Seth S. Schurman, M.D. WELCOME TO OUR OFFICE! Patient Information Date: Gender: ( ) M ( ) F DOB: Age: Patient's Name: First Middle Last

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Seth S. Schurman, M.D. WELCOME TO OUR OFFICE! Patient Information Date: Gender: ( ) M ( ) F DOB: Age: Patient's Name: First Middle Last Address: Home Phone: Are You On Medicare? ( ) NO ( ) YES: Medicare #: Social Security #: Marital Status: ( ) married ( ) separated ( ) divorced ( ) single ( ) widow ( ) minor Spouse's Name: For Children (Please Complete The Following) Mother's Name: Address: Home Phone: Father's Name: Address: Home Phone: Person Responsible For Bills: Method Of Payment Today: ( ) cash ( ) check ( ) credit card 1

If Using Insurance, You Are Responsible For Any Deductible &/or Co-pay on day of service All HMO/POS Patients Must Have Valid Authorization with Them On The Day of Service! ( ) Primary Care or Referring Physician ( ) Name: Office Address: Office Phone: Pharmacy Name: Pharmacy Address: Pharmacy Phone: Insurance Company: Insured's Name: Birth Date: Insured's Employer: Are You A: ( ) permanent resident: # of years ( ) seasonal visitor: # of months Patient's Responsibility I Understand That I Am Responsible For Paying For Appointments Not Canceled 24 Hours In Advance! Signature: Insurance Assignment I request that "A Adult & Pediatric Allergy & Asthma Associates", apply to my medical insurance carrier on my behalf for payment of all charges incurred. I understand that I must first meet my deductible and any co-payment required by my carrier, as well as pay all charges not fully paid by my insurance company. I further understand that what my insurance company considers reasonable, may fall far short of the actual charges, and that I will be responsible for the difference in costs. I further certify that all charges regarding my medical care have been previously explained in full. Patient: Date: Witness: Medicare Lifetime Authorization I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act, is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or it's intermediaries or carriers, any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for me. Patient: Date: 2

Seth S. Schurman, M.D. Patient's Name: DOB: First Middle Last Personal Medical History Have you ever had (" " ALL THAT APPLY): ( ) Asthma ( ) Hives ( ) Eczema ( ) Frequent Colds ( ) Frequent Sore Throat ( ) Frequent Infections ( ) Pneumonia ( ) Hay Fever ( ) Heart Disease ( ) Rheumatic Fever ( ) High Blood Pressure ( ) Low Blood Pressure ( ) Anemia ( ) Jaundice ( ) Hepatitis: A B C ( ) Pleurisy ( ) Prostate Trouble ( ) Meningitis ( ) Tuberculosis ( ) Gonorrhea/Syphilis ( ) Cancer: ( ) Arthritis/ Rheumatism ( ) Frequent Boils ( ) Diabetes ( ) Bone/Joint Disease/Bursitis ( ) Neuritis/Neuralgia/Sciatica ( ) Broken Bones/Broken Nose ( ) Hyperthyroidism (high) ( ) Hypothyroidism (low) ( ) Unconscious/Head Injury Other Medical Problems (Please List): Medications Current Medications (Please List Name, Dose & Frequency): Do you use the following Non-Prescription Drugs? (" " ALL THAT APPLY): ( ) Vitamins ( ) Antacids ( ) Tylenol ( ) Aspirin/Ibuprofen ( ) Laxatives ( ) Decongestants Allergy History Are you allergic to ( " " ALL THAT APPLY & Describe Reaction): ( ) Penicillin: ( ) Cosmetics: ( ) Sulfa Drugs: ( ) Adhesive Tape: ( ) Aspirin/Ibuprofen: ( ) Codeine/Narcotics: ( ) Any Foods: Other Drugs/Immunization Reactions: Ever stung by a: ( ) Bee ( ) Wasp ( ) Yellow Jacket ( ) Hornet ( ) Fire Ants? Describe Any Reactions: Localized Reactions Only: ( ) NO ( ) YES Social/Immunization History Unusual hobbies/habits: Drink Alcohol? ( ) NO ( ) YES: # of drinks: /day /month /Year Do you smoke? ( ) Never ( ) In the Past ( ) Now If so, packs/day, for years Do you use other recreational/non-prescription drugs? ( ) NO ( ) YES: Frequency: Have you had Tetanus shot/booster in the last 10 years? If so, when? 3

Have you ever had? Surgical History Tonsillectomy/Adenoidectomy: ( ) NO ( ) YES Nose/Sinus Surgery: ( ) NO ( ) YES Hysterectomy/Ovaries Out: ( ) NO ( ) YES Other Surgery (Please List): Family Medical History " " Boxes if Yes Father Mother Sibling(s) Spouse Children Age (if living) Health (G) Good (B) Bad Cancer Tuberculosis Diabetes Heart Disease High Blood Pressure Hives Asthma Hay Fever Eczema Other (Please List) Age (At Death) Cause of Death Environmental Survey (" " & Write-In Appropriate Response): Dwelling: ( ) House ( ) Apartment ( ) Condo Age of Building: years old Heating: ( ) Electric/Forced Air ( ) Steam ( ) Baseboard ( ) Radiators ( ) Oil Heat Flooring: ( ) Carpeted/Minimal Tile ( ) Half Carpet/Half Tile ( ) All Tile/Hardwood Window Treatments: ( ) Drapes ( ) Vertical Blinds ( ) Horizontal Blinds ( ) Other: Your Bedroom: ( ) Carpeted ( ) Hardwood/Tile ( ) Books ( ) Stuffed Animals ( ) Table Items Mattress: ( ) Conventional ( ) Waterbed Age: years old Pillows: ( ) Feather ( ) Synthetic Age: years old Pets (List): ( ) Indoors ( ) Outdoors Smokers in home? ( ) NO ( ) YES: # of smokers: Occupation/Specific Work: Symptoms Worse: ( ) At Work ( ) At Home ( ) Can't Tell ( ) Anywhere ( ) Outdoors ( ) Indoors Anything in or out of home that might be contributing to your symptoms: Explain Briefly The Main Problems You Are Having & What Brings You In To See Us Today: 4

FINANCIAL POLICY Thank you for choosing "A Adult & Pediatric Allergy & Asthma Associates" as your Allergy providers. We are committed to the success of your treatment and care. Please understand that payment of your account is part of the process. The following is our financial policy. Please read the information and let us know immediately if you have any questions regarding the information. Thank you. Payment Is Expected At The Time Services Are Rendered: At the time services are rendered, we will collect your co-payment or co-insurance, as well as any balance due from a previous date of service. We accept cash, check, credit card (Visa, MasterCard) and debit cards. Failure to pay your co-payment or co-insurance at the time of service will result in a billing service fee of $10.00. We participate with Medicare, specific commercial insurance plans and networks. Please ask our office if we participate with your insurance provider. We make every effort to comply with the terms and conditions of the plans with which we do business. However, it is solely your personal responsibility to determine whether your insurance company participates with "A Adult & Pediatric Allergy & Asthma Associates", or with any laboratory, radiology, hospital or other facility at which medical services may be scheduled on your behalf. "A Adult & Pediatric Allergy & Asthma Associates" assumes no financial responsibility for charges related to services rendered at non-participating facilities. Insurance Claims: As a courtesy to you, if "A Adult & Pediatric Allergy & Asthma Associates" is a participating provider with your insurance plan, we will file your insurance claim for you. Your insurance company makes the final determination regarding your eligibility and benefits. You agree to pay any portion of the charges that are not covered by your insurance company. If we are not participating with your insurance plan, we may file the initial claim, but, if payment is not received in 45 days, we will transfer the unpaid balance to you and require you to pre-pay for any future services before they are rendered. If your insurance requires a referral or pre-authorization prior to a visit or procedure, you are responsible for obtaining it. Failure to obtain the referral and/or pre-authorization may result in a lower payment from your insurance company and a higher "out-of-pocket" cost to you. Returned Checks: ** We Charge A Fee For All Returned Checks! ** Past Due Balances: We will take the necessary steps to collect "past due" balances. If we need to refer your account to a collection agency, you agree to pay all of the collection costs that are incurred. If your account is referred for legal action, you agree to pay all of the legal fees that we incur plus court costs. In the event of litigation, you agree the venue shall be in Lee County, Florida. You understand that if your account is submitted to an attorney, collection agency, litigated in court, or "past due" status is reported to a credit reporting agency, the fact that you received treatment at "A Adult & Pediatric Allergy & Asthma Associates" will become a matter in the public record. Appointments: We understand that unexpected circumstances can sometimes interfere with your scheduled appointments; however, you are responsible for contacting the office to: ** Cancel your scheduled appointment at least 24 hours before the scheduled service to avoid having a late cancellation fee added to your account. ** I have read and understand the Financial Policy of "A Adult & Pediatric Allergy & Asthma Associates". I agree to abide by the terms and conditions contained herein. I also acknowledge receiving a copy of this Policy for my records. / / PATIENT/PARENT/LEGAL GUARDIAN NAME DATE / / PATIENT/PARENT/LEGAL GUARDIAN SIGNATURE DATE 5

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I have been presented with a copy of A Adult & Pediatric Allergy & Asthma Associates Notice of Privacy Practices. Further, I permit a copy of this authorization to be used in a place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to medical assignment of benefits apply. May we mail to your home, or other designated location, any items that assist the practice in carrying treatment/ healthcare operations, such as appointment reminders, insurance items and lab results? ( ) YES ( ) NO May we leave a message with a member of your household regarding appointments, lab results and insurance? ( ) YES ( ) NO If yes, whom: Relationship: If yes, whom: Relationship: May we leave a message on an answering machine regarding appointments, lab results and insurance? ( ) YES ( ) NO If employed, may we contact you at your work place? ( ) YES ( ) NO I understand the contents of this notice? ( ) YES ( ) NO PATIENT OR LEGAL GUARDIAN SIGNATURE (IF UNDER 18, PARENT OR LEGAL GUARDIAN SIGNATURE & STATE YOUR RELATIONSHIP TO PATIENT) 6

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