When you arrive for your first appointment, please bring the following with you:

115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your primary care! It is our responsibility to deliver the best care possible to you and your family. We are a full spectrum family practice specializing in the care of patients of all ages. BUSINESS HOURS Monday: 8 a.m. 5 p.m. Tuesday: 8 a.m. 5 p.m. Wednesday: 8:00 AM 1:00PM Thursday: 8 a.m. 5 p.m. Friday: 8 a.m. 5 p.m. Patients are seen by scheduled appointments only. After-hours care is coordinated through our answering service. Patients will be directed to the appropriate On-Call physician for Carolina Family Medicine of Sumter by calling our office after hours, including weekends and holidays. We are affiliated with Tuomey Regional Medical Center as a practice of the Tuomey Medical Professionals Inc. If hospitalization is needed, you will be seen by your physician from Carolina Family Medicine of Sumter while in the hospital. PREPARING FOR YOUR VISIT In order to make your first visit more effective, please notify your health insurance company in advance of your appointment and your new primary care provider, if required by your health insurance plan. Please be on time for your appointments in order to keep your doctor on schedule. If you are late, your appointment MAY be rescheduled for the next available New Patient opening. Please arrive 15 minutes early if you have completed the new registration forms prior to your appointment, to allow plenty of time for our staff to get you registered for your appointment. If you are unable to complete this packet, please arrive 30 minutes early to allow plenty of time to complete your paperwork before your scheduled appointment. You may bring your paperwork by prior to your scheduled appointment or you may fax it to 803-774-9426. When you arrive for your first appointment, please bring the following with you: 1. All of your health insurance cards (we ask for them at every visit) 2. Photo Identification (current driver s license, state issued ID, student ID, military ID, or Passport) 3. All medications you are currently taking, including vitamins and over-the-counter medications. 4. Completed registration forms 5. Payment is due at the time of service. This includes all copays, co-insurance, deductibles or self-pay visits.

Please call our office if you have any questions or need to reschedule your first appointment. We do require 24- hour s notice if you are unable to keep your scheduled appointment. LABORATORY TESTING We draw labs in the office and depending on your insurance carriers preferred lab or your personal preference, your labs will be sent to one of the following laboratories for resulting: Tuomey, LabCorp, or Quest Diagnostics. Please fill out the enclosed Lab Testing form to indicate your preferred lab. All lab results must be reviewed by the physician prior to being released to the patient. Please allow 1-2 weeks for the clinical staff to call with the results. Urgent results are handled as first priority when notifying patients. The clinical staff will attempt to contact you with lab results twice via phone. If the clinical staff cannot reach you, then your results will be mailed to the address on file. MINORS Please make sure that you fill out the Health Care Surrogate Designee(s) form if you are the parent or legal guardian of a minor child being treated at Carolina Family Medicine of Sumter. If anyone other than the parent or legal guardian brings a minor to an appointment and they are not listed on the form we will NOT be able to see or treat the minor. MEDICATIONS Please bring all medications (prescription and over-the-counter) to all appointments. We must compare your medications bottles to our records to make sure you are taking the prescribed medication appropriately and to check for refills. If you request a prescription to be written or called into your pharmacy, please allow 24 hours for us to process your request. We must get authorization from the physician prior to writing or calling in your prescription. INSURANCE/BILLING Please be sure to bring all of your insurance cards to every visit. Payment is expected at the time of service for every visit. If you are unable to make your payment, please contact the Billing Office at least 24 hours prior to your scheduled appointment. If there is a change in your insurance coverage, please notify us immediately. There are filing deadlines and contractual agreements that we must abide by. If the correct insurance is not filed, it could result in the patient being responsible for the balance for that particular date of service. Your insurance is filed as a courtesy. However, if we are not contracted with your insurance company, we file the claim as an out of network provider. You will be responsible to pay 100% of your visit upon check-out. If your insurance company reimburses the charges for that date of service, we will refund your payment. These guidelines are in place so that every patient receives the best quality of care possible. We are honored that you have chosen us to be your primary care practice and look forward to a long and healthy relationship.

REGISTRATION FORM PATIENT INFORMATION PLEASE COMPLETE ALL INFORMATION Last Name: First Name: Middle: Previous Last Name: Is this your legal name? If not, what is your legal Social Security # Date of Birth: Sex: Yes No name? - - / / M F Physical Address: City: State: Zip Code: Mailing Address/PO Box: City: State: Zip Code: Marital Status: Single Married Divorced Widowed Separated Language: English Spanish Other: Race: African American Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander White Home Phone: ( ) Work Phone: ( ) Mobile Phone: ( ) Email Address: Contact Preference: Home Work Mobile Other: Emergency Contact: Emergency Contact Phone Number: Relationship: ( ) Employment: Employer: Student Status: Employed Unemployed Full Time Self Employed Retired Not a Student GUARANTOR INFORMATION PERSON RESONSIBLE FOR BILL Name of Guarantor: Mailing Address of Guarantor: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Do not wish to report Phone Number of Guarantor: Guarantor s Date of Birth: Guarantor s Social Security #: ( ) INSURANCE INFORMATION PLEASE COMPLETE ALL INFORMATION Primary Insurance Company: Policy Number/Member ID: Group Number: Part Time Address: City: State Zip Code: Phone Number: ( ) Policy Holder s Name: Policy Holder s SSN: Policy Holder s Date of Birth: Relationship to Patient: - - / / Secondary Insurance Company: Policy Number/Member ID: Group Number: Address: City: State Zip Code: Phone Number: ( ) Policy Holder s Name: Policy Holder s SSN: Policy Holder s Date of Birth: Relationship to Patient: - - / / The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the practice. I understand that I am financially responsible for any balance. I also authorize Carolina Family Medicine of Sumter or my insurance company to release any information required to process my claims. Signature of Patient or Legal Guardian Date

HEALTH CARE SURROGATE DESIGNEE(S) I (We) and, parent(s) or legal guardian of, authorize the adult(s) named in the list below to bring my minor child to Carolina Family Medicine of Sumter for, and consent to, treatment, or receive medical advice over the phone if they are taking care of my child in my absence. This does not let allow them to have access to protected health information that is not pertinent to the visit. Please check boxes to give them additional specific authorizations.* NAME BIRTHDATE RELATIONSHIP TO MINOR AUTHORIZATIONS *Any other type of documents to be picked up by someone other than the legal guardians listed above must have written consent from the legal guardian(s). I (We) understand that telephone triage and advice services will not be extended to the above persons unless it is regarding direct patient care while the child is in their care. When the above listed individuals bring a minor child for their medical care at Carolina Family Medicine of Sumter, we will verify their identity by asking for a picture ID. If the individual bringing the minor child to the office visit does not have a picture ID and is not listed on this form, we will not be able to see the minor and the appointment will be rescheduled. Parent/Legal Guardian Name (print) Relationship to Patient Parent/Legal Guardian Signature Date This authorization shall remain in effect until revoked in writing with my signature.

Release of Information Declaration I, give permission for the following individuals to have access and availability to any and all of my protected health information at Carolina Family Medicine of Sumter. Please check which information (Medical, Financial or Both) you would like the persons to receive. Individuals not listed on this form and/or those who do not have a picture ID will not have any access to your protected health information. Name Date of Birth Relationship to Patient Authorizations Medical Financial Medical Medical Medical Financial Financial Financial Do you want results of lab tests/x-rays left on your answering machine or voicemail? Home: Yes No Work: Yes No (We will still leave generic information on your answering machine or voicemail for an appointment or to call our office.) Do you want information given to your employer or school if they inquire about appointment absentee information? School: Yes No Employer: Yes No I authorize the staff to inform me by mail or phone (including home answering machines/voicemail) of various reports if necessary. Yes No Should any lab tests or pathology be done during the visit, I would prefer that my labs/pathology be sent to one of the following labs: LabCorp Tuomey Quest I understand that I am responsible for making sure that the above chosen lab is my insurance company s lab of choice and if not I will be responsible for any charges occurred. Carolina Family Medicine only bills my insurance company for labs that are CLIA waived (i.e. finger sticks, rapid flu and strep tests, urine analysis, etc.). All other tests and pathology are billed to the patient s insurance by the lab selected. Yes No Rights of the Patient I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document by sending a written notification to Carolina Family Medicine of Sumter. I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective going forward. I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal and state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient in writing. I understand by signing this form that I am consenting to medical treatment by Carolina Family Medicine of Sumter. I understand by signing this form that I am consenting to release of medication history to Carolina Family Medicine of Sumter. Patient Name (Print) Date Patient or Authorized Representative s Signature Date

TUOMEY MEDICAL PROFESSIONALS, INC. CONSENT AND CONDITIONS OF TREATMENT In consideration of the care and treatment to be provided to the patient whose name appears at the bottom of this page at Tuomey Medical Professionals, Inc. ( TMP ) d/b/a Sumter Ob/Gyn, Industrial Medicine and Wellness, Sumter Surgical, Sumter Plastic and Reconstructive Surgery, Sumter Orthopedic Associates and Carolina Family Medicine of Sumter. I/we, the undersigned, consent to and agree to the following conditions. CONSENT FOR TREATMENT I/we voluntarily consent to healthcare treatment and diagnostic procedures provided by TMP and its associated physicians, clinicians, and other personnel. I/we further consent to testing for infectious diseases, including, but not limited to, syphilis, AIDS/HIV, hepatitis and testing for drugs if such testing is deemed advisable by my physician. I/we am/are aware that the practice of medicine and surgery is not an exact science and I/we acknowledge that no guarantees have been made as to the result of treatments or examinations. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I/we consent to the use and disclosure of my/the patient s protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with the TMP s Notice of Privacy Practices. ASSIGNMENT OF BENEFITS AND PAYMENT I/we guarantee payment of all charges made for or on account of me/the patient. Unless my/the patient s account is paid in full upon discharge, I/we hereby assign the following to the physician and TMP: (1) my/our rights to any and all insurance benefits I/we have or to which I/we may become entitled; (2) the proceeds for all claims resulting from or relating to the liability of or payments made by a third party or by any person, employer, or insurance company on the third party s behalf to or for the patient; or (3) other funding. I/we understand that I/we am/are responsible for any charges not covered by insurance or other forms of benefits. I/we understand TMP can obtain my/our credit report for review in collection of this debt. For Medicare beneficiaries: I/we have provided all necessary information for proper assignment of Medicare benefits. PATIENT FINANCIAL POLICY It is the goal of TMP to provide the best of care on your behalf. Therefore, it is important for you to fully understand our insurance and collection policies. Please read the following information carefully and feel free to ask any questions. We ask that you initial this statement when you have read and understand each point covered. Upon registration, TMP may require a picture I.D. (if the patient is a minor a picture I.D. may be required of parent/legal guardian). In addition, each patient may be required to complete a Patient Information Form, Medical History and Consent and Conditions of Treatment. If we participate with HIPAA #1008A Consent and Conditions of Treatment

your insurance(s), a copy of your insurance card(s) will be required for verification of insurance coverage and benefits. If you have been referred to this office by your primary care physician and belong to an insurance plan that requires precertification or referral for this office visit, we request that you have this information available before you visit a physician. Failure to supply this information may postpone your visit to the physician or make you responsible for the full balance of your account. If you have health insurance, it should be understood that this is an agreement between you and your insurance carrier to pay for medical care. Your doctor s bill is an agreement between you and this office. You are ultimately responsible for the payment of your bill regardless of the status of your insurance claim. We will file all claims for those patients who are covered by insurance companies that our office has contracted to provide services within their fee schedule. The contracts are subject to change with or without notice. All copays are due at the time of service. If your insurance has a deductible, you will be required to pay any/all insurance allowed charges at the time of service. If you have your Explanation of Benefits from your insurance company (must be current year) that demonstrates that the deductible has been met, you will only be required to pay the percentage allowed by your particular insurance. You will receive regular statements (every 30 days) from our office informing you of the status of your balance. Please feel free to call our office, if you should have any questions. If we have not received any payment after 90 days from the date of service, we reserve the right to refer your account balance to an outside collection agency where you will be responsible for all collection and legal fees. There will be a $30.00 fee for all checks presented for payment with non-sufficient funds (bad checks). You will also be billed separately by the hospital or other sources, if it applies, for certain lab fees, radiology fees and/or outpatient or inpatient procedures, and orthopedic supplies (slings, braces, splints, etc.). NOTICE OF PRIVACY PRACTICES I/we acknowledge receipt of Tuomey Medical Professionals, Inc. s Notice of Privacy Practices. If not, why? DATE AND TIME SIGNATURE OF PATIENT or PERSONAL REPRESENTATIVE (Circle one: Parent, Guardian, or Legally Authorized Representative) Verification of Personal Representative by WITNESS (TMP Employee) HIPAA #1008A Consent and Conditions of Treatment