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1 380 HOSPITAL DRIVE, SUITE 320 MACON, GA NORTH HOUSTON ROAD, SUITE 140F WARNER ROBINS, GA Office Phone: (478) Office Fax: (478) W. Winston Wilfong, MD Lancing C. Patterson, MD Victor J. Andress, MD James H. Lewis, MD Thank you for choosing Southeastern Urology Associates for your medical needs. Please arrive 15 minutes prior to your appointment time. Late arrivals will be rescheduled or seen last. Please complete the enclosed forms and bring the completed forms to our office at your appointment. Patient Name: Account Number: Your appointment is with: Dr. Wilfong Dr. Patterson Dr. Andress Dr. Lewis Your appointment is scheduled for: am at pm Macon Office Warner Robins Office **Please Note** We will ask for proof of health insurance and picture identification at every visit due to insurance requirements. A referral is required for all HMO s and POS s. It is your responsibility as the patient to obtain the referral number and provide our office with this information prior to your visit. Co-payments and/or Co-Insurances are due at the time service is rendered.

2 NEW PATIENT INFORMATION Last Name: First Name: Middle Initial Social Security: Patient Employer: Date of Birth: Age: Gender: (Circle one) Male Female Home Address: (Street) City State Zip code: Home Phone: Work: Cell: Address: Preferred Language: Race: Ethnicity: Marital Status: (Circle one) Single Married Widowed Divorced Spouse Name: Spouse Home/Work/Cell Phone: Primary Care Physician: INSURANCE INFORMATION Primary Insurance Co. Name: Primary Policy Holder: Date of Birth: Relationship to patient: Employer: Secondary Insurance Co Name: Primary Policy Holder Name: Date of Birth: Relationship to patient: Employer: READ AND SIGN BELOW * I hereby authorize and request the medical treatment necessary for the care of the above patient. * I acknowledge full financial responsibility for services rendered by Southeastern Urology Associates. I understand payment is due at time of service unless other definite arrangements have been made prior to treatment. I understand I am responsible for any un-met deductibles and co-insurance fees. * I understand that insurance companies have agreements with certain laboratories for lab work and that it is my responsibility to know which laboratory my insurance authorizes and to inform the staff of Southeastern Urology Associates, as to which my insurance covers. * I further authorize and request that insurance payments be made directly to Southeastern Urology Associates, for services rendered. * I will allow verification for my appointments through your automated system and if I am not available at my given resources, the message can be left on my automated message system. I have read and fully understand the above consent for treatment, release of information, financial responsibility and insurance authorizations. PLEASE SIGN: DATE:

3 380 HOSPITAL DRIVE, SUITE 320 MACON, GA NORTH HOUSTON ROAD, SUITE 140F WARNER ROBINS, GA Office Phone: (478) Office Fax: (478) W. Winston Wilfong, MD Lancing C. Patterson, MD Victor J. Andress, MD James H. Lewis, MD Patient Name: Date:!! IMPORTANT!! Please list all medications you are currently taking and their strength: (Prescription and Over-the-counter medications) DRUG NAME / DRUG STRENGTH List all drug allergies: Name of Pharmacy/Drug Store You Use: Location: (Street Name) (City)

4 Revised 04/18/11 DATE: PATIENT NAME: DATE OF BIRTH: REASON YOU ARE SEEING THE DOCTOR TODAY? MEDICAL ILLNESSES: Medical illnesses that you have been diagnosed with or treated. (Examples: High blood pressure, diabetes, heart disease, emphysema, cancer, bleeding disorders, etc.) PRIOR SURGERIES: List any operations you have had and the year you had them. HABITS: Do you smoke? If yes, how many packs per day? If no, have you been a smoker in the past? If so, what year did you quit? Do you drink alcohol? If so, how many alcoholic beverages do you average per day? Do you drink caffeinated beverages? If so, how many cups of coffee, Iced Tea and Cokes per day? FAMILY HISTORY: List any illnesses in your immediate family. (Examples: Kidney or Bladder Problems, Prostate Problems, Bleeding Disorders, Breast Cancer, Prostate Cancer, etc.) Mother Grandmother Sister Father Grandfather Brother SOCIAL HISTORY: Marital Status (Please circle one): Single Married Widowed Divorced How many children do you have? How many still live at home? EMPLOYMENT: Are you employed? Employer: If employed, what type of work do you do? If retired, where were you employed and what type of work did you do? _

5 REVIEW OF SYSTEMS Revised 04/18/11 Patient Name: Date: Date of Birth: Do you currently have any of the following problems? Please check yes or no. CONSTITUTIONAL SYMPTOMS SKIN Weight Loss Persistent Itching Appetite Increase Skin Rash Appetite Decrease Chills Fever MUSCULOSKELETAL NEUROLOGICAL Arthritis Dizzy Spells Joint Pain Numbness Stroke RESPIRATORY Tremors Asthma ENDOCRINE Chronic Cough Emphysema Diabetes Bronchitis Pituitary Disease Short of Breath Thyroid Disease Tuberculosis Environmental GASTROINTESTINAL Allergies Abdominal Pain HEMATOLOGICAL Black Stools Heartburn/Indigestion Bleeding Problem Constipation Hepatitis Diarrhea HIV (Aids) Bloody Stools IV Drug use Rectal Bleeding Swollen Lymph Nodes CARDIOVASCULAR Sickle Cell Angina (Chest pain) FOR MEN: LAST PSA: Irregular Heartbeat Date: Mitral Valve Prolapse Value: Swelling Patient Height: Patient Weight:

6 FOR MALE PATIENTS ONLY 380 HOSPITAL DRIVE, SUITE 320 MACON, GA NORTH HOUSTON ROAD, SUITE 140F WARNER ROBINS, GA Office Phone: (478) Office Fax: (478) DATE: W. Winston Wilfong, MD Lancing C. Patterson, MD Victor J. Andress, MD James H. Lewis, MD PATIENT NAME: DATE: Please read the following questions and circle the number that applies to your urinary symptoms at this time. 1. Incomplete Emptying Over the last month, how often have you had a sensation of not emptying your bladder completely after you finished urinating? 2. Frequency During the last month, how often have you had to urinate again less than 2 hours after you finished urinating? 3. INTERMITTENCY During the last month, how often have you stopped and started again several times when you urinated? 4. urgency During the last month, how often have you found it difficult to postpone urination? 5. weak stream During the last month, how often have you had a weak urinary stream? 6. straining During the last month, how often have you had to push or strain to begin urination? 7. nocturia During the last month, how often times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? Now add up your Symptom Score (1-7 Mild, 8-19 Moderate, Severe): Adapted from American Urological Association Guideline in the Management of Benign Prostatic Hyperplasia (BPH) Linthicum, MD. American Urological Association Education and Research, Inc., 2003, 1-22, 1-23, 3-51 The Disease Specific Quality of Life Question The International Prostate Symptom Score uses the same 7 questions as the AUA Symptom Index (presented above) with the addition of the following Disease Specific Quality of Life Question (bother score) scored on a scale from 0 to 6 points (delighted to terrible). If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? Delighted Pleased Mostly Mixed Mostly Unhappy Terrible satisfied disappointed 6

7 FOR FEMALE PATIENTS ONLY 380 HOSPITAL DRIVE, SUITE 320 MACON, GA NORTH HOUSTON ROAD, SUITE 140F WARNER ROBINS, GA Office Phone: (478) Office Fax: (478) W. Winston Wilfong, MD Lancing C. Patterson, MD Victor J. Andress, MD James H. Lewis, MD DATE: INCONTINENCE CHECKLIST PATIENT NAME: DATE: Have you leaked any urine (even a small amount)? Yes No If yes, complete questions 1-5. If no, stop here. 1. Did you leak urine (please check all that apply): when you were performing some physical activity such as coughing, sneezing, lifting, laughing or exercising when you had the urge or feeling that you needed to empty your bladder but could not get to the toilet fast enough without physical activity and without a sense or urgency 2. Do you have the sensation of not emptying your bladder completely after you finished urinating? Yes No 3. Frequency Urinate again less than 2 hours after you finished urinating Urinate more than 8 times a day Urinate more than 4 times per night Have bladder pain that is relieved by voiding 4. Urgency - Difficult to postpone urination Find yourself rushing to locate the nearest bathroom Have had at least one accident Wear a pad daily 5. Quality of LIfe - if you had to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that? Happy Mostly satisfied

8 380 Hospital Drive, Suite 320 Macon, GA North Houston Road, Suite 140F Warner Robins, GA Office (478) Fax (478) W. Winston Wilfong, MD Lancing C. Patterson, MD Victor J. Andress, MD James H. Lewis, MD DISCLOSURE FORM Physicians in this office have investment interests in: Southeastern Urology Associates, P.A. 380 Hospital Dr. Ste 300 Macon, GA (478) and Coliseum Same Day Surgery Center, L.P. 340 Hospital Drive, Bldg. E Macon, Georgia (478) and Georgia Litho Group, LLLP (through GLG Partners, LLC) 750 Hammond Drive Building 18, Suite 100 Atlanta, GA (404) You may be referred to one or all of these companies for health care services, including, without limitation, diagnostic imaging services, pharmaceutical services, clinical laboratory services, transurethral microwave therapy (TUMT), lithotripsy, and outpatient surgical services. You have the right to obtain items and services for which you have been referred at the location or from the health care provider or supplier of your choice unless otherwise restricted by law, including a company in which the referring physician is an investor. Please print patient name: Patient Signature: Date: Witness: Date:

9 Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I,, understand that as part of my health care, Southeastern Urology Associates originates and maintains paper and/or electronic records describing my health history, symptoms, examination and 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 many health professionals who contribute to my care,. A source of information for applying my diagnosis and surgical information to my bill,. A means by which a third-party payer can verify the services billed were actually provided, and. A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:. The right to review the notice prior to signing this consent,. The right to object to the use of my health information for directory purposes, and. The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations. I understand that Southeastern Urology Associates is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the Code of Federal Regulations. Should their notice change, a copy of any revised notice will be provided. I wish to have the following restrictions to the use or disclosure of my health information: I understand that as part of this organization s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via FAX. I also give my permission to release my medical information to the following individuals: Name Relationship I fully understand and accept / decline the terms of this consent. Patient s Signature Date FOR OFFICE USE ONLY ( ) Consent received by on, ( ) Consent refused by patient, and treatment refused as permitted. ( ) Consent added to the patient s medical record on.

10 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. At our practice, we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Policies describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003, and applies to all protected health information as defined by federal regulations. UNDERSTANDING YOUR HEALTH RECORD Each time you visit our practice, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:. Basis for planning your care and treatment,. Means of communication among the many health professionals who contribute to your care,. Legal document describing the care you received,. Means by which you or a third-party payer can verify that services billed were actually provided,. Tool in educating health professionals,. Source of data for medical research,. Source of information for public health officials charged to improve the health of the state and nation,. Source of data for our planning and marketing, and. Tool by which we can assess and continually work to improve the care we render and outcomes we achieve.. You will allow appointment verification through our automated system and if you are not available, a message can be left on my personal message system. Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where and why others may access your health information; and make more informed decisions when authorizing disclosure to others. YOUR HEALTH INFORMATION RIGHTS Although your health record is the physical property of our practice, the information belongs to you. You have the right to:. Obtain a paper copy of this notice of privacy rights upon request,. Inspect and copy your health record as provided by 45 CFR ,. Amend your health record as provided by 45 CFR ,. Obtain an accounting of disclosures of your health information as provided by 45 CFR ,. Request confidential communications of your health information as provided by 45 CFR , and. Request a restriction on certain uses and disclosures of your information as provided by 45 CFR (our practice, however, is not required by law to agree to a request restriction). OUR RESPONSIBILITIES Our practice is required to:. Maintain the privacy of your health information,. Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,. Abide by the terms of this notice,. Notify you if we are unable to agree to a requested restriction, and. Accommodate reasonable requests you may have to communicate your health information. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. We will keep a posted copy of the most current notice in our facility. You may obtain a copy of the current Notice of Privacy Practices in effect upon request. We will not use or disclose your health information in a manner other than described in the section regarding Examples Of Disclosures For Treatment. Payment, And Health Operations, without your written authorization, which you may revoke as provided by 45 CFR (b)(5), except to the extent that action has already been taken. FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have questions and would like additional information, you may contact our practice s Privacy Officer at ( ) If you believe your privacy rights have been violated, you can either file a complaint with our Privacy Officer, or with the Office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our Privacy Officer or the OCR. The address for the OCR is as follows: Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C

11 EXAMPLES OF DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH OPERATIONS We will use your health information for treatment. For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your other physician(s) or subsequent health care provider(s) (when applicable) with copies of various reports that should assist them in treating you. We will use your health information for payment. For Example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We will use your health information for regular health operations. For Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.. Business Associates There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a transcription service we use to transfer dictated patient care into the medical record. Due to the nature of business associates services, they must receive your health information in order to perform the jobs we have asked them to do. To protect your health information, however, when these services are contracted we require the business associate to appropriately safeguard your information.. Research We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.. Funeral directors We may disclose health information to funeral directors to carry out their duties consistent with applicable law.. Organ Procurement Organization Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.. Fundraising We may contact you as part of a fund-raising effort.. Food And Drug Administration (FDA) We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.. Workers Compensation We may disclose health information to the extent authorized by and necessary to comply with laws relating to workers compensation or other similar programs established by law.. Public Health As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.. Appointment Reminders We may contact you or a family member at the phone number you have provided to us as a reminder that you have an appointment.. Marketing We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.. Directory Unless you notify us to object, we will use your name, location in the facility, and general condition for our directory purposes. This information may be provided to members of your family and to other people who ask for you by name.. Notification We may use or disclose information to notify or assist in notifying a family member or personal representative (or other person responsible for your care) of your location and general condition.. Communication With Family Health professionals, using their best judgment, may disclose to a family member, other relative, or close personal friend (or any other person you identify) health information relevant to that person s involvement in your care or payment related to your care.. Law Enforcement We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena. Federal law makes provisions for your health information to be released to an appropriate health oversight agency, public health authority, or attorney, provided that a work force member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers, or the public.

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