full Name: Nickname: Last First Middle Date f Birth: SS#: Mnth / Day / Cmplete Year Hme Address: City:_ State: Zip: (if different frm patient) Hme Phne: Cell Phne: ( ) Emplyer: Wrk Phne: ( ) Ext: PATIENT DEMOGRAPHICS (12/14) PAGE 1 OF 2

2 Patient Name DOB (Pediatric Patients Only) Brthers, Sisters & Other Family Members Full Name M r F Date f Birth Relatinship Lives with child Yes Yes Yes Yes N N N N Check here if n insurance. And, skip t Authrizatin (belw). Accident Infrmatin Is visit the result f an accident? (Examples: aut accident, wrkers cmpensatin, etc.) Yes N Type f Accident: Date f Accident: Cunty f Accident: Primary Insurance Infrmatin Subscriber: This is the persn wh carries the insurance. If Subscriber is the Patient, skip t Insurance C Name field. Subscriber s Name n card: Date f Birth: Mnth / Day / Cmplete Year Patient Relatinship t Subscriber: Sex: Male Female If address and phne number is same as patient, please indicate same. Address: SS#: City, State, Zip: Hme Phne: Emplyer: Wrk Phne: Ext. Insurance C. Name: Phne: Plicy/Cert #: Grup N: Effective Date: Subscriber Status: Full-Time Part-Time Self Emplyed Active Military Student Full Time Student Part-Time Retired Date Disabled Nt Emplyed Secndary Insurance Infrmatin SUBSCRIBER: This is the persn wh carries the insurance. If Subscriber is the Patient, skip t Insurance C Name field. Subscriber s Name n card: Date f Birth: Mnth / Day / Cmplete Year Patient Relatinship t Subscriber: Sex: Male Female If address and phne number is same as patient, please indicate same. Address: SS#: City, State, Zip: Hme Phne: Emplyer: Wrk Phne: Ext. Insurance C. Name: Phne: Plicy/Cert #: Grup N: Effective Date: Subscriber Status: Full-Time Part-Time Self Emplyed Active Military Student Full Time Student Part-Time Retired Date Disabled Nt Emplyed Authrizatin I authrize medical evaluatin & treatment, and release f infrmatin fr insurance/medical purpses cncerning my illness and treatment. I hereby authrize payment frm my insurance cmpany t the Greenville Health System fr services rendered. I will be respnsible fr any amunt nt cvered by my insurance. Signature f Patient/Guardian/Guarantr: Date: PATIENT DEMOGRAPHICS (12/14) PAGE 2 OF 2

3 AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION THE INFORMATION PROVIDED IN THIS FORM WILL BE RELIED UPON BY ALL HEALTH CARE PROVIDERS OF GREENVILLE HEALTH SYSTEM UNLESS REVOKED OR MODIFIED BY THE PATIENT IN WRITING. Patient Name (PRINT) _ DOB Authrizatin fr Disclsure f Medical Infrmatin: The privacy f yur medical infrmatin is imprtant. We will discuss yur medical cnditin with persn(s) yu designate. DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? (Check and cmplete ne) OR (Fr Office Use Only) MRN The fllwing family members r ther individuals may receive infrmatin regarding my medical cnditin: Print first and last name(s) Any family member r ther individual inquiring abut my medical cnditin may receive infrmatin frm my prvider, EXCEPT the fllwing individuals: Print first and last name(s) Yu may revke/cancel r mdify/change the abve designatin, but the revcatin r mdificatin must be in writing. NOTE: This designatin des nt give the abve named individuals the right t make health care decisins fr yu. If at any time yu are unable t cnsent t care r treatment, we will fllw the prcedure set frth in the Suth Carlina Adult Health Care Cnsent Act. Cnfidential Cmmunicatin: Please prvide phne number(s) where we can reach yu: Hme: Wrk: Cell Phne: I d nt authrize Other Messages: A request fr return calls may be left n the fllwing answering machine r vice mail: (Check all that apply) Hme Wrk Cell Phne I d nt authrize I authrize my medical infrmatin t be left n the fllwing answering machine r vice mail: (Check all that apply) Hme Wrk Cell Phne If we are unable t reach yu r leave a message at the abve phne number(s), please indicate with whm we may leave a message fr yu t call ur facility. Name Phne Number Name Phne Number Nte: An autmated appintment reminder system may call the number listed in ur data base. Signature: I hereby authrize the disclsure f my medical cnditin and infrmatin as described abve. Patient/Patient's Representative Signature: Date: Time: PRINT Name (if Patient's Representative): Relatinship t Patient (if Patient's Representative): GHS Representative: Date: Time: AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION (4/16) PAGE 1 OF 1

4 Tday s Date Patient Name DOB Hspitalizatin & Surgical Histry List all hspital admissins and peratins yu have had. Reasn fr Hspitalizatin/Surgery Year Scial Histry Did yu have any prblems with anesthesia? If yes, please describe. D yu currently smke r use ther tbacc prducts? If yes, hw many per day? Have yu smked r used ther tbacc prducts in the past? If yes, hw many per day? Hw many years since yu last smked? D yu drink caffeinated beverages? If yes, what type, hw ften, hw much? D yu drink alchl? If yes, what type, hw ften, hw much? D yu exercise regularly? If yes, what type? Hw ften and hw lng? Family Medical Histry Check the bx next t any medical cnditin belw that has affected any f yur immediate family members (parents, brthers, sisters), state yur relatinship and their age at nset. Relatinship Age at nset High Bld Pressure High Chlesterl Heart Disease Strke Migraines Seizures/Cnvulsins Diabetes Bleeding/Bld-cltting Disrder Allergies Asthma Thyrid Prblems Osteprsis Psychiatric Disrder/Mental Illness Alzheimer s/dementia Cancer - type: Other: HOSPITALIZATION, SOCIAL, & FAMILY HISTORIES (12/14) PAGE 1 OF 1

5 Medicatins, Allergies and Immunizatins Tday s Date Patient Name DOB Please Bring All Medicatins t Yur Visit Prescriptin Medicatins List all medicatins yu are presently taking Name and Dse Prescribed by: Hw Often Date Started Nn-Prescriptin Medicatins List all medicatins yu are presently taking Name and Dse Hw Often Date Started Current Pharmacy Name and Lcatin Preferred Other Phne Number MEDICATIONS, ALLERGIES (12/14) PAGE 1 OF 2 AND IMMUNIZATIONS

6 Tday s Date Patient Name DOB Allergies list all allergies r unusual reactins yu have t medicatins, fds, dyes latex and ther agents. Allergy Reactin List any reactins t bug bites r stings Adult Immunizatins Check the bx next t r list all immunizatins received including the mst recent date received. Date Received Others Date Received Tetanus Flu Pneumnia HPV Hepatitis B Screenings List the mst recent date and dctr fr the fllwing screenings: Date Dctr/Practice/Facility Name Cmplete Medical Physical Full panel f lab wrk Chlesterl (lipid) screening Chest X-ray Treadmill Stress Test Other heart tests Clnscpy Mammgram Bne Density MEDICATIONS, ALLERGIES (12/14) PAGE 2 OF 2 AND IMMUNIZATIONS

Release f Infrmatin Authrizatin Patient Name: _ Date f Birth: Last 4 Digits f SSN: Phne #: e-mail address: _ NOTE: All items, 1 thrugh 6 must be cmpleted, alng with signature and date 1.

7 Release f Infrmatin Authrizatin Patient Name: _ Date f Birth: Last 4 Digits f SSN: Phne #: address: _ NOTE: All items, 1 thrugh 6 must be cmpleted, alng with signature and date 1.) Release Recrds T: (Where d yu want the infrmatin sent? Wh may have the infrmatin?) Name f individual, healthcare prvider/hspital/practice: Address: City: State: Zip Cde: Day Phne Number: Fax Number: 2.) Obtain Recrds Frm: (Wh has the infrmatin yu want released?) Please list the specific Hspital and / r clinic. 3.) Release Instructins: (Hw d yu want the infrmatin?) 4.) Purpse f Release: (Why is it needed?) Name f Organizatin/Hspital r Medical Practice: Address: City: State: Zip Cde: Day Phne Number: Fax Number: Release Methd / Frmat Requested: (check ne) Mail My Chart / Epic Fax (T healthcare prvider ONLY) Electrnic Other Cntinuing Care Legal Patient Request Military Insurance Disability Schl Other I understand that fees fr cpies f medical recrds/images and pstage fees may be charged as prvided by S.C. Law. 5.) Treatment Date(s): (When were yu seen?) Treatment dates frm t (please be specific) OR All Treatment Dates 6.) Infrmatin t be Released: (What d yu want sent r released? Check the apprpriate bx. ) ENTIRE RECORD Immunizatin Recrds Medicatin List Physician Prgress / Visit Ntes Abstract Infrmatin Histry & Physical, Cnsults, Lab & Radilgy Reprts, Discharge Summary, Operative/ Prcedure Reprts,. Emergency Department Reprts, and Occupatinal / Physical Therapy Reprts. Psychtherapy Test Results Demgraphics Other: I understand this infrmatin may include reference t psychiatric / psychlgical care, sexual assault, drug abuse, alchl abuse, and/r results f tests fr all infectius diseases including HIV / AIDS. I understand that I have a right t cancel / revke this authrizatin at any time. I understand that if I cancel / revke this authrizatin I must d s in writing and present my written cancellatin / revcatin t the Health Infrmatin Services Department (Medical Recrds). I understand that the cancellatin / revcatin will nt apply t infrmatin that has already been released in respnse t this authrizatin, as stated in the Ntice f Privacy Practice. Unless therwise canceled / revked. This authrizatin will expire / end ne year frm this date r. I understand that authrizing the disclsure f prtected health infrmatin is vluntary. I can refuse t sign this authrizatin. I d nt need t sign this frm t receive treatment. I understand I may review and / r cpy the infrmatin t be disclsed as prvided in 45 CFR I understand that any disclsure f infrmatin carries with it the pssibility f unauthrized disclsure by the persn / rganizatin receiving this infrmatin. I understand I have a right t a cpy f this authrizatin. Prf f identity may be required, attaching a cpy f yur pht ID is recmmended. (NOTE: Allw 30 days fr prcessing accrding t Federal regulatin.) Printed Name f Patient r Legal Guardian / Representative x Signature f Patient r Legal Guardian Representative Date Relatinship t Patient, if Signed by Legal Guardian Dcument(s) f patient representative s authrity must be attached if patient is nt signing. When requesting GHS t send recrds, return this frm t: 255 Enterprise Blvd., Suite 120, Greenville, S.C ; Phne (864) Fax (864) Release f Infrmatin Authrizatin (6/16) PAGE 1 OF 1

8 Financial Plicy Please read this financial plicy carefully. If yu have any questins abut this plicy, any member f ur staff will be glad t assist yu. The fllwing are the cnditins fr services prvided t the patient by Greenville Health System, GHS Partners in Health, and the varius entities and prviders affiliated with them each individually and cllectively referred t as Greenville Health System r GHS. Payment fr Service: Each ffice will infrm yu f c-pay and deductible amunts at check in r check ut. These amunts are due at the time f service. As a curtesy t yu, we will file yur insurance claims if yu prvide us with a cpy f yur current insurance card. We require that yu pay yur deductible, c-payment, and/r any charges nt cvered by insurance. Methd f Payment: Yu may pay yur bill with cash, persnal check, certain credit cards, r debit card. Returned Checks: A $25.00 service charge will be added n all checks returned t us fr insufficient funds. Nn-appintment Prescriptin Refills: A $15.00 charge per incidence may be added fr nn-appintment prescriptin refills. Nn-appintment Prescriptin: A $25.00 charge may be billed t yu fr new prescriptins filled via phne. Cmpletin f Medical Frms: There may be a charge fr cmpletin f frms such as disability, camp physicals, etc. Cpies f Medical Recrds: There may be a charge fr cmpletin f this prcess; SC Sec fr Health Care Facilities $.65 per page fr the first 30 pages $.50 per page fr all ther pages Clerical fee nt t exceed $25.00 Plus actual pstage N-shw Appintments: A fee f $25.00 fr a fllw up visit and $50.00 fr a new patient visit r endscpy prcedure may be charged fr all missed appintments nt canceled at least 24 hurs prir t the appintment time. Yu will be financially respnsible fr the fee, as insurance plans d nt cver these charges. Yu may ntify ur ffice f any cancellatins by calling during nrmal ffice hurs. Payment fr Services Prvided by Certain Prviders: If yu are having labratry and/r diagnstic services by prviders ther than this ffice r ther practices ding business as GHS University Medical Grup, yu may be billed separately by that service prvider. This includes services prvided by Greenville Health System. Cllectin Plicy: Delinquent accunts will be frwarded t a cllectin agency. We will infrm yu f yur accunt status n yur statement. If yu are unable t pay yur balance prmptly, please call us at r t make payment arrangements. We will attempt t cntact yu by letter befre yur accunt is frwarded. Questins: We are here t help shuld yu have any questins regarding yur statement r insurance. FINANCIAL POLICY (12/14) PAGE 1 OF 1

CRG PATIENT REGISTRATION FORM

CRG PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: Birth : (Last) (First) (Middle) Scial Security Number: Male: Female: Hme Address: (Street / RR Bx # / Apt. #) (City/State) (Zip) Preferred