REX Surgical Specialists Surgical Specialists is authorized to release protected health information pertaining to the above named patient to the entities below

REX Surgical Specialists

NAME ________________________________ DOB ________________

Today’s Date ______________ Reason for Visit ________________________________________________

ALLERGIES:

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

___________________________________________ ___________________________________________

MEDICATIONS: Please list all prescriptions and over the counter medications, herbs and vitamins

Name _______Dose_____ Name___________________________Dose________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

________________________________________ ______________________________________________

PHARMACY:

Name: ______________________________________ Address: __________________________________

MEDICAL HISTORY:

Breast Cancer--------- Colon polyps-------- Pancreatitis--------------

Gallstones------------- Diverticulitis--------- Rectal bleeding---------

Colon cancer----------- Fibrocystic breast--- Thyroid nodule---------

Abnormal EKG------- Heart disease------- Heart attack-------------

Alcoholism------------ Diabetes-------------- Seizures -----------------

Anemia---------------- Hepatitis------------- Stroke--------------------

Asthma----------------- HIV/AIDS-----------

CHF-------------------- High blood pressure

Cirrhosis--------------- Kidney disease-----

Clotting disorder------

COPD------------------

Name: ______________________________ DOB: ___________________

SURGICAL HISTORY:

Appendectomy-----------------

C-section------------------

Prostate surgery------

Brain surgery-------------------

Eye surgery---------------

Small intest. Surgery

Breast surgery------------------

Fracture repair------------

Spine surgery--------

Open heart surgery-------------

Hernia surgery------------ Tubal ligation--------

Gallbladder surgery------------ Hysterectomy------------- Valve replacement---

Colon surgery------------------- Joint replacement--------- Vasectomy------------

Cosmetic Surgery-------------- Stent Placement----------

FAMILY HISTORY:

Relationship alive/deceased birth defects

breast cancer cancer

clotting disorder COPD

Heart disease Hypertension

kidney disease

Mother

Father

Sister

Brother

Daughter

Son

SOCIAL HISTORY DOMESTIC ABUSE

Tobacco Use No ___ Yes ___ former ____ Is abuse, violence, or sexual assault a problem for

Alcohol Use No ___ Yes ___ smoker you in any way? No ____ Yes ____

Drug Use No ___ Yes ___ Does your partner/caregiver threaten you in anyway?

No ____ Yes ___

INSTRUCTIONS: PLEASE CIRCLE "y" FOR ANY CURRENT SYMPTOMS

CONSTITUTIONAL RESPIRATORY ENDOCRINE NEUROLOGICAL

Y N Appetite change Y N Chest tightness Y N Cold intolerance Y N Dizziness

Y N Chills Y N Choking Y N Heat intolerance Y N Headaches

Y N Sweating Y N cough Y N Excessive thirst Y N Light-headedness

Y N Fatigue Y N Shortness of

breath GU Y N Numbness

Y N Fever Y N Wheezing Y N Painful urination Y N Seizures

Y N Weight change

CARDIOVASC. Y N Flank pain Y N Fainting

MUSCULOSKEL. Y N Leg swelling Y N frequency Y N Tremors

Y N Back pain Y N Palpitations Y N Blood in urine Y N Weakness

Y N Gait problems GI Y N penile/vaginal

discharge HEMATOLOGICAL

Y N joint swelling Y N Distention Y N scrotal/Pelvic pain Y N Adenopathy

Y N neck pain Y N Abdominal pain Y N Urinary urgency Y N Bruise/bleed easy

Y N Anal bleeding Y N Vaginal bleeding SKIN

Y N Blood in stool Y N Vaginal discharge Y N Color chagnes

Y N Constipation

Y N Rash

Y N Diarrhea

Y N Wound

Y N Nausea

Y N Rectal pain

Y N Vomiting

REX SURGICAL SPECIALISTS

PATIENT IDENTIFICATION Patient’s Legal Name _________________________________________________________________________________ (LAST) (FIRST) (MIDDLE) Rex Healthcare will compare your Legal Name to your name as it appears on your insurance card. Gender ____ Last 4 numbers Social Security# (some insurances require full SS) ___________________ Birth Date _____________________ PATIENT INFORMATION: Race__________Hispanic_____Non-Hispanic________Language_________________ Mailing Address _____________________________________________________________________________________ Physical Address (if different from mailing address) ________________________________________________________ City ___________________________________ State ________________________ Zip Code _____________________ Home Phone # ____________________Mobile Phone #_______________________Email Address_______________ Referring Physician __________________________________________________________________________________ Primary Care Physician_______________________________________________________________________________ Other Physicians to Whom You Want Communication Sent _________ ________________________________________ PATIENT EMPLOYMENT INFORMATION Status: Full-time ___ Part-time ____ Retired ____ Retirement Date _________ Full Time Student? Y/N Other Employer’s Name ___________________________________________ Phone # _______________________________

GUARANTOR INFORMATION (Person Financially Responsible if different than patient) Name of Guarantor _______________________________________ Relationship to Patient _______________________ Last 4 Digits of Social Security # _____________ Gender _________ Birth Date ______________________ Mailing Address _____________________________________________________________________________________ Physical Address (if different from mailing address) ________________________________________________________ City ______________________________________ State _______________________ Zip Code __________________ Home Phone # _____________________________ Employer’s Name ________________________________________ EMERGENCY CONTACT INFORMATION

Name of Emergency Contact _______________________________________ Relation to Patient ___________________ Mailing Address _____________________________________________________________________________________ Physical Address (if different from mailing address) ________________________________________________________ City ______________________________________ State __________________________ Zip Code _______________ Home Phone # _____________________Work Phone # ______________________Cell Phone # ____________________ PRIMARY INSURANCE Name of Insurance Company __________________________________________________________________________ Policyholder’s Name (if other than patient)_____________________________________ Relationship____________ Birth Date ________________ Gender ________ SECONDARY INSURANCE Name of Insurance Company __________________________________________________________________________ Policyholder’s Name (if other than patient)_____________________________________ Relationship____________ Birth Date ________________ Gender ________ ACCIDENT INFORMATION (Complete this section ONLY if your condition is accident related) Type of Accident (Auto, Work, Other) ________________________ Description______________ ___________________ Accident Date and Time ______________________Place of Accident (City,County,State) __________________________ Patient/Authorized Representative Signature __________________________________________Date_______________

Date: Authorization for Release of Patient Information Name of Patient: DOB: Rex Surgical Specialists is authorized to release protected health information pertaining to the above named patient to the entities below. Entity to Receive Information (Initial each that is subject to this information) Leave information on voice mail Give information to spouse Give information to the following persons: Relationship Employer FMLA/Disability Insurance

Description of Information to be Released (Initial each that is appropriate)

Financial Information Results from tests and/or x-rays Family Billing Information Disability Insurance/ FMLA Forms/Medical Insurance

Medical Information as follows: Other information as described: I do not authorize the release of any information at this time 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 information to be disclosed as described in this document by sending a written notification. I understand that a revocation is not effective in cases where I understand that 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. This authorization shall be in force and effect until revoked by the patient or representative signing the authorization. Signature of Patient or Personal Representative Date

July 2015 Chart Location: Consents

Patient Label Here

GENERAL CONSENT FOR TREATMENT (Page 1 of 4)

HIM #129s

I understand that the University of North Carolina Health Care System (UNC Health Care) is an integrated health system

made up of various entities, including (but not necessarily limited to) UNC Hospitals; Rex Hospital, Inc.; High Point

Regional Health; Regional Physicians, LLC; Premier Surgery Center, LLC; Caldwell Memorial Hospital, Incorporated;

Chatham Hospital, Inc.; Henderson County Hospital Corporation d/b/a Margaret R. Pardee Memorial Hospital; the

University of North Carolina at Chapel Hill, School of Medicine; Johnston Health Services Corporation; Nash Hospitals,

Inc.; Nash MSO, Inc.; NHCS Physicians, Inc.; UNC Physicians Network, LLC; and UNC Physicians Network Group

Practices, LLC (each referred to in this form as a “UNC Health Care affiliate” or collectively as “UNC Health Care

affiliates”). This consent will be effective for 1 year after the date it is signed at any UNC Health Care affiliate of

which I am a patient; however, this consent will not expire for services, claims processing or collection activities for

admissions or visits occurring while this consent was in effect.

Consent for Treatment/Care I consent to treatment and care by UNC Health Care affiliates and by their physicians and health care providers, including

those who are located at sites other than the one at which I am present and who provide treatment and care through

electronic communications/telemedicine. I also consent to treatment and care by physicians and health care providers who

are not employees or agents of UNC Health Care affiliates but are authorized by UNC Health Care affiliates to provide

treatment and care to me as a patient of the UNC Health Care affiliate. I am aware that the providers listed on Exhibit A to

this consent are independent contractors of UNC Health Care affiliates, as listed, and they provide services to the UNC

Health Care affiliate’s patients in accordance with their professional judgment. The providers listed on Exhibit A are not

employees or agents of the UNC Health Care affiliate. I understand that my treatment and care may include routine care,

such as immunizations, and a variety of other medical services depending on my condition, such as laboratory testing. I

can receive a list of services and care from my health care provider. I understand that my care team at UNC Health Care

affiliates may include resident physicians and students or other trainees. I am aware that the practice of medicine

(including surgery) is not an exact science, and no one has made any guarantees about the results of my treatments,

examinations, or procedures.

Consent for Use and Release of Information I give permission to UNC Health Care affiliates – including their treating and referring providers and other staff members

– to release any information about me, my health, the health services provided to me, or payment for my health services,

that may be necessary: (1) for my treatment (to health care providers or facilities that need the information for my

continued care); (2) for any purposes related to payment by me or a third party for services (to determine eligibility, to

process an insurance claim, for utilization and quality review, or for billing or collection purposes, as necessary to obtain

payment); (3) for the health care operations of the UNC Health Care affiliate or another health care provider that has had a

relationship with me (quality assessment, training programs, planning, and fundraising); or (4) as otherwise described in

the Notice of Privacy Practices and as permitted by law.

For more detailed information about the way my information may be used or released, I can read the UNC Health Care’s

Notice of Privacy Practices.

I give permission to UNC Health Care affiliates and their employees, agents, and contractors to take photographs or make

videos or drawings of me for permissible treatment, payment, or health care operations purposes (which may include

quality assessment, education, and training), as long as consistent with policies and laws that protect my rights.


Consent for Use Within UNC Health Care I further give permission to UNC Health Care affiliates and their treating providers and other staff members to disclose to

each other any of my sensitive information necessary for my treatment, including information related to behavioral and/or

mental health (including records of my treatment by a facility whose primary purpose is to provide services for the care,

treatment, habilitation, or rehabilitation of the mentally ill, developmentally disabled, or substance abusers, as defined by

N.C.G.S. Chapter 122C, Articles 1 and 3), drugs and alcohol (including records of a provider that provides alcohol or drug

abuse diagnosis, treatment, or referral, as defined by federal law at 42 C.F.R. Part 2), HIV/AIDS and other communicable

diseases, and genetic testing.

I further authorize release of financial information and activity related to payment for services to:

Name of Individual: _______________________________________________________________________

Relationship to Patient: ____________________________________________________________________

Financial Responsibility I understand and agree that physician charges for medical and related professional services performed or supervised by a

physician will be billed separately from hospital charges. I understand that my actual charges may be different from

charge estimates given to me. I also understand that an insurance company may not pay the full amount of my charges,

and I may be responsible (as a patient, spouse, or the parent of a minor child) for the amount not paid. If I do not have

health insurance or have not provided current or accurate insurance information, I am responsible for payment of all

charges. If I have overpaid any of my accounts with a particular UNC Health Care affiliate, I agree that the overpayment

may be applied to pay any outstanding charges on any of my accounts with other UNC Health Care affiliates.

Medicare/Medicaid/Insurance Certification, Assignment & Payment Request I have been informed that Medicare will only pay for services that it determines to be reasonable and necessary under

section 1862(a)(1) of the Medicare Law. I certify that the information given by me or by my authorized representative in

applying for payment for my health care under the Medicare or Medicaid programs is correct. I request that payment of

authorized benefits be made to the appropriate UNC Health Care affiliate on my behalf. I authorize UNC Health Care

affiliates to bill directly and assign the right to all health and liability insurance benefits otherwise payable to me, and I

authorize direct payment to the appropriate UNC Health Care affiliate.

Social Security Number I have given my social security number voluntarily. UNC Health Care affiliates may use it for accurate identification,

filing insurance claims, billing and collections, and compliance with federal and state laws.

Wireless Telephone Number UNC Health Care affiliates, or their agents or representatives, may contact me by telephone at any number contained in

my UNC Health Care affiliate’s records, including wireless telephone numbers, for the purpose of servicing my account

and collecting amounts due. Methods of contact may include pre-recorded or artificial voice messages and the use of

automatic dialing services.

Personal Property I understand that UNC Health Care affiliates do not assume responsibility for my personal belongings that I keep in my

possession, and I release UNC Health Care affiliates from all liability for the loss or theft of, or damage to, such

belongings.

Patient List As a convenience to patients and visitors, UNC Health Care affiliates may keep a list of patients currently receiving

services at its facility so that we may provide the location of the patient in the facility and the patient’s general condition

to people who ask for patients by name. Unless I have initialed below, I give permission for UNC Health Care affiliates to

give my location and general condition to individuals who ask for me by name.

_____ (initial) I do not want to be included in UNC Health Care affiliates’ patient lists. Please remove my name.


GENERAL CONSENT FOR TREATMENT (CONTINUED) – PAGE 3 OF 4 Patient Label Here

Religious Information UNC Health Care affiliates may provide a patient list for community clergy when they request it. This list includes the

name and location of the patient, the patient’s general condition, and the patient’s religious affiliation. Unless I have

initialed below, I give permission for UNC Health Care affiliates to give my name, location, general condition, and

religious affiliation to community clergy who request it.

_____ (initial) I do not want to be included in UNC Health Care affiliates’ list provided for clergy. Please remove my

name. I understand that those employed by a UNC Health Care affiliate as chaplains may still obtain this information.

Sharing Information with Family and/or Friends As a courtesy, limited health information may be shared with family, friends and authorized representatives under the

following conditions: (1) the information is related to that individual’s involvement in the patient’s care or payment for

care, or (2) the information is needed to notify individuals responsible for the patient’s care about the patient’s location,

general condition or death. Unless I have initialed below, I give permission for limited health information to be shared

with my family, friends and authorized representatives under the conditions mentioned above.

______ (initial) I do not want personal health information shared with family, friends, and/or representatives.

I UNDERSTAND THAT I MAY WITHDRAW THIS CONSENT IN WRITING. MY WITHDRAWAL WILL

NOT BE EFFECTIVE FOR ACTIONS ALREADY TAKEN BY ANY UNC HEALTH CARE AFFILIATE, OR IN

PROGRESS.

I AUTHORIZE UNC HEALTH CARE AFFILIATES TO RELEASE ALL RECORDS REQUIRED TO ACT ON

THESE REQUESTS. I HAVE READ AND UNDERSTAND THIS FORM, RECEIVED A COPY, AND I AM THE

PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS FORM.

__________________________________________ DATE: ________________ TIME: ________________

PATIENT SIGNATURE (or Authorized Representative)

_________________________________________________________________________________________

PRINTED NAME

RELATIONSHIP, if not patient: ______________________________________________________________

GUARANTOR: If I sign below as guarantor (not as the patient, or spouse of the patient, or the parent of a minor child), I

agree to pay all charges of any UNC Health Care affiliate not paid, even if I am otherwise not legally obligated to pay.

__________________________________________ DATE: __________________ TIME: ________________

GUARANTOR OF PAYMENT SIGNATURE

_________________________________________________________________________________________

PRINTED NAME


EXHIBIT A

Independent Contractors at UNC Health Care Affiliates

UNC Hospitals (“UNCH”)

I am aware that physicians, nurse practitioners and physician assistants who provide services to UNCH patients may be independent contractors who

provide services to UNC Hospitals patients in accordance with their professional judgment. These practitioners are not employees or agents of UNC

Hospitals.

Rex Hospital, Inc. (“Rex”)

I am aware that the emergency room physicians, anesthesiologists, CRNAs, neonatologists, pathologists, psychiatrists, radiologists, and radiation

oncologists, and their nurse practitioners and physician assistants, are independent contractors who provide services to Rex patients in accordance

with their professional judgment. These practitioners are not employees or agents of Rex.

High Point Regional Health (“High Point Regional”)

I am aware that the emergency room physicians, anesthesiologists, CRNAs, pathologists, radiologists, hospitalists and radiation oncologists, and their

nurse practitioners and physician assistants, are independent contractors who provide services to High Point Regional patients in accordance with

their professional judgment. These practitioners are not employees or agents of High Point Regional.

Caldwell Memorial Hospital, Incorporated (“Caldwell”)

I am aware that some providers, including but not limited to emergency room physicians, anesthesiologists, pathologist, radiologists, and medical and

radiation oncologists, and their nurse practitioners and physician assistants, are independent contractors who provide services to Caldwell patients in

accordance with their professional judgment. These practitioners are not employees or agents of Caldwell.

Chatham Hospital, Inc. (“Chatham”)

I am aware that the emergency room physicians, anesthesiologists, CRNAs, hospitalists, pathologists, and radiologists, and their nurse practitioners

and physician assistants, are independent contractors who provide services to Chatham patients in accordance with their professional judgment.

These practitioners are not employees or agents of Chatham.

Henderson County Hospital Corporation d/b/a Margaret R. Pardee Memorial Hospital (“Pardee”)

I am aware that the emergency department physicians, radiologists, anesthesiologist group, radiation oncologists, and pathologists, and their nurse

practitioners and physician assistants, are independent contractors who provide services to Pardee patients in accordance with their professional

judgment. These practitioners are not employees or agents of Pardee.

Johnston Health Services Corporation (“Johnston”)

I am aware that most physicians providing care at Johnston, and their nurse practitioners and physician assistants, are independent contractors who

provide services to Johnston in accordance with their professional judgment. These practitioners are not employees or agents of Johnston.

Nash Hospitals, Inc. (“Nash”)

I am aware that the physicians, including but not limited to emergency room physicians, anesthesiologists, CRNAs, pathologists, radiologists,

medical and radiation oncologists, and their nurse practitioners and physician assistants, are independent contractors who provide services to Nash

patients in accordance with their professional judgment; and I understand that these practitioners are not employees or agents of Nash, and that Nash

is not liable for their actions.

Premier Surgery Center, LLC (“Premier”)

I am aware that the providers at Premier are independent contractors who provide services to Premier patients in accordance with their professional

judgment; and I understand that these practitioners are not employees or agents of Premier, and that Premier is not liable for their actions.

*HIM129* HD3560S Rev. 07/01/2015 Chart Location: Consents

Patient Label Here

CONSENTIMIENTO GENERAL PARA RECIBIR TRATAMIENTO (Pág 1 de 4)HIM# 129s

Yo entiendo que la University of North Carolina Health Care System (UNC Health Care) es un sistema de saludintegrado formado por varias entidades incluyendo (pero no necesariamente limitada a) UNC Hospitals; Rex Hospital,Inc.; High Point Regional Health; Regional Physicians, LLC; Premier Surgery Center, LLC; Caldwell MemorialHospital, Incorporated; Chatham Hospital, Inc.; Henderson County Hospital Corporation d/b/a Margaret R. PardeeMemorial Hospital; the University of North Carolina at Chapel Hill, School of Medicine; Johnston Health ServicesCorporation; Nash Hospitals, Inc.; Nash MSO, Inc.; NHCS Physicians, Inc.; UNC Physicians Network, LLC; y UNCPhysicians Network Group Practices, LLC (en este formulario se denomina a cada uno como «afiliado de UNCHealth Care» o en forma colectiva como «afiliados de UNC Health Care»). Este consentimiento estará vigente 1año a partir de la fecha en que se firme en cualquiera de los afiliados de UNC Health Care en donde yo soy unpaciente; sin embargo, este consentimiento no caducará en lo que respecta a servicios, procesamiento dereclamaciones o actividades de cobros relacionados con las admisiones o visitas que ocurran durante el tiempode vigencia de este consentimiento.

Consentimiento para recibir tratamiento/cuidadoYo autorizo recibir tratamiento y cuidado de parte de los afiliados de UNC Health Care y sus médicos y proveedoresde cuidados de la salud, incluyendo aquellos que están ubicados en otros lugares aparte del que yo me encuentro ahoray que proporcionan tratamiento y cuidado a través de comunicaciones electrónicas/telemedicina. También autorizorecibir tratamiento y cuidado de médicos y proveedores de cuidados de la salud que no son empleados ni agentes delos afiliados de UNC Health Care pero que están autorizados por los afiliados de UNC Health Care paraproporcionarme tratamiento y cuidado como paciente de los afiliados de UNC Health Care. Yo estoy consciente deque los proveedores listados en el apéndice A de este consentimiento son contratistas independientes de los afiliadosde UNC Health Care, conforme a la lista, y ellos proveen servicios a los pacientes de los afiliados de UNC HealthCare de acuerdo con su juicio profesional. Los proveedores listados en el apéndice A no son empleados ni agentes delos afiliados de UNC Health Care. Yo entiendo que mi tratamiento y cuidado puede incluir cuidado de rutina comovacunaciones y una variedad de otros servicios médicos dependiendo de mi afección, como por ejemplo pruebas delaboratorio. Yo puedo recibir una lista de servicios y cuidados de mi proveedor de cuidados de la salud. Yo entiendoque mi equipo médico de los afiliados de UNC Health Care puede incluir médicos residentes y estudiantes u otropersonal en adiestramiento. Entiendo que la práctica de la medicina (incluyendo la cirugía) no es una ciencia exacta ynadie me ha dado ninguna garantía acerca de los resultados de los tratamientos, exámenes o procedimientos.

Consentimiento para el uso y divulgación de información.Yo les doy permiso a los afiliados de UNC Health Care –incluyendo sus proveedores que remiten y proporcionantratamiento y otros miembros del personal– para divulgar cualquier información acerca de mi persona, mi salud,servicios de salud que me presten, o pago por mis servicios de salud que pudiera ser necesaria: (1) para mitratamiento (a cualquier proveedor de cuidados de la salud o instalaciones que necesiten la información para micuidado continuo); (2) para cualquier propósito relacionado con el pago de servicios hecho por mí o un tercero (paradeterminar idoneidad, para procesar una reclamación al seguro, para revisión de utilización y calidad o con elpropósito de facturación o cobro, según sea necesario para obtener el pago); (3) para las operaciones del negocio decuidados de la salud del afiliado de UNC Health Care u otro proveedor de cuidados de la salud que haya tenidorelación conmigo (incluyendo la evaluación de calidad, programas de capacitación, planificación y actividades para larecaudación de fondos); o (4) de otra manera descrito en el Aviso de Prácticas de Privacidad y como la ley lo permita.

Para información más detallada sobre la forma en la cual se puede usar o divulgar mi información, puedo leer el Avisode Prácticas de Privacidad de UNC Health Care.Yo doy mi autorización a los afiliados de UNC Health Care y sus empleados, agentes y contratistas para tomarfotografías, videos o hacer dibujos de mi persona con propósitos permisibles de tratamiento, pago o de las operacionesde cuidados de la salud (los cuales pueden incluir evaluación de calidad, educación y capacitación) siempre y cuandosea consistente con las políticas y las leyes que protegen mis derechos.

CONSENTIMIENTO GENERAL PARA RECIBIR TRATAMIENTO (CONTINUACIÓN) – PÁG. 2 DE 4 Patient Label Here


Consentimiento para ser utilizado dentro de UNC Health CareYo además doy permiso a los afiliados de UNC Health Care y sus proveedores que proporcionan tratamiento y a otrosmiembros del personal para divulgar entre ellos cualquiera de mi información delicada necesaria para mi tratamiento,incluyendo información relacionada con la salud mental o conductual (incluyendo expedientes médicos de mitratamiento de otra institución cuyo propósito principal es proporcionar servicios de cuidado, tratamiento, habilitacióno rehabilitación de los enfermos mentales, discapacitados en el desarrollo o abusadores de sustancias, como se definenen N.C.G.S Capítulo 122C, Artículos 1 y 3), drogas y alcohol (incluyendo expedientes médicos de un proveedor queproporciona diagnóstico, tratamiento o remisión para el abuso de alcohol o drogas, como se define de acuerdo a la leyfederal en 42 C.F.R. Parte 2), VIH/SIDA y otras enfermedades contagiosas y pruebas genéticas.

Yo además autorizo la divulgación de información financiera y actividad relacionada con los pagos por losservicios a:Nombre del individuo: ____________________________________________________________________Relación con el paciente: __________________________________________________________________

Responsabilidad financieraYo entiendo y estoy de acuerdo que los cargos de los médicos por los servicios médicos y profesionales realizados osupervisados por un médico, se facturarán por separado de los cargos del hospital. Entiendo que el costo actualpudiera ser distinto del costo estimado que me dieron. También entiendo que es posible que una compañía de seguromédico no pague el monto total de mis cuentas, y yo pudiera ser responsable de la cantidad no pagada (como paciente,cónyuge o padre de un menor de edad). Si yo no tengo cobertura de un seguro médico o no he proporcionadoinformación vigente y exacta del seguro, soy responsable por el pago de todo el adeudo. Si he pagado de más encualquiera de mis cuentas con un afiliado en particular de UNC Health Care, estoy de acuerdo en que el monto que sepagó de más se transfiera para pagar cualquier deuda pendiente de cualquiera de mis cuentas con otros afiliados deUNC Health Care.

Certificación de cobertura, asignación y solicitud de pago de Medicare/MedicaidYo he sido informado de que Medicare solamente pagará por servicios que determine razonables y necesariosconforme a la sección 1862(a)(1) de la ley de Medicare. Yo certifico que la información proporcionada por mí o mirepresentante autorizado en mi solicitud de pago para mis cuidados de la salud bajo los programas de Medicare yMedicaid es correcta. Yo solicito que el pago de los beneficios autorizados se haga al afiliado apropiado de UNCHealth Care en mi nombre. Yo autorizo a los afiliados de UNC Health Care a facturar directamente y a traspasar elderecho a todo beneficio por seguro médico o de responsabilidad civil, de otra manera pagadero a mi persona, yautorizo el pago directo al afiliado apropiado de UNC Health Care.

Número de seguro socialYo he dado voluntariamente mi número de seguro social. Los afiliados de UNC Health Care pueden usarlo parafines de identificación exacta, presentación de reclamaciones de seguro, facturación y cobros y cumplimiento de lasleyes federales y estatales.

Número de teléfono celularLos afiliados de UNC Health Care o sus agentes o representantes se pueden comunicar conmigo por teléfono acualquier número anotado en mi expediente de los afiliados de UNC Health Care incluyendo teléfonos celulares conel propósito de proporcionarle servicios a mi cuenta y cobrar las cantidades adeudadas. Los métodos de contactopueden incluir mensajes pregrabados o mensajes con voz artificial y el uso de servicios de llamada automáticos.

Objetos personalesYo entiendo que los afiliados de UNC Health Care no asumen responsabilidad por mis objetos personales que yomantenga conmigo y yo relevo a los afiliados de UNC Health Care de toda responsabilidad por la pérdida, robo odaño de esas pertenencias.

Lista de pacientesPara la conveniencia de los pacientes y visitantes, los afiliados de UNC Health Care pueden mantener una lista de lospacientes que están recibiendo servicios actualmente en sus instalaciones para que podamos proporcionar el lugardonde se encuentra el paciente en las instalaciones y el estado general del paciente a las personas que preguntan porun paciente por su nombre. A menos que yo haya escrito mis iniciales abajo, yo les doy mi autorización a los afiliados



de UNC Health Care para proporcionar mi ubicación y estado general a los individuos que pregunten por mí por minombre.

_____ (iniciales) Yo no quiero que me incluyan en la lista de pacientes de los afiliados de UNC Health Care. Porfavor quiten mi nombre.

Información religiosaPuede que los afiliados de UNC Health Care proporcionen una lista de pacientes al clero de la comunidad cuando lasolicitan. Esta lista incluye el nombre y la ubicación del paciente, su estado en general y su afiliación religiosa. Amenos que yo haya escrito mis iniciales a continuación, yo doy mi autorización a los afiliados de UNC Health Carepara proporcionar a los clérigos de la comunidad, que lo pidan, mi nombre, ubicación, estado general y afiliaciónreligiosa.

_____ (iniciales) Yo no quiero que me incluyan en la lista que proporcionan al clero los afiliados de UNC HealthCare. Por favor quiten mi nombre. Yo entiendo que, aun así, aquellas personas que trabajan para los afiliados deUNC Health Care como capellanes pudieran obtener esta información.

Compartiendo información con los familiares o amistadesComo una cortesía, la información de salud limitada pudiera compartirse con familiares, amistades o representantesautorizados bajo las siguientes circunstancias: (1) la información está relacionada con la participación del individuoen el cuidado del paciente o pago por su cuidado, o (2) la información es necesaria para notificar a individuosresponsables del cuidado del paciente sobre la ubicación del paciente, estado en general o la muerte. A menos que yohaya escrito mis iniciales abajo, doy mi autorización para compartir información de salud limitada con mi familia,amigos y representantes autorizados bajo las condiciones mencionadas anteriormente.

______ (iniciales) Yo no quiero que la información personal de salud se comparta con los familiares, amistades orepresentantes.

YO ENTIENDO QUE PUEDO REVOCAR ESTE CONSENTIMIENTO POR ESCRITO. MIREVOCACIÓN NO TENDRÁ VIGENCIA PARA ACCIONES YA TOMADAS POR PARTE DECUALQUIER AFILIADO DE UNC HEALTH CARE O A ACCIONES EN PROCESO.

Yo autorizo a los afiliados de UNC HEALTH CARE A DIVULGAR TODOS LOS EXPEDIENTESNECESARIOS PARA CUMPLIR CON ESTAS SOLICITUDES. YO HE LEÍDO Y ENTIENDO ESTEFORMULARIO, HE RECIBIDO UNA COPIA, Y SOY EL PACIENTE O ESTOY AUTORIZADO PARAACTUAR EN NOMBRE DEL PACIENTE PARA FIRMAR ESTE FORMULARIO.

_________________________________________ FECHA: _________________ Hora:_____________________FIRMA DEL PACIENTE (o representante autorizado)

_________________________________________________________________________________________NOMBRE EN LETRA DE MOLDE

RELACIÓN, si no es el paciente: ______________________________________________________________

GARANTE: Si yo firmo a continuación como garante (no como el paciente o cónyuge del paciente o padre de unmenor de edad), yo estoy de acuerdo en pagar todas las cuentas no canceladas de los afiliados de UNC Health Care,indistintamente de si de otra forma no estoy legalmente obligado a pagarlas.

_________________________________________ FECHA: _________ HORA:________FIRMA DEL GARANTE DE PAGO

_________________________________________________________________________________________NOMBRE EN LETRA DE MOLDE

Translated by UNC Health Care Interpreter Services, 06/23/15



APÉNDICE A

Contratistas independientes de los afiliados de UNC Health Care

UNC Hospitals («UNCH»)

Estoy consciente de que los médicos, enfermeras especializadas y asociados médicos que proveen servicios a pacientes de UNCH pueden sercontratistas independientes que proporcionan servicios a los pacientes de UNC Hospitals de acuerdo con su juicio profesional. Estosprofesionales médicos no son empleados ni agentes de UNC Hospitals.

Rex Hospital, Inc. («Rex»)

Yo estoy consciente de que los médicos del departamento de emergencias, anestesiólogos, enfermeras anestesistas registradas certificadas,neonatólogos, patólogos, psiquiatras, radiólogos y oncólogos de radiación y sus enfermeras especializadas y asociados médicos, son contratistasindependientes que les proporcionan servicios a los pacientes de Rex de acuerdo con su juicio profesional. Estos profesionales médicos no sonempleados ni agentes de Rex.

High Point Regional Health («High Point Regional»)

Yo estoy consciente de que los médicos del departamento de emergencias, anestesiólogos, enfermeras anestesistas registradas certificadas,patólogos, radiólogos, hospitalistas y oncólogos de radiación y sus enfermeras especializadas y asociados médicos, son contratistasindependientes que proporcionan servicios a los pacientes de High Point Regional Health de acuerdo con su juicio profesional. Estosprofesionales médicos no son empleados ni agentes de High Point Regional.

Caldwell Memorial Hospital, Incorporated («Caldwell»)

Yo estoy consciente de que algunos proveedores, incluyendo pero no limitados a los médicos del departamento de emergencias, anestesiólogos,patólogos, radiólogos y médicos oncólogos y oncólogos de radiación y sus enfermeras especializadas y asociados médicos son contratistasindependientes que proporcionan servicios a los pacientes de Caldwell de acuerdo con su juicio profesional. Estos profesionales médicos no sonempleados ni agentes de Caldwell.

Chatham Hospital, Inc. («Chatham»)

Yo estoy consciente de que los médicos del departamento de emergencias, anestesiólogos, enfermeras anestesistas registradas certificadas,hospitalistas, patólogos, y radiólogos y sus enfermeras especializadas y asociados médicos son contratistas independientes que le proporcionanservicios a los pacientes de Chatham de acuerdo con su juicio profesional. Estos profesionales médicos no son empleados ni agentes deChatham.

Henderson County Hospital Corporation d/b/a Margaret R. Pardee Memorial Hospital («Pardee»)

Yo estoy consciente de que los médicos del departamento de emergencias, radiólogos, el grupo de anestesiólogos, oncólogos de radiación y lospatólogos y sus enfermeras especializadas y asociados médicos, son contratistas independientes que proporcionan servicios a los pacientes dePardee de acuerdo con su juicio profesional. Estos profesionales médicos no son empleados ni agentes de Pardee.

Johnston Health Services Corporation («Johnston»)

Yo estoy consciente de que la mayoría de los médicos que proporcionan cuidados en Johnston, y sus enfermeras especializadas y asociadosmédicos, son contratistas independientes que proporcionan servicios en Johnston de acuerdo con su juicio profesional. Estos profesionalesmédicos no son empleados ni agentes de Johnston.

Nash Hospitals, Inc. («Nash»)

Yo estoy consciente de que los médicos, incluyendo pero no limitados a los médicos del departamento de emergencias, anestesiólogos,enfermeras anestesistas registradas certificadas, patólogos, radiólogos, médicos oncólogos y oncólogos de radiación y sus enfermerasespecializadas y asociados médicos, son contratistas independientes que le proporcionan servicios a los pacientes de Nash de acuerdo con sujuicio profesional; y yo entiendo que estos profesionales no son empleados o agentes de Nash, y que Nash no es responsable por sus acciones.

Premier Surgery Center, LLC («Premier»)Yo estoy consciente de que los proveedores de Premier son contratistas independientes que les proporcionan servicios a los pacientes de Premierde acuerdo con su juicio profesional; y yo entiendo que estos profesionales no son empleados ni agentes de Premier y que Premier no esresponsable por sus acciones.

Translated by UNC Health Care Interpreter Services, 06/23/15

Documents

REX Surgical Specialists Surgical Specialists is authorized to release protected health information pertaining to the above named patient to the entities below