The Comprehensive Breast Care Center of Tampa BayPeter W. Blumencranz, M.D., FACS

Medical DirectorSurgical Oncology

Diseases of the Breast/Melanoma

Kathleen G. Allen, M.D., FACS Surgical Oncology

Diseases of the Breast

MBA,

Thank you for choosing The Comprehensive Breast Care Center of Tampa Bay.

Appointment Location

___ Axelrod Pavilion 400 Pinellas Street Appointment Date: __________________ Suite 200 Clearwater, Florida 33756 Please arrive at: _________:________am/pm (727) 462-2131

___ Morton Plant Mease Outpatient Center 2102 Trinity Oaks Boulevard Suite 202 Trinity, FL 34655 (727) 462-2131

Please bring the following information to the appointment with you:

Photo ID

Insurance Card(s)

Completed paperwork

and reports from imaging center outside of Morton Plant (example: SDI, Rose Radiology, Gateway Radiology, Palm Harbor MRI, Westcoast Radiology)

Failure to bring completed paperwork and imaging reports/disks may result in your appointment being

rescheduled.

Thank You!

The Comprehensive Breast Care Center of Tampa Bay

Rev. 3/2017

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__________________

Uses and Disclosures of Your Protected Health Information (PHI)I understand that as part of my health care, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination, test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment

A means of communication among the health professionals who contribute to my care, such as referrals

A source of information for applying my diagnosis and treatment information to my bill

A means by which a third-party payer can verify that services billed were actually rendered

A tool for routine health care operation, such as assessing quality and reviewing the competence of sta�

I have been provided with a “Notice of Patient Privacy Practices” that provides a more complete description of information uses and disclosures.

Tell us with whom we may discuss your protected health information: (Name and relation - Example: Jane Doe, Wife; Jan Doe, Daughter) ____________________________________________________________________________________________________________

Messages or Appointment RemindersMessages will be of a non-sensitive nature, such as, appointment reminders.May we leave a message on your voice mail using doctor’s/practice name? Yes NoMay we leave a message with another individual using doctor’s/practice name? Yes NoMay we leave a message at your work using doctor’s/practice name? Yes No

I understand that as part of treatment, payment or health care operations, it may become necessary to disclose health information to another entity, e.g. referrals to other health care providers. I understand that my information may be used or disclosed, without an authorization, as permitted or required by law.

_________________________________________________________________ _________________________________Patient/guardian signature Date

_________________________________________________________________Print name of person signing

If other than the patient (patient name) _______________________________________________________________________is signing, are you the legal guardian, custodian, or have Power of Attorney for this patient, for treatment, payment or health care operations? Yes No

Patient ConsentRequest for Care and Consent for Treatment�e undersigned consents to the medical care and treatment, as may be deemed necessary or advisable in the judgment of my physician or other provider, which may include but are not limited to laboratory procedures, X-ray examination, medical or surgical treatment or procedures, anesthesia or other services rendered to the patient under the general and special instructions of the patient’s physician. BayCare Medical Group has the right to refuse to treat you if you refuse to sign this consent or if, at any time, you choose to revoke this consent.

Assignment of Insurance BenefitsI authorize payment directly to BayCare Medical Group of any insurance bene�ts otherwise payable to me for services, at a rate not to exceed BayCare Medical Group regular charges for such services.

Releasing Medical InformationI understand that BayCare Medical Group, its business associates, any treating physician/surgeon and/or my insurance company may obtain, use and/or disclose information for the purposes of treatment, payment and normal health care operations. �is use and disclosure may include collection agencies and credit bureaus. Information may include psychiatric, drug abuse, alcohol and/or HIV status. I understand that if I do not consent to release of information for payment purposes, the Facility and other health care providers will be unable to bill my insurance company or other party which is or may be responsible for payment for the services documented by the withheld information, and I will be billed directly for these services. Patients with implantable devices consent to the release of their Social Security numbers to the device manufacturer to comply with the Safe Medical Devices Act. For a more detailed description of uses and disclosures for treatment, payment or normal health care operations, review BayCare Medical Group’s Notice of Privacy Practices.

Permission for TreatmentPermission is hereby granted for physicians, employees or agents of the Practice to render the patient named below such medical and surgical treatment as is deemed necessary.

�e undersigned certi�es that he/she has read the forgoing, received a copy therof and is the patient or is duly authorized by the patient as patient’s general agent to execute the above and accepts its terms.

Patient (print name): __________________________________________________________________________________Signature of patient or authorized person: __________________________________________________________________Relationship: _______________________________________________________________ Date: ____________________Witness signature: __________________________________________________________ Date: ____________________If the patient did not sign, please state reason: _______________________________________________________________

BC1505258_0815 BC 1873

Financial ResponsibilityImportant Information Regarding Your Account

Statement of Financial ResponsibilityI understand that I am responsible for the payment of this account, and hereby assume and guarantee prompt payment of all expenses incurred.

Notice of “Non-Covered” ServicesI am aware that some services performed by the Practice may be considered “non-covered” by my insurance carrier or Medicare, therefore I will become fully responsible for payment of these services.

Waiver of “Usual, Customary and Reasonable” Clauses (For patients with “Out-of-Network” coverage)I acknowledge that the fee charged by the Practice for services rendered to me, or to the person for whom I assume �nancial responsibility, may exceed the fees considered “usual, customary and reasonable,” due to specialized services and sta�. However, I agree to pay the Practice fees in full, even if the amount is greater than what I am reimbursed from my insurance company.

Bill To/Payment Instructions_____ Commercial Insurance/�ird Party Payor _____ Medicare _____ Medigap*Initial Initial Initial

I hereby authorize the Practice to bill my insurance company and/or Medicare (indicated or initialed above) for services provided to me and request that payments for such services to be made to the Practice on my behalf.

*If Medigap _______________________________ ___________________________ __________________________ Name of Bene�ciary Medigap Policy Number Health Insurance Claim Number

List Names of Those with Whom You Want Us to Share Your Financial Responsibility Information: Name: Relationship:_______________________________________________________________ ____________________________________________________________ _______________________________________________________________ ____________________________________________________________ _______________________________________________________________ ____________________________________________________________

Financial Agreement�e undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient, he/she obligates himself/herself to pay the account of the clinic in accordance with the regular rates and terms of the clinic. Should the account be referred to an outside agency or an attorney for collections, the undersigned agrees to pay reasonable collection and attorney fees for collection expenses.

Patient’s name: ____________________________________________________________________________________________________________________________ (please print)

Patient (or legal guardian’s) signature: ____________________________________________________________

Date: ____________________________________________________________________________________________

If legal guardian, relationship to the patient: _____________________________________________________

Authorization to Use or Disclose Protected Health Information

Physician___________________________________________________________________________________

I hereby authorize the above physician(s) to use or disclose the following information from the health records of the individual whose name is described below.

Patient Name:_________________________________________ Date of Birth:___________________ (Please Print) Address:__________________________________________________________________________________ (City) (State) (Zip) Phone Number:_______________________________ Social Security #______________________________

I authorize the above physician(s) to release medical, mental, alcohol and/or drug abuse, HIV (human immunodeficiency virus) testing, AIDS, eating disorders or any other medical information of a sensitive nature to the following individuals or organization(s):

Name:____________________________________________________________________________________

Address:__________________________________________________________________________________ (City) (State) (Zip)

This information for which I’m authorizing disclosure will be used for the following purpose: Description:_______________________________________________________________________________

Dates of service to be released:________________________________________________________________

The type of information to be used or disclosed is as follows (check the appropriate boxes and include other information where indicated). Copy medical records to Electronic medium or Paper

Office Notes Radiology Results Immunization Record Lab Results EKG Medications Other: (please describe)_______________________________________________________________

I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the release information may no longer be protected by Federal privacy regulations. I understand that I need not sign this authorization to ensure treatment. This authorization shall remain valid for six months from the date signed below.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the department or facility listed on the authorization. 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.

Signed_______________________________________________ Date________________________ Patient or Authorized Person, Parent Legal Guardian Executor Power of Attorney Photo ID checked

Witness:______________________________________________ Date:________________________

Copied by:____________________________ Date:____________________ Pages copied:_____________

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION BC 2958 4/16

P A T I E N T