Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Address:

Patient Information: Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Email Address: Race: Ethnicity: Gender: Primary Language: Preferred Spoken Language: Would you like to enroll in our secure patient portal for lab results and appointment requests? YES NO How did you hear about us? Community Event Direct Mail Friend/Relative Dr. Directory Insurance Radio Call Center Another Dr. Other: Responsible Party Only If Not Patient: Name: DOB: SS: Mailing Address: City: State: Zip: Home #: Cell phone #: Martital Status: Relationship to Patient: Employment Information: Employer: Office Phone #: Address: Occupation: Primary Insurance: Company: Insured Name: Claims address: Insured DOB: Phone #: ID# Group # Secondary Insurance: Company: Insured Name: Claims address: Insured DOB: Phone #: ID# Group # Emergency Notification/Next of Kin-Someone Not In Household Name: Relationship to Patient Home Phone #: Work Phone #: Address: City: State: Zip: Authorization For Release of Personal Medical Information: I understand, as outlined in the HIPAA Notice of Patient Privacy Practices, my personal medical information will only be released as it pertains to my medical treatment, payment of charges, or operation of the practice and/or hospital. The practice is also authorized to release my personal medical information to the following individual(s). Name: Relationship to patient: Name: Relationship to patient: Patient Signature or Responsible Party Signature 1 P a g e

PATIENT: DOB: SS# PATIENT CONSENT AND AUTHORIZATIONS CONSENT FOR TREATMENT: I, the undersigned patient, parent or legal guardian, knowing that I am (the patient is) suffering from a condition requiring medical care, do hereby present myself for treatment at Florida Hospital Memorial Medical Center, Foot and Ankle of Volusia, and voluntarily consent to the rendering of such care, including treatments, photographs for treatment evaluations, administration of anesthetics and performance of diagnostic and/or surgical procedures. In the event a medical device is implanted or explanted, I agree to the release of my Social Security number to the manufacturer/fda for tracing of the device. I understand that I am under the care and supervision of my attending physician (or in the emergency department, the emergency department physician) and it is the responsibility of the hospital and its staff to carry out the instructions of such physician(s). I understand that the physicians furnishing services to me may be employees of the hospital or may be independent contractors and not employees or agents of the hospital, and that all physicians expect payment in full upon receipt of a bill and I will assist in billing appropriate insurance companies if insurance or other benefits are involved. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of treatments of examination in the office or hospital. ASSIGNMENT OF BENEFITS: I hereby assign payment directly to Florida Hospital Memorial Medical Center, Foot and Ankle of Volusia and the physicians accepting this assignment of all medical benefits applicable and otherwise payable to me. I understand that I am financially responsible to Florida Hospital Memorial Medical Center and their physicians for charges not covered by this assignment or for any and all charges which the insurance carrier declines to pay. RELEASE OF MEDICAL INFORMATION: I, the undersigned patient, parent, or legal guardian, do hereby authorize Florida Hospital Memorial Medical Center,, its officers and employees, to release to any third party payor (such as an insurance company or government agency; Example: Blue Cross/Blue Shield of Florida or ) any medical, psychiatric, alcohol, drug abuse, and/or HIV (AIDS or AIDS related complex) treatment information and records, in accordance with the policy of Florida Hospital Memorial Medical Center, Foot and Ankle of Volusia and any applicable State or Federal Statues, concerning diagnosis and treatment for the above admission when requested by such third party payor for its use in connection with determining a claim for payment for such treatment and/or diagnosis. I authorize the release of any and all medical information to all physicians involved in my care and treatment. I do hereby release Florida Hospital Memorial Medical Center, Foot and Ankle of Volusia from all liability that may arise from the release of the information requested. FLORIDA LAW: Section 817.234 Florida Statutes, stipulates that any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree. FOR MEDICARE AND MEDICAID PATIENTS ONLY CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII or /or Title XIX 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 its intermediary-carriers, any information needed for this or a related of Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for Florida Hospital Memorial Medical Center physician(s). I understand that I am responsible for any health insurance deductibles and coinsurance. MEDICARE BENEFICIARY NOTICE OF NON-COVERED SERVICES: does not (initials) cover some inpatient, outpatient, and emergency services. Items not covered include, but are not limited to INPATIENT: (lotion, toothpaste, deodorant, etc.) OUTPATIENT AND EMERGENCY: medications typically self-administered, annual testing and physicals. ACKNOWLEDGEMENT OF RECEIPT OF AN IMPORTANT MESSAGE FROM MEDICARE (FOR MEDICARE PATIENTS ONLY): My signature only acknowledges my receipt of this message from Florida Hospital Memorial Medical Center, Foot and Ankle of Volusia, as dated below and does not waive any of my right to request a review of make me liable for any payment. I PERMIT A COPY OF THESE AUTHORIZATIONS AND ASSIGNEMENTS TO BE USED IN PLACE OF THE ORIGINAL WHICH IS ON FILE IN FLORIDA HOSPITAL MEMORIAL MEDICAL CENTER. FINANCIAL AGREEMENT: The undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient, he/she individually hereby obligates himself/herself to pay the account of Florida Hospital Memorial Medical Center physician(s) in accordance with the regular rates and terms of the physicians(s). Should the account be referred to an attorney for collection, the undersigned shall pay reasonable attorney s fees and collection expense. Patient s signature Patient s representative/policy holder or spouse Indicate relationship Witness Patient unable to sign due to: 2 P age pg.1-10

Patient Name of Birth Acknowledgement of Receipt HIPAA Notice of Patient Privacy Practices By signing this Written Acknowledgement of Receipt for HIPAA Notice of Patient Privacy Practices( Acknowledgement ) and Patient Financial Statement, I hereby expressly acknowledge my receipt of HIPAA Notice of Patient Privacy Practices and the Patient Financial Statement. Patient, or Legal Representative, Signature Printed Patient, or Legal Representative, Name (or label) of Birth Acknowledgment NOT obtained because: Patient, or Legal representative, declined Notice of Patient Privacy Practices; Other Employee Signature Employee Printed Name Patient Self Determination Act Questionnaire In order to comply with the Omnibus Budget Reconciliation Act of 1990 and Chapter 745, Florida Statutes, please answer the following: I have a Declaration to Decline Life-Prolonging Procedure (Living Will): Yes or No I have a Health Care Surrogate: Yes or No I have a Durable Power of Attorney: Yes or No If you have the above document, please provide a copy for your chart. Signature of Patient or Representative 3 P a g e

RELEASE OF INFORMATION AUTHORIZATION Patient Name: Address: City: of Birth: Phone #: State: MR#: SS#: Zip Code: To be completed by requester: Pick Up Mail Other: If requested health information is needed for a doctor s appointment please specify date: The following individual or organization is authorized to make the following disclosure: Name: Phone: Address: Fax: City: State: Zip Code: Visit (s): Forward to Health Information Management (Medical Records) for: Discharge Summary Operative Report Urgent Care Note Pathology Report History & Physical Laboratory Report Assessment Note Other (specify) Progress Note Radiology Report Forward to Patient Business Office for: Billing Information Reason for requesting information: Requests may be subject to copying fee This information may be disclosed to and used by the following individual or organization: Name: Phone: Address: Fax: City: State: Zip Code: I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Physician s Office Manager. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition (not to exceed 90 days):. If I fail to specify an expiration date, event or condition, this authorization will expire 90 days from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by Federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure. I understand the information in my health record may include psychiatric, alcohol or drug abuse/testing information which may be protected by Federal and State Regulations. I also understand that my health record may include information relating to AIDS, HIV, and/or sexually transmitted disease. Patient Signature: : Authorized Representative/Parent: Printed Name of Authorized Representative/Parent: Relationship to Patient: Address and Phone # of Authorized Representative/Parent: : PATIENT ID LABEL AUTHORIZATION FOR USE AND/OR DISCLOSURE AND REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION Florida Hospital Memorial Medical Center HealthCare Partners rev. 11/6/2013 4 P a g e

HealthCare Partners, a Member of Adventist Health System Consent to Release of Health Care Information Patient Name of Birth General Release of Information I acknowledge that I have received a copy of the Physician Office s Notice of Patient Privacy Practices, which describes the permitted uses and disclosures of my health care information related to my care by the Physician Office, and payment of my charges for the services received at the Physician Office. I specifically authorize the uses and disclosures of my health care information described in the Physician Office s Notice of Patient Privacy Practices. I consent to release of my health care information, including but not limited to medical, psychiatric, substance abuse or HIV information, for medical purposes and for payment purposes to third parties including but not limited to federal or state health plans, insurance companies, collection agencies, employers or other organizations responsible for payment of my charges for the services received at the Physician Office. I consent to release of the following health care information to the Physician Office s institutionally related foundation for fundraising purposes: name, address and other contact information, age, gender, dates of services, and insurance status. Affiliated Entities of Adventist Health System I consent to the use and release of all my health care information, including but not limited to mental health, HIV/AIDS, genetic testing, venereal disease, and tuberculosis information, for treatment, payment and health care operations, among the affiliated entities of Adventist Health System listed in the Physician Office s Notice of Patient Privacy Practices, as amended from time to time. Health Information Exchange Health information exchange allows health care providers to share health care information about patients electronically for several purposes, such as treatment, quality assurance and state law reporting requirements. I understand that if I go to the Physician Office for treatment, the Physicians and/or their staff may get a copy of my health care information electronically through various health information exchange connections with other health care providers. I understand I may request that my health care information not be shared through electronic health information exchange by following the directions in the Hospital s Notice of Patient Privacy Practices. Substance Abuse I authorize the Physician Office and Adventist Health System to release all of my substance abuse health care information (which includes drug and alcohol abuse information) to the hospitals, physicians and care providers who are treating me and are affiliated with (owned or operated by) Adventist Health System for my treatment, payment of the health care services I receive and health care operations activities, like quality assurance and peer review. The list of Adventist Health System affiliated entities is available in hard copy form at the front desk of any site of service or on the websites of Adventist Health System. I understand that this authorization for release of substance abuse health care information may be terminated at any time, unless Adventist Health System and its affiliated hospitals, physicians and care providers have already acted in reliance on it. If not previously revoked, I understand that this authorization is effective until I die. I further understand that I may decline to sign this authorization today by checking the box below. Decline 5 P a g e

HealthCare Partners, a Member of Adventist Health System Consent to Release of Health Care Information (pg 2) Patient Name of Birth THE UNDERSIGNED MAY RECEIVE A COPY OF THIS AGREEMENT UPON REQUEST, AND CERTIFIES THAT HE OR SHE HAS READ THIS RELEASE AND HAS BEEN ABLE TO ASK QUESTIONS. Printed Name of Patient Printed Name of Witness of Birth Patient s Signature & Witness Signature & Printed Name of Legal Representative/Principal Obligor Legal Representative/Principal Obligor s Signature & Relationship to Patient (Self, Legal Representative, Principal Obligator, General Agent) Printed Name of Interpreter [if applicable] IF THE PATIENT, PRINCIPAL OBLIGOR, LEGAL REPRESENTATIVE, OR GENERAL AGENT IS ONLY ABLE TO GIVE VERBAL CONSENT, AS AN EMPLOYEE OF THE PHYSICIAN OFFICE I HAVE SIGNED THIS FORM ON BEHALF OF THE PATIENT TO ACKNOWLEDGE THE VERBAL CONSENT BY THE PATIENT OR THE PATIENT S PRINCIPAL OBLIGOR, LEGAL REPRESENTATIVE, OR GENERAL AGENT, TO THE PROVISION OF TREATMENT BY THE PHYSICIAN OFFICE. Printed Name of Patient of Birth Relationship to Patient (Self, Principal Obligor, Legal Representative or General Agent) Printed Name of Individual Providing Verbal Consent Printed Name of Witness Printed Name of Hospital Employee Witness Signature & Physician Office Employee s Signature & 6 P a g e Reason Verbal Consent Obtained

Patient Name: of Birth: CO-INSURANCE NOTICE TO MEDICARE PATIENTS Dear Patient: We would like to take this opportunity to inform you that this physician practice is a provider-based clinic. This provides increased continuity of care and improved reimbursements, thus allowing Florida Hospital Memorial Medical Center to continue to provide quality medical care and services. Your visits to this office are billed by a Central Billing Office(CBO), which is a service of Florida Hospital Memorial Medical Center. You will be registered in this office as an outpatient of Florida Hospital Memorial Medical Center. Any services you receive will still be billed by Florida Hospital Memorial Medical Center to and any secondary insurance companies. If you have any questions regarding your service provided at this office, please call 386-671-4500 to speak to a Billing Representative. In accordance with s laws and regulations, you will incur a co-insurance liability to Florida Hospital Memorial Medical Center that you would not have incurred if this office were not provider-based. Your actual co-insurance liability will depend upon the actual services furnished by this office. For example, co-insurance balances for an average follow up visit for an established patient (99213) would be approximately $13.02 for the hospital charge and $ 8.97 for the physician charge. After the hospital and physician have been reimbursed by, co-insurance balances will be billed to secondary insurers. If co-insurance is still owed to Florida Hospital Memorial Medical Center and/or physician, you will be billed. If you have no secondary insurance you will be required to pay your portion at time of service. You may request an estimate of this amount of co-insurance liability by contacting your physician s office. As required by policy, for this physician s office, you will be required to read and sign this letter at every visit. I have read and understand that I will incur a liability to Florida Hospital Memorial Medical Center for coinsurance as permitted by law. Signature of Patient or Authorized Representative Signature of Patient or Authorized Representative Signature of Patient or Authorized Representative Signature of Patient or Authorized Representative Signature of Patient or Authorized Representative 7 P a g e

MEDICARE SECONDARY PAYOR (MSP) QUESTIONNAIRE Patient Name: of Birth I AM ENTITLED TO MEDICARE BENEFITS: [ ] NO - RETURN FORM TO THE FRONT DESK [ ] YES - PROCEED TO SECTION I. SECTION I Select the ONE statement that is true for you: [ ] I am over 65 and married Proceed to section II [ ] I am over 65 and not married (includes widowed) Proceed to section III [ ] I am under 65, Disabled and currently employed Proceed to section IV [ ] I am under 65, Disabled and unemployed Disability : IV Proceed to section SECTION II Select the one statement that is true for you: [ ] My spouse and I are both fully retired The date of my retirement: The date of my spouse s retirement: Proceed to section V [ ] I work full or part-time (my spouse is retired) for a company with: [ ] LESS than 20 employees Proceed to section V [ ] MORE than 20 employees Proceed to section IV [ ] My spouse works full or part-time (I am retired) for a company with: [ ] LESS than 20 employees Proceed to section V [ ] MORE than 20 employees Proceed to section IV SECTION III Select the one statement that is true for you: [ ] I am fully retired The date of my retirement:.proceed to section V [ ] I work full or part-time for a company with: [ ] LESS than 20 employees Proceed to section V [ ] MORE than 20 employees Proceed to section IV SECTION IV Select the one statement that is true for you: (This does not apply to supplemental plans or employer plans offered during retirement.) I have health care coverage through my employer. [ ] NO [ ] YES I have health care coverage through someone else. [ ] NO [ ] YES IF YES, list name of guardian and relationship: Proceed to Section V 8 P a g e

Patient Name: of Birth SECTION V Is this visit related to an injury due to a fall? [ ] YES - Did the accident occur in [ ] your home [ ] public location of Accident: OR [ ] other Is this visit related to an illness/injury due to an automobile accident? [ ] YES - of Accident: RETURN TO FRONT DESK AND PRESENT YOUR AUTOMOBILE INSURANCE CARD. [ ] NO Proceed to Section VI SECTION VI Indicate which statements apply to you. [ ] I am entitled to Worker s Compensation for this service. [ ] I am entitled to Black Lung benefits. [ ] I am entitled VA benefits. [ ] I am entitled ESRD benefits. [ ] I am entitled COBRA benefits. [ ] I am entitled to other Federal benefits. (UMWA, Gov t research programs, Hospice) Please Explain: Patient Signature Staff Signature 9 P a g e

Secondary Payor Questionnaire Review Signature Form Patient Name: of Birth: To be completed by the patient at each appointment: Appointment I have reviewed the information on the Secondary Payor Questionnaire that I completed at a previous visit. I attest that all information is correct or I have indicated changes to my health insurance coverage to the best of my knowledge. This section is to be completed by the medical practice personnel only. I have obtained a legible copy of each insurance card and a driver s license. I have determined whether is the primary or secondary payer for today s visit Please return this form, your insurance cards and your drivers licenses to the front desk personnel. 10 P a g e