Patient Registration Form

PATIENT INFORMATION Patient Registration Form Date Patient Name (Last) (First) (Middle) Address City State Zip 911 Address (if different from above) Sex: M/F Birth date Age Social Security # Marital status: (circle one) S M W D Race: (circle one) Asian Black Native American White Other Email Address: Home Phone Cell Phone Employer Work Phone (Circle one): Full time Part time Referring Physician Emergency contact Relationship to patient Phone No. Spouse s Name (if applicable) Spouse s Social Security # Spouse s Birth date Spouse s Employer Work phone Employer Address City, State & Zip Preferred method of reminder contact (please circle one): Mail/Letter Relay Health Phone: (If patient is less than 18 years of age) RESPONSIBLE PARTY (Circle one) Father Mother Guardian Other (If different from patient information) Responsible party s name Responsible party SS# Sex: M/F Address City, State & ZIP 911 Address (if different from above) Responsible party Birth date Responsible Party Employer Employer Address City, State & Zip OTHER PARENT/GUARDIAN INFORMATION Name Address City, State & ZIP Relationship to Patient Employer Employer Address City, State & Zip SS# Birth date Sex: M/F ***************************** 1/15 Page 1 of 2

PRIMARY INSURANCE Name of Insurance Company Policy Holder Pt. Relation to Policyholder ID# Group# Ins. Phone No. Policyholder s Birth date Sex: M/F SECONDARY INSURANCE Name of Insurance Company Policy Holder Pt. Relation to Policyholder ID# Group# Ins. Phone No. Policyholder s Birth date Sex: M/F HAC Registration Date Requested Medical Record No. D.O.B. S.S. # Acct. # Date Completed Sentara Dominion Health Medical Associates Rev. 12/14 Pg. 2 of 2

Consent to Treat I, the undersigned, hereby consent to and authorize the administration and performance of all treatments, the administration of any needed anesthetics; the performance of such procedures as may be deemed necessary or advisable in the treatment of this patient, the use of prescribed medication; the performance of diagnostic procedures; the taking and utilization of cultures and performance of other medically accepted laboratory test, all of which in the judgment of the attending physician or their assigned designees, may be considered medically necessary or advisable. I fully understand that this consent applies to all Sentara Dominion Health Medical Associates affiliate practices. Practices included in Sentara Dominion Health Medical Associates are Sentara Halifax Family Medicine, Sentara Volens Family Medicine, Sentara Chase City Family Medicine, Sentara Clarksville Family Medicine, Sentara Southern Virginia Orthopedics, Sentara Southern Virginia Ear, Nose & Throat, Sentara Halifax Neurology, Sentara Halifax Urology, Sentara Southside Hematology & Oncology, Sentara Halifax Dental Clinic, Sentara Halifax General Surgery. I fully understand that this consent is given in advance of any specific diagnosis or treatment. I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I hereby authorize Sentara Dominion Health Medical Associates affiliate practices to release medical information to any of my physicians or insurance companies that may be pertinent to my case. I hereby authorize payment directly to Sentara Dominion Health Medical Associates affiliate practices of benefits otherwise payable to me. I hereby authorize release of my medical records to third party insurers or other authorized persons to whom disclosure is necessary to establish or collect a fee for the services provided. I understand that I am financially responsible for charges not covered by this authorization. A photocopy of this authorization shall be considered as valid as the original. Further, I acknowledge that if I am indebted for past due charges that I am financially responsible for those charges also. I consent and authorize Sentara Dominion Health Medical Associates affiliate practices to collect my personal medical information in order to obtain and maintain on file the information necessary to verify and process electronic prescriptions. The received information can include prescription insurance eligibility, prescription insurance claims history, and prescription insurance formulary files I consent and authorize Sentara Dominion Health Medical Associates affiliate practices to transmit prescription information to the pharmacy of my choice through a third party intermediary operating under a business associate agreement with the electronic prescription software vendor. I further consent to these options: Publish Data to Relay Health YES NO Transmit Data to Immunization Registry YES NO Receive Immunization Reminders from the Registry YES NO Should the Immunization Registry Protect Data YES NO Mail Order Prescriptions Preferred YES NO Preferred Method of Contact: Mail/Letters Phone Call Relay Health No Preference MEDICARE PATIENTS: I authorize Sentara Dominion Health Medical Associates affiliate practice to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to the appropriate Sentara Dominion Health Medical Associates affiliate practice. In accordance with the provisions of Section 32.1-45.1 of the Code of Virginia, (whenever any healthcare provider, or any person employed by or under the direction and control of a health care provider, is directly exposed to body fluids of a patient in a manner which may, according to the current guidelines of the Centers of Disease Control, transmit human immunodeficiency virus), the patient whose body fluids were involved in the exposure shall be deemed to have consented to testing for infection with human immunodeficiency virus. If there is an exposure, and the patient s test is positive, the attending physician will notify the patient, any person exposed and the Virginia Health Department and appropriate counseling will be offered. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. Patient s Signature (or responsible party): Date: January 2015

Consent to Treat a Minor I (we), the undersigned parent(s) or legal guardian(s) of, a minor, hereby consent to and authorize the administration and performance of all treatments, the administration of any needed anesthetics; the performance of such procedures as may be deemed necessary or advisable in the treatment of this patient, the use of prescribed medication; the performance of diagnostic procedures; the taking and utilization of cultures and performance of other medically accepted laboratory test, all of which in the judgment of the attending physician or their assigned designees, may be considered medically necessary or advisable. I (we) fully understand that this consent applies to all Sentara Dominion Health Medical Associates practices. I (we) fully understand that this consent is given in advance of any specific diagnosis or treatment. I (we) intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing. I (we) hereby authorize Sentara Dominion Health Medical Associates affiliate practices to release medical information to any of the patient s physicians or insurance companies that may be pertinent to his/her case. I (we) hereby authorize payment directly to Sentara Dominion Health Medical Associates affiliate practices of benefits otherwise payable to me (us). I (we) hereby authorize release of his/her medical records to third party insurers or other authorized persons to whom disclosure is necessary to establish or collect a fee for the services provided. I (we) understand that I (we) am (are) financially responsible for charges not covered by this authorization. A photocopy of this authorization shall be considered as valid as the original. Further, I (we) acknowledge that if I (we) am (are) indebted for past due charges that I (we) am (are) financially responsible for those charges also. I (we) consent and authorize Sentara Dominion Health Medical Associates affiliate practices to collect the patient s personal medical information in order to obtain and maintain on file the information necessary to verify and process electronic prescriptions. The received information can include prescription insurance eligibility, prescription insurance claims history, and prescription insurance formulary files. I (we) consent and authorize Sentara Dominion Health Medical Associates affiliate practices to transmit prescription information to the pharmacy of my (our) choice through a third party intermediary operating under a business associate agreement with the electronic prescription software vendor. I further consent to these options: Publish Data to Relay Health YES NO Transmit Data to Immunization Registry YES NO Receive Immunization Reminders from the Registry YES NO Should the Immunization Registry Protect Data YES NO Mail Order Prescriptions Preferred YES NO Preferred Method of Contact: Mail/Letters Phone Call Relay Health No Preference In accordance with the provisions of Section 32.1-45.1 of the Code of Virginia, (whenever any healthcare provider, or any person employed by or under the direction and control of a health care provider, is directly exposed to body fluids of a patient in a manner which may, according to the current guidelines of the Centers of Disease Control, transmit human immunodeficiency virus), the patient whose body fluids were involved in the exposure shall be deemed to have consented to testing for infection with human immunodeficiency virus. If there is an exposure, and the patient s test is positive, the attending physician will notify the patient s parent or legal guardian, any person exposed and the Virginia Health Department and appropriate counseling will be offered. I (we) certify that I (we) have read and fully understand the above statements and consent fully and voluntarily to its contents. Patient Date of Birth: Parent Legal Guardian Signature Date Revised January 2015

FINANCIAL POLICY Sentara Dominion Health Medical Associates It is the policy of SDHMA to have a financial policy that clearly outlines patient and practice financial responsibilities. We are committed to providing our patients with the best possible medical care in a comfortable, personal and cost effective manner. Payment is expected at the time of service. Payments made to SDHMA practices may be made by cash, check, or credit. Patients seen at the practice for their first visit are required to pay their responsible balance in full. All co-insurance and deductible amounts are due at the time of service. We do our best to include all charges at the time of service. Occasionally, charges may be added or modified after your visit. Insurance Billing Insurance claims are filed as a courtesy to our patients. You are expected to pay your co-insurance and the balance for any non-covered services at the time of service. We expect payment in full within 60 days for services billed to insurance. It is your responsibility to pay any balance older than 60 days and to follow up with your insurance company for reimbursement. If we receive a payment from your insurance company after your balance has been paid, we will issue you a refund. It is your responsibility to contact your insurance company if a claim is denied, paid at a lower rate than you expected or if it has not been paid within 60 days. If we have made an error, we will gladly resubmit a corrected claim. Third Party Litigation Our office will not become involved in disputes arising from Third Party Claims (i.e., automobile accidents, liability claims, Worker s Compensation) with the exception of Medicare or Medicaid. Credit Patients who are financially able are expected to pay for medical services. Special consideration will be made to patients who are financially unable to pay for medical services. Budget and payment plans are available for accounts based on individual needs. Financial assistance is available for qualified patients. If you feel that you may qualify for assistance, please notify the front office staff. Adequate information will be obtained on each new patient so that the account can be processed properly. Details of when and how the fees for services are to be paid will be on an individual basis. Itemized bills are available per patient/guarantor request After carrying out all our policies on granting credit, we will take the necessary steps within the realm of ethical medical public relations to seek payment from those who are able to pay. We do this in fairness to our patients who pay their accounts.

Collection Accounts Accounts with balances over 90 days will be turned over to a collection agency unless you are making timely payments on an approved payment plan. A $70 deposit is required for each office visit for any SDHMA collection accounts. The $70 deposit also applies to collection accounts that have been processed for any legal proceedings until satisfied. Bankruptcy Accounts A $70 deposit is also required for all Bankruptcy accounts, in order to re-establish credit within SDHMA facilities. This will be required for as long as deemed necessary per SDHG discretion, to collect all deductibles and copays to be determined when insurance is verified during the check in process. Credit Balances/Refunds Patient refunds will not be processed until all active or past due accounts are paid in full. Refunds less than $15.00 will not be refunded unless specifically requested by the patient/guarantor or insurance company. FINANCIAL AGREEMENT NOTICE I have read the policies above and understand them. I agree to promptly pay all fees and charges for treatments provided to me and/or my family. All insurance payments for services rendered are assigned to this office. I understand that it is my responsibility to contact my insurance company should a claim be denied or not paid in full. I promise that I will pay all charges in full within 60 days after receipt of insurance payment. I understand that charges may occasionally be added or modified by my clinician. I understand that I am financially responsible for all charges, whether or not they are covered by my insurance. I authorize this clinic to release to my insurance carrier any medical information needed to obtain payment for services rendered. I understand that if I disagree with any charges, I will contact this office in writing within 30 days of the billing date. If my outstanding balance has to be referred to a collection agency or attorney for collection, I agree to pay all reasonable collection costs including late charges, interest, court costs and/or attorneys fees. Do not sign this agreement before you read and agree to the conditions set forth above. You may request a copy of this agreement for your records. Signature Patient/Responsible Party if minor Relationship Date Revised June 2015 2

Dear Patient: All affiliated physician practices of Sentara Halifax Regional Hospital implemented a Patient Financial Assistance Policy. Qualification for financial assistance is determined by the Federal Poverty Guidelines. Should you wish you to apply, please complete the attached Patient Financial Assistance Application (PFAA) and return within 30 days with required supporting financial documentation related to household income and dependents. The acceptable types of proof of income are indicated on the application. These MUST be included for consideration. If no income exists, the patient or responsible party is required to sign a statement of no income. Revised 6/2015 FEDERAL POVERTY INCOME GUIDELINES (FPG) Household Size 100% 150% 175% 200% 225% 1 $11,770 $17,655 $20,598 $23,540 $26,483 2 $15,930 $23,895 $27,878 $31,860 $35,843 3 $20,090 $30,135 $35,158 $40,180 $45,203 4 $24,250 $36,375 $42,438 $48,500 $54,563 5 $28,410 $42,615 $49,718 $56,820 $63,923 6 $32,570 $48,855 $56,998 $65,140 $73,283 7 $36,730 $55,095 $64,278 $73,460 $82,643 8 $40,890 $61,335 $71,558 $81,780 $92,003 Once your application has been processed, our office will notify you by letter of the results. If a discount is approved, your account will be adjusted appropriately. The approved discount is effective for a period of 12 months from the date of the application. It is the patient s responsibility to reapply once the application has expired. You are expected to pay a minimum of $25 for family practices and $50 for specialty practices at the time of service. You are responsible for any remaining balance once your application is processed and adjustments have been made to your account. SDHMA reserves the right to designate certain services which are not subject to this charity care policy. Granting of charity care is contingent upon satisfactory payment arrangements on any remaining non-charity portion of the bill. Failure to honor payment arrangements on amounts exceeding the charity adjustment may result in the total charity care being revoked. This discount applies to: Sentara Chase City Family Medicine Sentara Clarksville Family Medicine Sentara Halifax Family Medicine Sentara Volens Family Medicine Sentara Halifax Urology Sentara Southern Virginia Ear, Nose, & Throat Sentara Southern Virginia Orthopedics Sentara Halifax Neurology Sentara Southside Hematology & Oncology Sentara Halifax General Surgery Sentara Halifax Pediatrics This policy establishes the framework pursuant to SDHMA that will identify patients that may qualify for charity care; provide charity care; and account for charity care in accordance with the requirements set forth in the Virginia Code and consistent with generally accepted accounting practices. The determination of eligibility for reduced fee care only covers physician services. This does not cover charges billed separately by Sentara Halifax Regional Hospital or private physicians, including radiologists. Effective June 1, 2015 non-medically necessary procedures and drug testing will not be a covered service under the PFAA. Thank you for allowing the physicians and staff of Dominion Health Medical Associates the opportunity to serve your health care needs. RESERVATION OF RIGHTS: DHMA reserves the right to limit or deny financial assistance at its sole discretion.

PATIENT FINANCIAL ASSISTANCE APPLICATION Today s Date: Account #: Name of Practice: Reviewed By: Date: Patient s Name: Guarantor s Name: Address: Number of Dependents: First Middle Last First Middle Last Phone: (including yourself, spouse, children under 21 years of age, unless FT student) Name Relationship Age 1. _ 2. 3. 4. 5. 6. Guarantor s Total Monthly Income*: Spouse s Total Monthly Income*: Other Income*: Do You File Taxes?: YES NO **In order to be considered for discount, copies of most recent tax return or two most recent check stubs, SSA benefit letters, or any other source of income FOR ALL HOUSEHOLD MEMBERS must be included and attached to this application.** Authorization I/We authorize Sentara Dominion Health Medical Associates to verify all information contained in this financial statement. Everything on this financial statement is correct to the best of my knowledge. Signature: Excess Income: Date: DO NOT WRITE BELOW THIS LINE. FOR OFFICE USE ONLY. Total Annual Income: $ Recommendation for Financial Assistance Charge Discount 100% 75% 50% 25% Office Staff Date Revised June 2015

SUMMARY NOTICE OF PRIVACY PRACTICES This is a summary and the detailed notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Sentara collects health information from you and stores it in a chart and on a computer. This is your medical record. The medical record is the property of Sentara, but the information in the medical record belongs to you. Sentara protects the privacy of your health information. The law permits Sentara to use or disclose your health information for the following purposes: Treatment : Example: a Sentara nurse may read your medical chart in order to care for you Payment: Example: We may send information about you to your insurance company in order to get paid. Regular Health Care Operations: Example: We may provide health information to students who are authorized to receive training in our facility. As a Patient you have the following rights: Right to Notice of Privacy Practices Right of access and inspection Right to amend Right to authorize non- treatment uses Right to accounting of disclosures Right to request restrictions on use Right to request alternative channels of communication Right to complain to entity or HHS Effective Date of this notice: 04/14/2003 Updated August 2013. ACKNOWLEDGEMENT OF RECEIPT This is to acknowledge that I have received this Summary Notice of Privacy Practices and been offered a written copy of the Sentara Notice of Privacy Practices or to access via the internet. http://www.sentara.com/policies/pages/websitepolicies.aspx or http://www.hrhs.org Name: Signature: Date: Relationship if other than patient: Acknowledgement of Receipt Notice of Privacy Practice Rev. 1/15 Pg 1 of 1

PERMISSION TO DISCUSS PERSONAL HEALTH INFORMATION (PHI) Patient Name: Date of Birth: Account Number: NAME RELATIONSHIP Signature of Patient, Parent or Guardian: Date: In order to obtain information by telephone, the party calling the practice must share the patient identifier with the staff. Patient identifier: (Patient Date of Birth) Reviewed 1/15

NAME: List ALL of your medical diagnoses/problems. Example: High Blood Pressure, Diabetes, Anemia Diagnosis/Problem Treating Physician HEALTH HISTORY DOB: PAST MEDICAL HISTORY Date Age: Today's Date: List all past surgeries (be as specific as possible), include the date of the procedure (estimate if not known). Example: ACL repair to right knee 1998, Hysterectomy 2009 Surgery Surgeon PRESENT MEDICATIONS List ALL medications that you are currently taking, including prescriptions, "over-the-counter" medications, vitamins and herbal supplements. Name of medication: Example: Aspirin Dose: Example: 81 mg Frequency: Example: one tablet daily Substance Reaction ALLERGIES Severity Onset Date Revised January 2015

My Halifax Medical Record My Halifax Medical Record is your online resource for accessing your health information securely and privately. By using this resource, you are able to maintain a secure, electronic file of you and your family s personal health information and stay informed about events to help you focus on good health. To sign up, simply provide us with the information requested below and we will get you started. In a few days you will receive an email from us. All you have to do is open and follow the easy instructions for getting connected. Soon, our front office, nurses, office manager and your health care provider will only be a click away. To learn more visit www.sentara.com and click on the Patient Login button located on the top of the page. Patient name E-mail address Provider s name Date Revised 6/2015

No Show Policy Primary Care Offices It is the policy of Sentara Dominion Health Medical Associates to monitor and manage appointment no-shows. Any patient who fails to arrive for a scheduled appointment or cancels an appointment less than 24 hours prior to appointment is considered a noshow. A patient who is a no-show more than three times in one year will be dismissed from the Practice. Procedures 1. A patient is notified of the no-show policy at the time of initial registration. The no-show policy is provided in writing upon the patient s arrival. 2. A patient s appointment status is automatically or manually updated by marking the system N for no-show when patient cancels an appointment within 24 hours prior to the scheduled appointment. 3. By the end of the same day the appointment is missed, the provider will review the patient s chart. 4. No-Show is noted in the patient s chart and the provider determines the following: a. No Follow-Up Necessary b. Follow-up Urgent locate patient immediately c. Follow-up necessary contact patient and schedule visit in days 5. If this is a patient s first missed appointment, the Practice will attempt to call the patient. If the patient cannot be reached, a letter will be mailed to the patient. 6. If this is a patient s second missed appointment, the Practice will mail a letter to the patient. 7. If this is a patient s third missed appointment, the patient will be dismissed from the Practice and cannot schedule an appointment with any other SDHMA primary care practice. January 2015