Homewood Family Medicine PATIENT INFORMATION SHEET

NAME: ________________ _

Last First Ml DOB

ADDRESS: _____ __________ _ _______ _______ __

CITY:. _________ ___ _ STATE: ___ _ ZIP: ___________ _

PHONE (HOME):----------- (CELL):------------

EMAIL ADDRESS:------ - ------ PREFERRED METHOD OF CONTACT: __ _

MAY WE LEAVE A MESSAGE AT THE PREFERRED NUMBER OF CONTACT? ___ YES _ __ NO

WHOM MAY WE THANK FOR REFERRING YOU TO HOMEWOOD FAMILY MEDICINE?--------

DO YOU HAVE AN ADVANCED CARE DIRECTIVE? ____ YES ___ NO

(THIS INCLUDES: LIVING WILL, DO NOT RESUSCITATE, HEALTHCARE PROXY OR POWER OF ATTORNEY)

MARRITAL STATUS: MARRIED __ SINGLE __ DIVORCED __ WIDOW(ER) __

RELIGION: _________ ETHNICITY ________ RACE--------

(THESE ARE REQUIRED BY THE FEDERAL GOVERNMENT FOR STATISTICAL PURPOSES)

SOCIAL SECURITY NUMBER: (THIS IS OPTIONAL HOWEVER, NUMEROUS INSURANCE

COMPANIES STILL REQUIRE THIS FOR CLAIMS SUBMISSION AND VERIFICATION PURPOSES)

EMERGENCY CONTACT: ______________ PHONE: _________ _

RELATIONSHIP TO PATIENT:-------------------------

PRIMARY INSURANCE: - ------------

POLICY/CARD HOLDER NAME: ___________ _ ___ DOB: ------

POLICY/ID #: _____ _________ GROUP# _ ___________ _

PATIENT RELATIONSHIP TO INSURED: _ _ SELF __ SPOUSE CHILD OTHER

EMPLOYER: ________________ EMPLOYER PHONE#: _______ _

{IF YOU HAVE SECONDARY INSURANCE, PLEASE MAKE THE FRONT DESK AWARE OF THIS SO THAT THEY CAN COPY YOUR

SECONDARY INSURANCE CARD)

I hereby authorize Homewood Fami ly Medicine to furnish the above insurance company all medical information necessary to process any claims. 1 also authorize payment of

medical benefits to Homewood Fami ly Medicine. I have read the no show policy and agree to provide the appropriate notice if I am unable to make my scheduled appointment.

I accept responsib ility for all accrued charges, including those my insurance company may not cover at the anticipated level. Additionally, I understand I may be held

responsib le for charges should my insurance company delay payment. I also agree to pay all fees associated in collecting my balance.

PATIENT/PARENT OR GUARDIAN SIGNATURE: - - - - ---------------

NAME (PRINTED): ________ ________ DATE:----------

Patient Communication Log

PATIENT NAME: ______________ _ DATE: _______________ _

THE FOLLOWING INSTRUCTIONS PERTAIN TO THE ABOVE NAMED PATIENT:

OK TO CALL HOME AND LEAVE A MESSAGE?_ YES_NO

OK TO CALL WO.RK NUMBER? _YES_NO OK TO CALL CELL PHONE?_YES NO

CALL THIS NUMBER ONLY:-----------------I AUTHORIZE YOU TO SPEAK WITH AND GIVE MY PERSONAl MEDICAL INFORMATION TO :

NAME: _________________ PHONE: _______________ ___

NAME: __________________ PHONE: _______________ ___

PATIENT NAME {PRINT) :-------------- DATE: _______ ~-------

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I ACKNOWLEDGE RECEIPT OF THE NOTICE OF PRIVACY PRACTICES AND HAVE BEEN GIVEN THE OPPORTUNITY TO REVIEW IT.

PA!IENT NAME {PRINT): ________________ DATE:-------------

PATIENT/PARENTGUARDIAN {SIGN): _________________________ _

CONSENT TO TREAT MINOR PAT1ENT

I ~UTHORIZE HOMEWOOD FAMILY MEDICINE TO PROVIDE MY SON/DAUGHTER WHOM IS AT LEAST 16 YEARS OF AGE, MEDICAL CARE INCLUDING, BUT NOT LIMITED TO, .LAB TESTING, VERIFICATION AND/OR ADMINISTRATION OF IMMUNIZATIONS AND NECESSARY MEDICAL TREATMENT {INCLDUING MINOR SURGICAL PROCEDURES).

PATIENT NAME: DATE:-----------------

PARENT OR GUARDIAN (SIGN):----------------------------

I GIVE MY PERMISSION FOR THE FOLLOWING INDIVIDUALS (MUST BE 21 YEARS OR ODLER) TO AUTHORIZE ANY MEDICAL

TREATMENT FOR MY MINOR SON/DAUGHTER. I AUTHORIZE THESE INDIVIDUALS TO MAKE DECISIONS REGARDING PRESCRIPTIONS AND IMMUNIZATIONS IF I AM NOT AVAILABLE TO GIVE MY CONSENT.

NAME (PRINT) RELAHON TO PATIENT (PRINT)

PATIENT NAME (PRINT):------------------ DATE: ___________ _

PATIENT/PARENT OR GUARDIAN {SIGN):-------------------------

HOMEWOOD FAMILY MEDICINE FINANCIAL POLICY

1. NO SHOW/CANCELLATION POLICY: OUR GOAL IS TO BE ABLE TO ACCOMMODATE THOSE PATIENTS WHO NEED SAME DAY SICK APPOINTMENTS. WE ASK THAT

IF YOU NEED TO CANCEL YOUR APPOINTMENT THAT YOU DO SO 24 HOURS IN ADVANCE TO ALLOW ANOTHER PATIENT TO USE THAT TIME. CANCELLING YOUR APPOINTMENT ALSO HELPS SCHEDULING AND AIDS IN OUR PROVIDERS STAYING ON TIME. YOU WILL BE CHARGED A $75 FEE FOR MISSED APPOINTMENTS AND APPOINTMENTS THAT ARE CANCELED IN LESS THAT THE 24 HOURS BEFORE YOUR SCHEDULED APPOINTMENT TIME. CANCELLATIONS ON THE SAME DAY AS THE

APPOINTMENT ARE NOT ACCEPTABLE AND WILL ALSO RECEIVE A $75 CHARGE AS WELL. TO AVOID THIS CHARGE, YOU MUST CANCEL YOUR APPOINTMENT 24 HOURS PRIOR TO THE SCHEDULED APPOINTMENT TIME.

2. COPAYMENTS:

COPAYMENTS ARE DUE AT THE TIME OF SERVICE. PLEASE COME PREPARED TO PAY ALL COPAYMENTS. 3. INSURANCE:

YOUR INSURANCE SCHEDULED OF BENEFITS IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. FOR THIS REASON IT IS NOT OUR POLICY TO CALL YOUR INSURANCE IN ORDER TO PROVIDE YOU WITH A BENEFIT QUOTE. WE

ENCOURAGE YOU TO REFER TO THE SCHEDULE OF BENEFIT PROVIDED TO YOU BY YOUR INSURANCE PLAN, AND/OR CALL

YOUR INSURANCE TO CLARIFY ANY BENEFIT QUESTIONS YOU MAY HAVE BEFORE SERVICES ARE RENDERED. AFTER YOUR CLAIMS HAVE BEEN PROCESSED, IF YOU FEEL YOUR PLAN BENEFITS WERE NOT APPLIED TO YOUR CLAIM CORRECTLY, WE ENCOURAGE YOU TO CALL YOUR INSURANCE COMPANY TO WORK OUT ANY BENEFIT ISSUES, NOTATING THE DATE, CUSTOMER SERVICES REPRESENTATIVES NAME, CALL REFERENCE NUMBER (IF AVAILABLE), AND THE TIME FRAME YOUR

INSURANCE NEEDS FOR REPROCESSING YOUR CLAIM. PLEASE THEN CALL OUR BILLING OFFICE WITH THIS INFORMATION, WE WILL NOTATE IT ON YOUR ACCOUNT. OF COURSE, IF A CLAIM ISSUE IS IN REGARD TO OUR NETWORK STATUS WITH

YOUR INSURANCE, OR IS THE RESULT OF A CODING ERROR, WE WILL CONTACT YOUR INSURANCE OR APPEAL THE CLAIM TO

RESOLVE THESE PROVIDER-RELATED ISSUES. YOU HAVE AN OBLIGATION TO PAY CHARGES THAT ARE NOT COVERED BY YOUR INSURANCE CARRIER. PLEASE VERIFY BENEFITS PRIOR TO ANY PROCEDURE AND PROVIDE US WITH CURRENT INSURANCE INFORMATION.

4. UNINSURED/SELF PAY:

WE ARE HAPPY TO OFFER DISCOUNTS TO OUR PATIENTS WHOM ARE UNINSURED. PLEASE NOTE WE DO NOT ACCEPT

"DISCOUNT CARDS" BECAUSE WE DO NOT WANT TO ENCOURAGE YOU TO PAY FOR A DISCOUNT WE ARE HAPPY TO PROVIDE TO YOU FOR FREE. PAYMENT IS EXPECTED AT TIME OF SERVICE IF YOU ARE UN INSURED. IF YOU FIND YOU NEED A

PAYMENT PLAN INSTEAD, PLEASE FEEL FREE TO DISCUSS THIS WITH US, PREFERABLY BEFORE SERVICES ARE RENDERED, AS WE CAN SUGGEST OTHER COST SAVING MEASURES WITH YOU .

5. DELINQUENT ACCOUNTS:

AN ACCOUNT IS DELINQUENT AND ELIGIBLE TO BE SENT TO AN OUTSIDE COLLECTIONS AGENCY WHEN IT IS 90 DAYS PAST DUE. AT THIS POINT, ALL COLLECTION AND LEGAL FEES WILL BE ADDED TO THE BALANCE DUE AND WILL BE YOUR RESPONSI Bl LITY.

6. PAYMENT ARRANGEMENTS:

IF YOU WOULD LIKE TO MAKE PAYMENT ARRANGEMENTS ON YOUR ACCOUNT, WE ARE HAPPY TO SET UP AN AUTOMATED PAYMENT PLAN TAILORED TO YOUR NEEDS AND BUDGET. CALL US, WE ARE HERE TO HELP!

7. PERSONAL CHECKS:

WE ARE HAPPY TO ACCEPT YOUR PERSONAL CHECK FOR PAYMENT ON YOUR ACCOUNT. PAYMENT MADE BY CHECK ON THE DATE OF SERVICE WILL NOT BE ACCEPTED OVER $40. CHECKS WILL NOT BE ACCEPTED FOR URINE DRUG SCREENS. IF YOUR CHECK IS RETURNED TO US BY YOUR BANK AS NON-PAYABLE, YOU WILL BE CHARGED AN ADDITIONAL $50.

I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL POLICY AND I AGREE TO ABIDE BY ITS TERMS.

PATIENT NAME (PRINT):-------- ---- DATE: _______________ _

PATIENT/PARENT OR GUARDIAN (SIGN) :------------------------

HEALTH HISTORY FORM

Name: -------------------- DOB: ____ _ Age: ___ Male: Female:

Who do you currently live with? Alone __ Family Friends __ Significant other

Do you feel safe at home? Yes No Highest level of education: ____ _

Current job: --------------------- Previous job: _______________ _

I - - I VI I I MEDICATIONS (Please include all prescriptions over the counter 'tam·ns and supplements)

NAME/ DOSAGE OF MEDICATION REASON FOR TAKING MEDICATION

ALLERGIES: Any medications, x-ray dyes or other substances? (If yes, please list name of medication and type of reaction)

YES NO

SURGERIES I HOSPITALIZATIONS (Please list date and details· circle either surgery or hospitalization for each) I

DATE SURG / HOSP REASON/ DETAILS SURG / HOSP SURG / HOSP SURG / HOSP SURG / HOSP SURG / HOSP SURG / HOSP

SEVERE INJURIES (Please list dates and details of any injuries you have ever had)

IMMUNIZATIONS: Date of last TB screening? POS __ NEG Date of last Tetanus vaccine? ___ _ Date of chicken pox disease or shot? ----Dates of Hepatitis B series? ___ _ Date of last Flu vaccine? ___ _

Date of last Pneumonia vaccine? ___ _ Date of Guardasil series? ----

HEALTH MAINTENANCE: Date of your last colonoscopy? Date of your last pap smear? ___ _ Date of your last mammogram? Date of your last bone density test? ___ _

Date of your last eye exam? Date of your last wellness exam? ___ _ Do you consider yourself: __ Underweight __ Normal weight __ Overweight __ Obese Whatkindofexe~~edoyoudo? ______________________________ _ How often? ___________ __

Do you wear seatbelts? __ Yes __ No Do you use sunscreen? __ Yes __ No Do you feel safe at home? __ Yes __ No Do you text while driving? __ Yes __ No

Do you drink coffee/soda/tea? __ Yes __ No If yes, how many cups/cans a day?----------

What type of birth control is used between you and your partner? ------------------ ---

Which of the following conditions are currently being treated or have been treated for in the past? __ Allergies __ Asthma __ Arthritis __ Anxiety __ Abnormal EKG __ Alcoholism Acid Reflux Blood Clots __ Blood Trans __ Back Pain ==Breast lumps ~Cancer __ Colitis __ Concussion __ Cold Sores __ Constipation __ Diabetes __ Depression Dizziness __ Diarrhea _Eczema __ emphysema __ Erectile Dysfunction __ Epilepsy __ Gallbladder Dis __ Genital Herpes __ Gout __ Headaches __ Hernia __ Heart Attack __ Heart Murmur __ Heart Disease __ Herniated Disc __ High Blood Pressure __ Hemorrhoids __ Heart Failure __ HIV/AIDS __ Hodgkins __ Insomnia __ Irritable Bowel __ Kidney Stones __ liver Disease __ leukemia __ lung Problems _Meningitis __ Migraines __ Muscle Disease __ OCD __ Panic Attacks __ Pneumonia __ Psoriasis __ Polio __ STD __ Stroke _ _ Skin Disease __ Sinus Disease __ Thyroid Disease Tuberculosis Ulcer Disease __ Urinary Infections FAMILY HISTORY (Please put a check mark in all applicable boxes) Were you adopted? Yes NO

Anemia _ _ Bleeding Problem _ _ Chest Pain __ COPD __ Drug Abuse __ Glaucoma __ Hearing Problem __ Hepatitis __ High Cholesterol __ Kidney Disease __ lupus __ Pancreatitis __ Sickle Cell Dis __ Suicide attempt __ Other __ _

Illness Father Mother Sibling Child Maternal Maternal Paternal Paternal Other

Grandma Grandpa Grandma Grandpa

Heart Disease High Cholesterol High Blood Pressure Diabetes

Heart Attack Stroke

Kidney Disease Liver Disease

Bleeding/Clotting Disorder Asthma

Anemia

Colon/ Bowel Problems

Breast Cancer

Skin Cancer

Prostate Cancer

Lung Cancer

Ovarian Cancer

Other Cancer

Glaucoma

Thyroid Disease

Drug/Alcohol Addiction

Depression/ Anxiety

Suicide

Seizures/Epilepsy

HIV/AIDS

Other OB/GYN HISTORY: Age of first menses __ Date of last penod Do you suffer from PMS? __ Yes __ No

Have you ever had and abnormal pap smear? __ Yes __ No If yes, date and results---------------Pregnancies: Total number __ Full term __ Miscarriages __ Abortions _ _ Premature __ Tubal __ Complications ___________________________________________ _

SOCIAL HISTORY: Are you sexually active? __ Yes __ No If yes, are your partners: __ Men __ Women __ Both Have you ever had a sexually transmitted disease? __ Yes __ No Diagnosis? ________________ _

Do you smoke? __ Yes __ No How many per day? Have you ever quit? __ Yes __ No

Do you use other tobacco products? __ Yes __ No If yes, what? When? ______ _

Do you drink alcohol? __ Yes __ No How many per day? How many per week?--------Have you ever had a problem with alcohol in the past? __ Yes __ No

Has anyone ever expressed concerns about your alcohol use? _ _ Yes _ _ No

Do you currently use any recreational drugs? __ Yes __ No What types?-------------------Have you ever had a drug problem in the past (prescription drug addiction/illegal drug use)? __ Yes __ No If yes, explain ________________________________________ _

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

PATIENT NAME:------------------ DOB: --------------

THE ABOVE LISTED PATIENT AUTHORIZES THE FOLLOWING HEALTHCARE FACILITY TO MAKE RECORD DISCLOSURE :

FACILITY NAME:---------------------------------FACIL TY PHONE:----------------- FACILITY FAX:-----------AZ REGIONAL 480-223-4035 CHANDLER REGIONAL 480-728-3980 BANNER DESERT 480-412-8777 GILBERT HOSPITAL 480-840-3795 BANNER BAYWOOD 480-321-4179 BANNER GATEWAY 480-543-2252 BANNER GOOD SAM 602-839-6150 CARDON CHILDRENS 480-512-4898 PURPOSE OF DISCLOSURE IS :

___ CHANGE OF INSURANCE OR PHYSICIAN

• CONTINUATION OF CARE ___ OTHER

MERCY GILBERT

MOUNTAIN VISTA

480-728-9618 480-358-6407

SCOTISDALE OSBORNE 480-882-4377 ST. JOSEPH'S 602-406-4120 TYPES OF INFORMATION TO DISCLOSE:

• MOST RECENT 2 YEARS OF RECORDS

___ DATES/OTHER

___ SPECIFIC INFORMATION ____ _

RESTRICTIONS: ONLY MEDICAL RECORDS ORIGINATED THROUGH THIS HEALTHCARE FACILITY WILL BE COPIED UNLESS

OTHERWISE REQUESTED. THIS AUTHORIZATION IS VALID ONLY FOR THE RELEASE OF MEDICAL INFORMATION DATED

PRIOR TO AND INCLUDING THE DATE OF THIS AUTHORIZATION UNLESS OTHER DATES ARE SPECIFIED.

I UNDERSTAND THE INFORMATION IN MY HEALTH RECORD MAY INCLUDE INFORMATION RELATIONG TO SEXUALLY

TRANSMITIED DISEASE, ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS), OR HUMAN IMMUNODEFICIENCY VIRUS

(HIV) . IT MAY ALSO INCLUDE INFORMATION ABOUT BEHAVIORAL OR MENTAL HEALTH SERVICE, AND TRATEMENT FOR

ALCOHOL AND DRUG ABUSE.

THIS INFORMATION MAY BE DISCLOSED AND USED BY THE FOLLOWING INDIVIDUAL OR ORGANIZATION:

RELEASE TO: HOMEWOOD FAMILY MEDICINE ADDRESS: 4540 E. BASELINE RD. #113 MESA, AZ 85206

PHONE: 480-558-4700 FAX: 480-558-1936 ___ PLEASE MAIL RECORDS • PLEASE FAX RECORDS

I UNDERSTAND I MAY REVOKE THIS AUTHORIZATION AT ANY TIME. I UNDERSTAND THAT IF I REVOKE THIS AUTHORIZATION I MUST

DO SO IN WRITING AND PRESENT MY WRITIEN REVOCATION TO THE HEALTH INFORMATION MANAGEMENT DEPARTMENT. 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: . IF I FAIL TO SPECIFY AN

EXPIRATION DATE, EVENT OR CONDITION, THIS AUTHORIZATION WILL EXPIRE 1 YEAR 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 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 HAVE READ THE ABOVE FOREGOING AUTHORIZATION FOR RELEASE OF INFORMATION AND DO HEREBY ACKNOWLEDGE THAT I

AM FAMILIAR WITH AND FULLY UNDERSTAND THE TERMS AND CONDITIONS OF THIS AUTHORIZATION.

SIGNATURE OF PATIENT/PARENT OR GUARDIAN DATE

PRINTED NAME OF PATIENT/PARENT OR GUARDIAN

Homewood Family Medicine Notice of Privacy Practices

(Effective June 10th, 2013) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PEASE REVIEW IT

CAREFULLY.

OUR PLEDGE REGARDING MEDICAL INFORMATION:

EHectiue April 2016 we are participating in Health Information Exchange (HIE) in the state of Arizona. If you do not wish have your medical history shared in this HIE please

complete sign the "Opt out" form with our front desb staH.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at Homewood Family Medicine. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records of your care generated at our practice. This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights to certain obligations we have regarding the use and disclosure of medical information. We are required by law to: 1. Make sure that medical information that identifies you is kept private; 2. Give you this notice of our legal duties and privacy practices concerning medical information about you; and 3. Follow the terms of the notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU: We use and disclose medical information in many ways. For each category of uses or disclosure will explain what we mean and try to find some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. 1. FOR TREATMENT: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, nursing and medical students, or hospital personnel who are involved in taking care of you . For example, a doctor treating you for a broken leg and may need to tell a dietician if you have diabetes so that we can arrange for a nutritional counselling. We also may share medical information about you in order to coordinate the different things you need such as prescriptions, lab work, diagnostic testing. We also may disclose medical information about you people who may be involved in your medical care such as family members, clergy, rehabilitation centers, etc. 2. FOR PAYMENT: We may use and disclose medical information about you so that the treatment and services you receive at Homewood Family Medicine may be billed for and payment may be collected from you or on your behalf from an insurance company or third party. For example, we may need to give your health plan information about testing that you received at our practice so your health plan will pay us or reimburse you for those services. We may also tell your health plan about a treatment you're going to receive to obtain prior approval or to determine whether your plan will cover the treatment. 3. FOR HEALTH CARE OPERATIONS: We may use and disclose medical information about you for our Homewood Family Medicine operations. These uses and disclosures are necessary to run our organization and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Homewood Family Medicine patients to decide what additional services our practice should offer, what services are not needed, and whether certain new treatments are effective. We may

also disclose information to doctors, nurses, technicians, nursing and medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other similar organizations to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from the set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. 4. APPOINTMENT REMINDERS: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment of medical care at Homewood Family Medicine. 5. TREATMENT ALTERNATIVES: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. 6. INDIVIDUALS INVOLVED IN YOUR CARE PR PAYMENT OF YOUR CARE: We may release medical information about you to a friend or family member who is involved in your medical care. We may also tell your family or friends your condition and that you have been seen in our office. In addition, we may disclose medical information about you to a friend or family member should an emergent situation arise while you are at our office.

7. RESEARCH: Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients' need for the privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave our organization. We will always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care. 8. AS REQURIED BY LAW: We will disclose medical information about you when required to do so by federal, state or local law. 9. TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to prevent the threat. 10. FOR ALL OTHER USES AND DISCLOSURES: All other uses and disclosures of information not contained in this Notice of Privacy Practices will not be disclosed without your authorization.

SPECIAL SITUATIONS: 1. ORGAN AND TISSUE DONATION: If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. 2. MILITARY AND VETERANS: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. 3. WORKERS COMPENSATION: We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work related injuries or illness. 4. PUBLIC HEALTH RISKS: We may disclose medical information about you for public health activities. These activities generally include the following • To prevent or control disease, injury or disability • To report births and deaths • To report child abuse or neglect • To report reactions to medications or problems with products • To notify people of recalls of products they may be using • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition

• To notify the appropriate government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. 5. HEALTH OVERSIGHT ACTIVITIES: We may disclose medical information to a healt h oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care systems, government programs and compliance with civil rights laws. 6. LAWSUITS AND DISPUTES: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 7. LAW ENFORCEMENT: We may release medical information if asked to do so by a law enforcement official: • In response to a court order, subpoena, warrant, summons or similar process • To identify or locate a suspect, fugitive, material witness or missing person • About the victim of a crime if, under certain limited circumstances, we are unable to obtain a person's agreement. • About a death we believe may be the result of criminal conduct • About criminal conduct at the hospital, and • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description of location of the person who committed the crime.

8. CORONERS, MEDICAL AXAMINERS AND FUNERAL DIRECTORS: We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person to determine the cause of death. We may also release medical information about the patients to funeral directors as necessary to carry out their duties. 9. NATIONAL SECURITY AND INTELLIGENCE ACTIVITIES: We may release medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized bylaw. 10. PROTECTIVE SERVICES FOR THE PRESIDENT AND OTHERS: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. 11. INMATES: If you are an inmate of a correctional institution or under the custody of a law enforcement official we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care: (2) to protect your health and safety or the health and safety of others: or (3) for the safety and security of the correctional institution.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding medical information we maintain about you : 1. RIGHT TO INSPECT AND COPY: You have the right to inspect and copay medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer. If you request a copy of the information, we may charge a fee for costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances, If you are denied access to medical information, you may request, in writing, that the denial be reviewed. Another licensed health care professional chosen by Homewood Family Medicine will review your request and the denial. The person conducting the review will not be the person who previously denied your request. We will comply w ith the outcome of the review. 2. RIGHT TO AMEND: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to include additional information in your medical record. You have a right to request an amendment for as long as all of the information, both old and new, is kept by or for Homewood Fami ly Medicine. To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must

provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; • Is not part of the medical information kept by or for our Practice; • Is not part of the information which be permitted to inspect and copay; or • Is accurate and complete

3. RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to request an "accounting disclosures." This is a list of disclosures we made of medical information about you, excluding disclosures for the purposes of treatment, payment and healthcare operations. To request this list or accounting of disclosures, you must submit your request in writing to the Administrator. Your request must state a time period, which may not be longer than 6 years. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12 month period will be free. For additional list, we may charge for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. 4. RIGHT TO REQUEST RESTRICITION: You have the right to request restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. WE ARE NOT REQUIRED TO AFREE TO YOUR REQUEST. If we do agree, we will comply with your request unless information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. 5. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION: You have the right to request that we communicate with you about medical matters in a certain way or at certain locations. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all the reasonable requests. Your request must tell us how or where you w ish to be contacted. If you do not tell us how or where you wish to be contacted we are not obligated to follow your request. 6. RIGHT TO RESTRICT RELEASE OF INFORMATION FOR CERTAIN SERVICES: You have t he right to restrict the disclosure of information regarding services for which you have paid in full or on an out of pocket basis. This information can be released only upon your written authorization. 7. RIGHT TO A PAPER COPY OF THIS NOTICE: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy if this notice. To obtain a copy of this notice, ask any of our office staff or our Privacy Officer or you may write to our Practice at Homewood Family Medicine, 4540 E. Baseline Rd., Ste. 113, Mesa, AZ 85206. 8. RIGHT TO BREACH NOTIFICATION: You have the right to be notified of any breach of your unsecured healthcare information.

CHANGES TO THIS NOTIFICATION We reserve the right to change this notice, we reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the correct notice in our office. The notice will contain on the first page, the effective date. In addition, each time you are seen for treatment or health care services at our office, we will offer you a copy of the current notice in effect.

COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with our practice ir with the

Secretary of the Department of Health and Human Services. To file a complaint wit h Homewood Family

Medicine, please write to the Privacy Officer at Homewood Family Medicine, 4540 E. Baseline Rd., Ste. 113,

Mesa, AZ 85206. All complaints must be submitted in writing. YOU WILL NOT BE PENALIZED FOR FILING A

COMPLAINT.

I acknowledge receipt and have read and understand the Notice of Health Information Practices

regarding my providers participation in The Network, the statewide Health Information Exchange

{HIE), or I previously received this information and decline another copy.

( Patient Signature) (Date)