PATIENT INFORMATION. (Please Print) (Street) (City) (State) (Zip) How did you learn of our office? Referring Dr Yellow Pages Friend/Relative Other

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1 Doctor Account # PATIENT INFORMATION (Please Print) Patient s Name (Last) (First) (Middle) Birthdate Address (Street) (City) (State) (Zip) Home Phone ( ) Cell Phone ( ) Address Social Security # Employer/Student Work Phone # ( ) Employer s Address (Street) (City) (State) (Zip) School Phone # ( ) How did you learn of our office? Referring Dr Yellow Pages Friend/Relative Other Referring Physician Family Physician Reason for today s visit? of last physical examination EMERGENCY CONTACT In case of Emergency, Notify Phone # ( ) Address (Street) (City) (State) (Zip) Relationship Parent ( if minor) Parent DOB Parent Employer (if minor) Work Phone # WORKER S COMPENSATION Is this a worker s compensation case? (Check one): NO YES If yes, please answer the following: Employer Work Phone # ( ) Address to send claims Name of contact person of Accident Please explain how the accident happened

2 INSURANCE INFORMATION Primary Insurance Company Insured s Name Insured through work? Yes No Insured s Social Security # Insured s Birthdate Certification/Policy # Group/Plan # Secondary Insurance Company Insured s Name Insured through work? Yes No Insured s Social Security # Insured s Birthdate Certification/Policy # Group/Plan # (A copy of Insurance cards will be made) MEDICAL RELEASE AUTHORIZATION I, the undersigned patient, or my authorized representative hereby authorize my physician and whomever he/she may designate as his/her assistant to render medical treatment on me. I consent to any medical care which encompasses laboratory, diagnostic, or medical treatment which my physician or his/her assistant may deem necessary during my office visit. I, the undersigned patient or my authorized representative hereby authorize my physician and whomever he/she may designate as his/her assistant to release any medical information accumulated in the course of my examination and treatment to any other doctor, hospital or other parties assisting in my medical care. I, the undersigned patient, or my authorized representative authorize the release of medical information and request payment of benefits to Coastal Surgical Vascular and Vein Specialists when they accept payment. I understand I am responsible for any amount no covered by my insurance. I authorize use of photostatic copy of the assignement in lieu of the original when necessary. PATIENT S SIGNATURE (Parent, if minor) DATE SOCIAL SECURITY ADMINISTRATION If you have health coverage through Medicare, please sign this authorization: I authorize any holder of medical or other information about me to release, to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers, any information needed for this or a related Medicare claim. I permit a copy of the authorization to be used in place of the original and request payment of the medical insurance benefits either to myself or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B fo the Social Security Act and 31 U.S.C provides penalties for withwolding this information). Regulations pertaining to Medicare assignment of benefits also apply. PATIENT S SIGNATURE DATE

3 HIPAA/Alternate Contact Authorization I have received a copy of the Notice of Privacy Practices for COASTAL VASCULAR & VEIN CENTER. Signature I DO DO NOT authorize COASTAL VASCULAR & VEIN CENTER to contact me or leave messages for me at my place of work. I DO DO NOT authorize COASTAL VASCULAR & VEIN CENTER to contact me at my address. address if authorized: I hereby authorize COASTAL VASCULAR & VEIN CENTER to leave messages on my home answering machine or voic regarding appointments and to inform me that laboratory results are available. I realize I must call the office to obtain laboratory results. I DO DO NOT authorize COASTAL VASCULAR & VEIN CENTER to discuss my appointments, medical evaluation, treatment, and results to relatives or other person as indicated. Authorized person(s)/relationship: Advance Directives I acknowledge that I am aware of the need for Advance Directives and that I understand information is available if needed. I also acknowledge that I DO DO NOT have such Directives. If I do not have such Directives at this time, but establish them at a later date, I will provide the Center with a copy. Ownership Acknowledgement I acknowledge that the Center is owned by Drs. Edward C. Morrison, Thomas C. Appleby, and Adam J. Keefer and that I have a right to choose another facility to have my procedure. FOR OFFICE USE ONLY We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because: An emergency existed and a signature was not possible at the time. The individual refused to sign. A copy was mailed with a request for a signature by return mail. Unable to communicate for the following reasons: Prepared by: Signature: :

4 Today s : NEW Patient History Form Patient s Name: of Birth: Account #: Referring Physician: What other physicians participate in your care? Physician CHIEF COMPLAINT: Primary Care: Condition Treated What is the main reason for your visit today? (Describe your problem in detail) Have you already had any tests performed regarding this problem? When did you first notice the problem? (days, weeks, or years?) Does anything help the problem or make it worse? Does the problem interfere with your daily activities? Current Medications: Name (ex. Plavix) Dose (ex. 10mg) Frequency (ex. Every day) Name (ex. Plavix) Dose (ex. 10mg) Frequency (ex. Every day) Provider Notes:

5 Past Medical History Please check all that apply: Cardiovascular Heart Attack Congestive Heart Failure Heart Valvular Disease Atrial Fibrillation High Blood Pressure High Cholesterol Peripheral Artery Disease Leg Ulcers DVT/Blood Clots Varicose Veins Phlebitis Pulmonary Lung Disease COPD/Emphysema Asthma Neurology Migraines Stroke TIA/Mini Stroke Syncope/Black Outs Seizures Gastrointestinal GI/Stomach Bleeding Gall Bladder Disease Hepatitis Liver Disease Endocrinology Diabetes Thyroid Problems Other Disease Depression/Anxiety HIV Cancer: Prostate Problems Arthritis Back Problems Kidney Disease Other medical problems not listed above: Are you allergic to any medications? If yes, what is your allergic reaction? PAST SURGICAL HISTORY Procedure FAMILY HISTORY Has anyone in your immediate family (parents, brother, sister) had any of the following problems? (Check all that apply and specify whom) Diabetes Heart Attack Cancer (specify type) Phlebitis Stroke Aortic Aneurysm DVT Varicose Veins Other Diseases or Illnesses

6 SOCIAL HISTORY Do you smoke: Yes No If so, how many years have you smoked? If not, did you smoke in the past? Yes No If so, how many years and what year did you quit? Do you drink alcohol: Yes No If so, how many drinks per week? Illicit Drugs Living Arrangements Marital Status: Single Married Divorced Widowed Occupation REVIEW OF SYSTEMS Check symptoms you currently have or have had in the past year General Chills Night sweats Fever Weight Loss lbs over weeks Weight Gain lbs over weeks Eyes Sudden loss of vision Blurry vision Cardiovascular Chest pain at rest Chest pain on exertion Irregular heart beat Rapid heart beat Heart Murmur Pulmonary Cough Sputum Wheezing Shortness of breath while lying flat Shortness of breath at rest Shortness of breath with exertion Gastrointestinal Constipation Diarrhea Rectal bleeding Abdominal pain Vomiting Vomiting blood Genito-Urinary Blood in urine Frequent urination Painful urination Waking at night to urinate Neurologic Balance difficulty Difficulty speaking Tingling/numbness Walk with a cane Walk with a walker Endocrine Excessive hunger Excessive thirst Fatigue Cold intolerance Heat intolerance Extremities Leg pain worsened by walking Leg pain at rest Leg swelling Skin Bruise easily Hives Recent change in moles Rash Sore that won t heal Hematology Easy bruising Prolonged bleeding Recent blood transfusion Do not write below this line Physical Exam Vascular Pulses R L General FEM Cardiovascular POP Chest PT Abdomen DP Extremities Carotids Skin Radial Neuro Brachial Vascular studies

7 eehx Collaborative Permission to Create an eehx Summary and share My Medical Information We are taking part in an exciting program to improve your health care and make office visits easier and more convenient. To do this, your doctor would like your permission to enroll you in our eehx Summary program. This means sharing important parts of your medical information with other providers (doctors, nurses and health professionals) through an electronic medical chart. Only authorized healthcare professionals, their agents, and others whose job it is to secure, monitor, and evaluate the operation of the information system and quality of care would be able to access your information. The eehx Summary will allow your providers to access your health information more quickly and accurately that with paper charts. The eehx Summary is an overview of vital medical information. For instance, the eehx Summary may include a list of your current medications, allergies, recent diagnoses (problems) and any surgery you may have had. It will not include detailed confidential notes from your office visits. Information in the eehx Summary may include, but is not limited to, that which South Carolina law considers sensitive such as mental health, substance abuse, sexually transmitted disease, and sexual abuse information. HIV/AIDS diagnoses and any genetic testing results for health screening purposes will not be included in the eehx Summary without your written permission each time it is used. The eehx Summary has a security system to protect your healthcare information. All authorized healthcare professionals with access to the eehx Summary agree to follow strict privacy and security policies. Technology will encrypt (scramble) the information and track who and when someone has accessed your summary. You may request a list from your doctor s office of who has accessed your electronic records. Your doctor is asking permission to share your vital medical information through the eehx Summary for all legally permitted uses and disclosures. These include but are not limited to: Clinical care Billing and financial management Administrative management Reports to public health agencies and other governmental requirements Reports to protect the security of your medical information Reports to evaluate the use of the eehx Summary Reports to track and evaluate the quality of your healthcare services.

8 Ye Yes, I want my health information included in the Roper St Francis Healthcare Collaborative eexh Summary and described above and in the provided information booklet. By my signature below: I acknowledge that I have been given sufficient information and have had the opportunity to have my questions answered ab out the eehx Summary. I give permission to those described above to use and disclose my information, as described above and in the provided information booklet. I understand that I have the option to withdraw permission and can do so by giving written notice to my doctor s office. Should I withdraw my permission, this request will be effective within one (1) business day of my written notice. Signature of Patient/Representative No, I do not want my information included in the Roper St Francis Healthcare Collaborative eexh Summary. I understand that my information will still be stored electronically for my provider s records, but an eehx Summary will not be available to other providers. I also understand that, without the eehx Summary, it may be more difficult for doctors and healthcare providers to coordinate my care. This could have an adverse effect on the quality and efficiency of my health care services. Signature of Patient/Representative

9 FINANCIAL POLICY Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. Address, name, insurance information etc.). C0-PAYS Please be prepared to pay any co-payments, deductibles and non-covered services at the time of each visit. We will also collect all previous outstanding patient balance during check out at the end of your visit. As a convenience to our patients, we accept cash, check (there will be $35.00 fee assessed for all checks returned unpaid by banks), Visa, MasterCard, Discover, and American Express. SELF PAY If you do not have medical insurance we offer a self-pay discount. You are required to pay for services in full at the time of each visit. REFERRALS and PREAUTHORIZATIONS If your insurance company requires a referral form or pre authorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in lower or no payment from your insurance company, and the balance will become your responsibility. INSURANCE As a participating provider, we follow all mandatory guidelines as specified in each individual carrier s contract. Upon verification that we participate with your plan, we will file our charges with your carrier. With most participating contracts, we are required to collect the full allowed amount. (The allowed amount is specified by your carrier.) Therefore, you will be expected to pay your co-payment and/or deductible at the time services are rendered. Many insurance carriers have provisions in their policies resulting in non-payment of certain services. In these cases, the patient will be responsible for the non-covered charges. In the event a procedure is necessary, we will estimate our charges, insurance company s payment, and your co-payment, and/or deductible. Your estimated co-payment and/or deductible is due prior to your procedure. (In the event of an emergency procedure you will be allowed 30 days to pay estimated portion.) Upon payment from the carrier, you will be billed or refunded for any difference between the estimate and the actual amount due after your carrier s payments. If we do not receive payment or rejection from your insurance company in a timely manner, we will transfer the balance to your responsibility. We request your assistance in following up with your insurance company to resolve any non-payment issue. PATIENT RESPONSIBILITIES Our providers recommend care based on the patient s best interest, which is independent of insurance coverage issues. We do our best to check benefits, eligibility, and obtain precertification, but we cannot know all of the benefits and exclusions of each patient s coverage. It is your responsibility to check with your insurance company so that you are aware of any deductibles, copays, coinsurance, or pre-existing exclusions. If you have any questions, about our policy, please call our Billing Dept. at MISSED APPOINTMENTS/LATE ARRIVAL TO APPOINTMENTS If you fail to call to cancel or reschedule an appointment, you will be charged a $30.00 N0-SHOW FEE. If you arrive 30 or more minutes late for your appointment, you will be asked to reschedule. I have read, understand, and agree to comply with the terms of your Office/Financial Policy. Signature Print Name DOB:

10 COASTAL VASCULAR & VEIN CENTER COMMUNICATION CONSENT FORM 1. Risk of Using . Coastal Vascular & Vein Center (CVVC) offers patients the opportunity to communicate by . Transmitting patient information by , however, has a number of risks that patients should consider before using . These include, but are not limited to, the following risks: a. can be circulated, forwarded and stored in numerous paper and electronic files. b. can be immediately broadcast worldwide and received by many intended and unintended recipients. c. senders can easily misaddress an . d. is easier to falsify than handwritten or signed documents. e. Backup copies of may exist even after the sender or the recipient has deleted his or her copy. f. Employers and on-line services have a right to archive and inspect s transmitted through their systems. g. can be intercepted, altered, forwarded or used without authorization or detection. h. can be used to introduce viruses into computer systems. i. can be used as evidence in court. j. can be lost in transmission. 2. Conditions for the Use of . CVVC will use reasonable means to protect the security and confidentiality of information sent and received; however, because of the risks outlined above, CVVC cannot guarantee the security and confidentiality of communication will not be liable for improper disclosure of confidential information that is not caused by CVVC s intentional misconduct. Therefore, a patient must specifically grant his or her consent to the use of for communication between the patient and CVVC. Consent to the use of includes agreement with the following conditions: a. All s to or from the patient concerning diagnosis or treatment will be made part of the patient s medical record. Because they are a part of the medical record, other individuals authorized to access the medical record, such as support staff and billing personnel, will have access to those s. b. Coastal Vascular & Vein Center may forward s internally to CVVC staff and agents as necessary for diagnosis, treatment, reimbursement and other handling. CVVC will not, however, forward s to independent third parties without the patient s prior written consent, except as authorized or required by law. Patient understands and acknowledges that all s between the patient and CVVC will be maintained in the patient s medical file and any person authorized to access the patient s medical file shall have access to such . c. Although CVVC will endeavor to read and respond promptly to an from the patient, CVVC cannot guarantee that any particular will be read and responded to within any particular period of time. The patient shall not use for medical emergencies or other time-sensitive matters. d. If the patient s requires or invites a response from CVVC and the patient has not received a response within a reasonable time period, it is the patient s responsibility to follow up to determine whether the intended recipient received the and when the recipient will respond.

11 e. The patient should not use for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability or substance abuse. f. The patient is responsible for informing CVVC in writing of any types of information the patient does not want to be sent by , in addition to those set out in 2.e. above. g. The patient is responsible for protecting his/her password or other means of access to . CVVC is not liable for breaches of confidentiality caused by the patient or any third party. h. It is the patient s responsibility to follow up and/or schedule an appointment if warranted. 3. Instructions. To communicate by , the patient shall: a. Limit or avoid use of his/her employer s computer. b. Inform Coastal Vascular & Vein Center of changes in his/her address. c. Put the patient s name in the body of the . d. Include the category of the communication in the s subject line, for routing purposes (e.g., billing question, prescription information, medical advice). e. Review the to make sure it is clear and that all relevant information is provided before sending to CVVC. f. Send a reply message or delivery receipt to CVVC to acknowledge patient s receipt of any from CVVC. g. Take precautions to preserve the confidentiality of s, such as using screen savers and safeguarding his/her computer password. h. Withdraw consent only by or written communication to CVVC. 4. Patient Acknowledgment and Agreement. I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of between Coastal Vascular & Vein Center and me, and I consent to the conditions outlined herein. I further agree to waive any and all claims that may arise against CVVC, its affiliates, subsidiaries, directors, employees, agents, and representatives resulting from the use or misuse of . In addition, I agree to the instructions outlined herein as well as any other instructions that Coastal Vascular & Vein Center may impose to communicate with patients by . Any questions I may have had were answered. Signed: :