SURGICAL ASSOCIATES OF FREDERICKSBURG, LTD. PATIENT REGISTRATION FORM

Patient’s Name ________________________________________________________________________________ Social Security #___________-_________-________ Last First Middle Initial

Reason for visit _________________________________________________________ Referring MD _______________________ Primary MD______________________ Date of Birth ____________________ Age ______ Sex ______ Marital Status _________ Home Phone # __________________ Cell Phone # ____________________ Month / Day / Year

Ethnicity: _______________________________ Race: _____________________________ Primary Language: __________________________ Preferred Pharmacy____________________________________Pharmacy Address______________________________________________________________________ Preferred Method of Communication: Home Phone Cell Phone Work Phone E-mail US Mail Other_________________________________________ Home Address _________________________________________________________________________________E-mail Address ________________________________ Street City State Zip

Mailing Address (if different from above) ________________________________________________________________________________________________________ Employer ________________________________________________________________________ Occupation _______________________________________________ Work Address _______________________________________________________________________________________ Work Phone #___________________________ Street City State Zip

Spouse’s Name ___________________________________________________ Date of Birth__________________ Social Security #_______________________________ Spouse’s Employer __________________________________________________________________________________ Work Phone # ___________________________ Emergency Contact _____________________________________ Relationship _________________________________ Phone Number # _________________________

IF THE PATIENT IS A MINOR OR STUDENT

(The party requesting care for a minor is responsible for payment) Father’s Name ________________________________________________________ Date of Birth __________________ Social Security #__________________________ Father’s Employer __________________________________ ________________________________________________ Work Phone #___________________________ Mother’s Name ________________________________________________________ Date of Birth__________________ Social Security #_________________________ Mother’s Employer __________________________________ ________________________________________________ Work Phone #___________________________

INSURANCE INFORMATION

PRIMARY _________________________________________________________________________________________________________________________________ Name of Insurance Co. Subscriber # Group # Address Relationship to Insured SECONDARY ______________________________________________________________________________________________________________________________ Name of Insurance Co. Subscriber # Group # Address Relationship to Insured

WORKERS COMPENSATION (if applicable)

Type of injury sustained ___________________________________________________________________________________ Date of Injury ______________________ Employer’s Name & Address at time of injury ____________________________________________________________________________________________________ Contact Name ____________________________________________________________________________ Contact Phone # ___________________________________ Worker’s Compensation Carrier _____________________________________ Address __________________________________________________________________ Contact Name ____________________________________________________ Contact Phone # __________________________ Claim # ______`____________________

ASSIGNMENT OF INSURANCE BENEFITS AND AUTHORIZATION TO OBTAIN OR RELEASE PATIENT INFORMATION I hereby authorize the physician’s office to release such information as may be necessary for claims to the insurance companies listed above. I also hereby authorize

payment directly to Surgical Associates of Fredericksburg for any benefits otherwise payable to me, but not to exceed the regular charges for this period. I understand that I am financially responsible to the above physicians for charges not covered by this assignment. Patients not covered by insurance are responsible at the time of service for charges incurred or arrangements for payment must be made with the business office.

I also authorize the physician’s office to release or obtain such information as may be necessary to assist in my medical treatment, as well as obtain prescription history via electronic RX database. This form will be placed in your chart and be applicable until such information is changed.

If this account is turned over to an attorney or collection agency for collection services, the undersigned agrees to pay all costs of collections, inclusive of 29% in collection agency fees, interest at 18% per annum, court costs, and any additional costs associated with collection of outstanding balances to Surgical Associates of Fredericksburg.

Signature: ______________________________________ Date: ___________________________

SURGICAL ASSOCIATES OF FREDERICKSBURG, Ltd. 4548 Empire Court, Fredericksburg, VA 22408

NOTICE OF INFORMATION PRACTICES

1. This notice describes how Personal Health Information (PHI) about you may be used and disclosed and how you can gain access to this Information. Please review it carefully.

2. Surgical Associates is required by law to maintain the privacy of PHI, to provide individuals with notice of its legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured protected health information.

3. Surgical Associates of Fredericksburg may use and disclose protected health information for treatment, payment and healthcare operations, including appointment reminders. Examples of these include, but are not limited to, requested preschool, or sports physicals, referral to nursing homes, foster care homes, home health agencies and/or referral to other providers for treatment. Payment examples include, but are not limited to, insurance companies for claims including coordination of benefits with other insurers or collection agencies. Healthcare operations include, but are not limited to, internal quality control and assurance including auditing of records and providing records to business associates, i.e. internal ancillary services.

4. Although Surgical Associates will not sell or disclose PHI for marketing, fundraising, or other purposes, we are required to notify you that your authorization would be required for us to do so.

5. Surgical Associates of Fredericksburg is permitted or required to use or disclose protected health information without the individual's written consent or authorization in certain circumstances. Two examples of such are for public health requirements or court orders.

6. Surgical Associates of Fredericksburg will not make any other use or disclosure of a patient's protected health information without the individual's written authorization. Such authorization may be revoked at any time. Revocation must be written and submitted to address of record on this form.

7. Surgical Associates of Fredericksburg will abide by the terms of this notice currently in effect at the time of the disclosure.

8. Surgical Associates of Fredericksburg reserves the right to change the terms of its notice and to make new notice provisions effective for all protected health information that it maintains. Surgical Associates of Fredericksburg will provide each patient with a copy of any revisions of its Notice of Information Practices at the time of their next visit, or at their last known address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at our offices.

9. You have the right to restrict disclosures of PHI to your health plan if you pay out of pocket in full for services rendered.

10. Any patient, guardian or personal representative has the right to inspect and obtain copies of their medical record.

11. Any patient, guardian or personal representative has the right to request amendments be made to their medical record.

12. Any patient, guardian or personal representative has the right to request a six-year accounting of all disclosures of their medical record. The history will be provided within 60 days of the request and a reasonable charge may be assessed for any copies after the first requested in a 12-month period.

13. Any patient, guardian, or personal representative has the right to request restrictions as to how their health information may be used or disclosed to carry out treatment, payment or healthcare operations. The Practice is not required to agree to the restrictions requested, but if the Practice does agree, the Practice must abide by those restrictions.

14. Any person/patient may file a complaint to the Practice and to the Secretary of Health and Human Services if they believe their privacy rights have been violated. To file a complaint with the practice, please contact the Privacy Officer at the following address and/or phone number: Surgical Associates of Fredericksburg, 4548 Empire Court, Fredericksburg, VA 22408, For inquiries or additional information, contact Administrator/Privacy Officer: Telephone 540-373-2244 Fax 540-371-4849. All complaints will be addressed and the results will be reported to the Privacy Officer.

15. It is the policy of Surgical Associates of Fredericksburg that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.

16. Surgical Associates of Fredericksburg may call the patient's home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out healthcare operations, such as appointment reminders, insurance items and any call pertaining to the patient's clinical care, including laboratory results among others.

17. Surgical Associates of Fredericksburg may mail to the home or other designated location any items that assist with carrying out the patient's treatment plan, such as appointment reminders and other material.

18. Surgical Associates of Fredericksburg will accept revocations of the Authorization to disclose Protected Health Information by certified mail only. This revocation must be sent to the attention of the Privacy Officer, Surgical Associates of Fredericksburg, 4548 Empire Court, Fredericksburg, VA 22408.

19. The signature of patient or guardian on this privacy form authorizes Surgical Associates of Fredericksburg to release Personal Health Information on the respective patient via all FMLA documents, documents provided by the patient’s employer, or documents submitted by disability or insurance carrier on behalf of the patient.

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SURGICAL ASSOCIATES OF FREDERICKSBURG 4548 Empire Court

Fredericksburg, VA 22408 (540) 373-2244 FAX (540) 371-4849

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION (PHI)

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and subsequent changes and

modifications, I have certain rights to privacy regarding my protected health information. I understand that this information can and

will be used to:

• Conduct, plan and direct my treatment and care among multiple providers

• Obtain payment from third party payers

• Conduct normal healthcare operations such as quality assessments and physician certifications

• Provide information to referring physicians or other medical professionals providing treatment

I have received and reviewed Surgical Associates of Fredericksburg's NOTICE OF INFORMATION PRACTICES (reverse side, Page 1 of

this form) which contains a more complete description of the uses and disclosures of my health information. I understand that

Surgical Associates of Fredericksburg has the right to change its NOTICE OF INFORMATION PRACTICES from time to time and that I

may contact them at any time to obtain a current copy.

I understand that I have the right to revoke this authorization in the future. In order to be effective, the request must be in writing

and will take effect when both the patient and the practice have signed the revocation. The revocation must include the patient's

name, address, phone number, patient signature, date the revocation submitted, and reason for the request.

This authorization permits Surgical Associates of Fredericksburg to discuss my Personal Health Information (PHI) to ONLY those

individuals I have listed below (SAF cannot discuss your PHI with anyone not listed below):

Spouse ___________________________ Mother _______________________________

Father ____________________________ Adult Children _________________________

Other_____________________________ Other _________________________________

I may elect to have this authorization expire on a date I specify in the future. The date I have entered below represents the date I

wish this authorization to expire:

□ Check box to the left if you do not wish this authorization to expire; however, I may notify the practice in writing at a

future time with an expiration date.

DATE OF AUTHORIZATION EXPIRATION: _________ / ______ / ______

I fully understand and accept the terms of this authorization. I understand when the information is used or disclosed pursuant to this

authorization, it may be subject to re-disclosure by the recipient and may no longer be protected health information.

NAME (print): ____________________________________ DOB: ____/____/_____ DATE:_____________________

SIGNATURE OF PATIENT OR GUARDIAN: ______________________________________

OFFICE USE ONLY

Date Received: ____________________________ By: _______________________________

□ Patient declined to sign the Authorization Form for the following reason: rev 1.3 9/11/2013

Surgical Associates of Fredericksburg, Ltd. HEALTH HISTORY FORM

(All information will remain confidential)

Name ______________________________________________________ Today’s Date _________________

Age ______ Date of birth _______________ Sex ______________

Reason for visit _________________________________________Weight __________ Height ____________

PAST MEDICAL HISTORY Check items where previous history applies.

Abdominal Aneurysm Carotid Artery Stenosis Diabetes Mellitus, Type I Lung Cancer Anal Fissure/Ulcer Cataracts Diabetes Mellitus, Type II Kidney Stone

Arterial Disease Stroke Diabetic Neuropathy Osteoporosis Asthma Ischemic Heart Disease Diverticulitis of Colon Peptic Ulcer Disease

Atrial Fibrillation Migraine Headaches Heartburn Pilonidal Cyst Atherosclerosis Colon Cancer End Stage Renal Disease Previous Heart Attack

High Blood Pressure (Hypertension) Colon Polyps Gallstones Rectal Abscess Benign prostate hyperplasia Crohn’s Disease Hiatal Hernia Sleep Apnea

Bowel Obstruction Congestive Heart Failure High Cholesterol Spastic Colon/Irritable Bowel

Breast Cancer COPD Hyperthyroidism Ulcerative Colitis Irregular Heart Beat Degenerative Disc Disease Hypothyroidism Venous (Vein) Disease

List other conditions here: Wound Infection Post Surgery

PAST SURGICAL HISTORY Please check or list all previous operations; insert year of surgery adjacent to operation.

Abdominal Aneurysm Cholecystectomy (Gallbladder) Hemorrhoidectomy Ovarian Cyst Drainage

Abdominal Hernia Clotting/Bleeding Disorder Hip Replacement Pacemaker/Defibrillation

Anal Fissure/Ulcer Colectomy Hysterectomy Prostate Surgery

Appendectomy Coronary Artery Bypass Inguinal Hernia Rectal Abscess Arterial Bypass, Leg Dialysis Access Knee Surgery Thyroidectomy

Back Surgery Dilation and Curettage (D&C) Lithotripsy Tonsillectomy

Cardiac Stents DVT or Pulmonary Embolus Lung Resection Tubal Ligation

Cataract Surgery Bowel Surgery Mastectomy Umbilical Hernia

C-Section

List other surgeries here: Heart Valve Replacement Neck Surgery

MEDICATION LIST List all current prescription and over-the-counter (non-prescription) medications such as vitamins, Aspirin, Tylenol, and herbals (ex: Ginseng, Gingko Biloba, St. John’s Wort). Include prescription meds taken as needed, (ex. Viagra, Nitroglycerin.)

NAME OF MEDICATION DOSE HOW OFTEN DO YOU TAKE? REASON FOR MEDICATION?

(Please see reverse side for Page 2)

ALL INFORMATION IS IMPORTANT PLEASE COMPLETE ALL SECTIONS DRUG ALLERGY LIST Please check/list all medications or vaccinations that have caused an allergic reaction in the past: Penicillin Sulfa Drugs IV/Dye Novacaine/Lidocaine Codeine No Known Drug Allergies Other, Please List

LATEX ALLERGY? Are you allergic to latex? Yes No

ANESTHESIA PROBLEMS? Have you had any previous difficulties with general anesthesia or sedation? Yes No If yes, please

provide detail below

PREGNANCY? Are you currently pregnant? Yes No Possibly

FAMILY HISTORY Check if any of your blood relatives have had any of the following conditions:

Indicate Relationship to You(Maternal or Paternal) Indicate Relationship to You

Stroke Ischemic Heart Disease

Breast Cancer Kidney Disease

Colon Cancer Ovarian Cancer

Colon Polyps Regional Enteritis (Crohn’s Disease)

Diabetes Mellitus Thyroid Cancer

Other: Other:

Other: Other:

SOCIAL HISTORY Check which substances you use and how much you use:

Alcohol, no use Alcohol, heavy use Tobacco, 1 ppd Other

Tobacco, no use Chewing Tobacco Tobacco, 1.5 ppd

Alcohol, rare use Tobacco, former smoker ____Yrs Tobacco, 2.0 ppd Illegal Drugs, specify:

Alcohol, moderate use Tobacco, ½ ppd Tobacco, > 2 ppd

REVIEW OF SYSTEMS Check symptoms you CURRENTLY have or ARE ASSOCIATED WITH THE REASON FOR YOUR VISIT.

GENERAL BREASTS RESPIRATORY GENITOURINARY MUSCULOSKELETAL Fever Lumps Shortness of breath Blood in urine Limitation of Motion

Chills Tenderness Wheezing Incontinence Muscular Weakness Weight Loss Swelling Cough Urinary retention Muscle Cramps Weight Gain Nipple Discharge Hoarseness Difficulty voiding Other: _____________

Fatigue Rash/Scaling Coughing up blood Urinary hesitancy ENDOCRINE Loss of Appetite Nipple Retraction Sleep Apnea Irregular period Cold intolerance

Malaise Other: ____________ Anesthetic Problems Vaginal discharge Heat intolerance

Body Aches CARDIOVASCULAR GASTROINTESTINAL Possible pregnancy Weight Gain

Night Sweats Chest Pain Loss of appetite Scrotal mass Weight Loss

Other:____________ Irregular Heart Beat Feel full after eating small amounts of food

Other: __________ Hot Flashes

EYES Rapid Heart Rate SKIN Other: _____________

Blurred Vision Shortness of Breath w/ exercise

Heartburn Rash PSYCHIATRIC Impaired Vision Difficulty Swallowing Itching Anxiety

Double Vision Shortness of Breath when lying down

Painful Swallowing New Skin Lesions Depression

Eye Pain Vomiting Blood Changes to Skin Lesions Hallucinations

Other:____________ Episodes of unconsciousness

Nausea Other: _____________ Other:______________

Head, Ear, Nose, Throat Vomiting NEUROLOGIC HEME-LYMPH Sore Throat Shortness of Breath

at nighttime Bloating Tingling or numbness Easy bleeding

Headaches Diarrhea Weakness Easy bruising

Vertigo (dizziness) Lower extremity swelling Constipation Poor coordination Tiny red spots on skin

Lightheaded Lower extremity blueness Abdominal Pain Speech difficulties Purple areas on skin

Dental Problems Varicose veins Jaundice-yellow skin, eyes Loss of Balance Lymph node swelling

Dentures Venous cords Blood in stool Other: _____________ Other: _____________

Neck Pain Leg pain with walking Black, tarry stool MUSCULOSKELETAL ALLERGIC/IMMUNOLOGIC Thyroid Mass Lightheadedness Other: _____________ Bone Pain Sinus Allergies

Recent Head Injury Dizziness when standing GENITOURINARY Back Pain Allergic dermatitis Hearing Loss Other: _______________ Urgency Joint Pain Frequent Infections

Other:____________ Frequency Muscle Pain Other:______________ Painful Urination