The Providers and Staff of Baptist Medical Group Primary Care- LiveOak BAPTISTMEDICALGROUP.ORG. Primary Care - Live Oak.

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1 BAPTISTMEDICALGROUP.ORG Primary Care - Live Oak Dear Patient, Thank you for choosing Baptist Medical Group Primary Care - Live Oak to provide you with compassionate care for your health care needs. We look forward to providing you with the quality health care you deserve. Our goal is to provide excellent care to our patients while respecting their valuable time. In order to keep the clinic moving smoothly we ask that you complete the new patient paperwork prior to your appointment. Also, please bring a list of your current medications, as well as your insurance card(s) and picture ID. Please arrive 30 minutes early, as this allows time for the staff to enter pertinent information before seeing the provider. Our office hours are Monday - Friday, 8 a.m. to 5p.m.. Please be sure to carefully read the enclosed Patient Responsibility Disclosure Statement. It gives you information about our office policies and procedures. This is valuable information that will enable us to provide you with quality health care. If you have any questions, please do not hesitate to contact our office at Again we thank you for choosing Baptist Medical Group Primary Care - Live Oak. Healthy Regards, The Providers and Staff of Baptist Medical Group Primary Care- LiveOak William A. Zimmern Jr., M.D. / David Kellen, M.D. Julie Baltz, MHS, PA-C / Lorena Cornwell, MSN, FNP-BC, ARNP / Mary Ellen Neal, ARNP-C 2896 GUlf Breeze Parkway, Gulf Breeze, FL / P

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6 Communication with Family Members and Friends Involved In Patient Care This form documents my request to allow family members and/or friends to be involved in relevant verbal discussions regarding my health care. By signing this form, I permit Baptist Medical Group ("BMG") staff to discuss information about me with the people listed below. This information may include diagnoses, test results, treatments, and payment information, but shall be limited to only the information that, in the professional judgment of your provider, needs to be shared. I understand that signing this form is voluntary and that I am not required to sign this form in order to receive health care. I understand that information may be released to family members or others without this form, if allowed by federal and state law. I understand that listing a person on this form does not give them the right to receive or copy my written medical records. It does not allow them to consent for health care services on my behalf. I understand that my health care provider will discuss only the information that the person involved needs to know about my care or treatment. I can update this form at any time by completing a new form and giving it to BMG staff. I understand that BMG staff will verify the identity of the people below (if not known to the staff) prior to discussing this information. I understand that this is not a Health Insurance Portability and Accountability Act {HIPAA} authorization form that would allow the people below to have access to my written Protected Health Information. Name: Phone#: Relationship: Name: Phone#: Relationship: Name: Phone#: Relationship: Name: Phone#: Relationship: Signature: Print Name: Date: Time: Relationship to Patient: o Self o Legal Representative or Guardian (proof of power of attorney or legal guardianship required) Baptist Medical Group Family Members and Friends Involved in Patient Care (08-16) FM-0430 Pg. 1 of 1 I llllll lcnt

7 William A. Zimmern Jr., M.D., David Kellen, M.D. Julie Baltz, PA-C, Lorena Cornwell, FNP-BC, ARNP, Mary Ellen Neal, ARNP-C Name Birthdate Age Date Allergies: Please list any allergies to medications or foods. Example of reactions: rash or hives, trouble breathing, nausea Name Reaction Name Reaction Medications: Include prescription and over-the-counter medications. Feel free to attach a list of medications. Name Dose Frequency rev Jun2015

8 William A. Zimmern Jr., M.D., David Kellen, M.D. Julie Baltz, PA-C, Lorena Cornwell, FNP-BC, ARNP, Mary Ellen Neal, ARNP Name Birthdate Age Date Welcome: Please complete the following health history before you see your physician. Date Last Tetanus shot Last Flu Shot Last Pneumonia Shot Shingles Shot Last Dilated Eye Exam Last Colonoscopy Last Cholesterol Test Last Bone Density Test Female Male Date of Last Mammogram Date of Last PSA Date of Last Pap smear Have you ever had an abnormal Pap smear? No Yes If yes, date: Chief complaint: (current symptoms) Past Medical History: Please mark if you have ever had: Yes Yes Yes Alcoholism Depression Respiratory Disease (e.g. COPD) Allergies (Seasonal, Environmental) Diabetes Seizure Disorder Anemia Heart Arrhythmia/Palpitations Sexually Transmitted Infection Anxiety Disorder Heart Attack or Bypass Surgery Steroid Use Arthritis Heart Disease Stomach Ulcer Asthma High Blood Pressure Stroke Birth Defects High Cholesterol Thyroid Disorder Blood Clots Kidney Disease Tobacco Use Blood Transfusion Liver Disease Other: Bone Fracture Osteoporosis Cancer: Type Reflux Please list any surgeries you have had below and the approximate dates: 1. Date: 4. Date: 2. Date: 5. Date: 3. Date: 6. Date: Family History: Please indicate the relationship of the family member who has had any of the following: (e.g. father, sister, grandparent) Who Who Who Blood Clots Diabetes Prostate Cancer Breast Cancer Heart Disease Stroke Colon Cancer Osteoporosis or hip fracture Depression Ovarian Cancer Father: Age (if Living) Age at death (if deceased) Mother: Age (if Living) Age at death (if deceased) Sibling: Age (if Living) Age at death (if deceased) Sibling: Age (if Living) Age at death (if deceased) Sibling: Age (if Living) Age at death (if deceased) Social History: Marital Status: Married Single Divorced Widowed Number of children: Tobacco Use: Never Current: # packs per day Previous: # packs per day began in year quit in year Alcohol Use: Current Previous: began in year quit in year Never Approximate number of alcoholic drinks per day per week per month Exercise: Number of sessions per week Type Caffeine : Never Yes amount per day Type Occupation: Recent Travel: None Out of State Out of Country Location: Do you have an Advanced Directive: Yes No Does this office have a copy? Yes No rev Jun2015

9 PATIENT BILL OF RIGHTS The Rights and Responsibilities of Our Patients Baptist Health Care, in order to foster better channels of communication, closer patient/hospital relationships and more efficient care, presents the following Patient Bill of Rights. Federal and State of Florida Jaw (Fla. Stat ) requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of the patients. You (or when appropriate, your designated patient representative) shau be informed of these rights and may request a copy of the full text of these laws from your health care provider or health care facility. YOU (OR WHEN APPROPRIATE, YOUR DESIGNATED REPRESENTATIVE) HA VE THE RIGHT TO: Be treated with courtesy and respect, with appreciation of your individual dignity and with protection of your need for privacy Prompt and reasonable responses to questions and requests Know the identity and professional status of the individuals providing your medical services and care Know what patient support services are available, including whether an interpreter is available (at no cost to you) if you do not speak English or experience vision, speech, hearing or mental impairments. Know what rules and regulations apply to your conduct as a patient Be provided with information about advance directives, living wills, or durable powers of attorney for health care decision making, and have your health care provider or facility comply with these directives. Be given information by your health care provider about diagnosis, planned course of treatment, alternatives, risks, benefits and prognosis and participate in the development and implementation of your treatment/ care/ discharge plan and pain management plan. Being informed of your health status and being able to request or refuse treatment that is medically necessary. Accept or refuse medical care or treatment, except as otherwise provided by law Be given, upon request, full information and necessary counseling on the availability of known financial resources for your care Know, upon request, and in advance of treatment, whether or not your health care provider or health care facility accepts the Medicare assignment rate if you are eligible for Medicare Receive, upon request, a copy of a reasonably clear and understandable itemized bill. Impartial access to medical treatment or accommodations regardless of race, national or ethnic origin, religion, handicap, or source of payment Treatment for any emergency medical condition that will deteriorate from failure to provide treatment Know if medical treatment is for purposes of experimental research and to give your consent or refusal to participate in such experimental research Express grievances regarding any violation of your rights_through the grievance procedure of your health care provider or health care facility which served you, and to the appropriate state licensing agency* Expect safe care To be asked upon admission whether you want a family member (or representative) and your physician notified of your admission, and if so, they will be promptly notified. Inform you of Patient Visitation Rights as outlined below. BAPTIST HEAL TH CARE Patient Bill of Rights FM-0034 Page 1 of 2 (03/14)

10 PATIENT VISITATION RIGHTS: Each patient (or his/her Patient Representative) will be informed of their visitation rights as follows: o o o o Patient's right to be informed of any clinically necessary or reasonable restriction or limitation that the hospital may need to place, and the reasons for such limitations. Patient's right to receive the visitors whom he/ she designates, including, but not limited to, a spouse, domestic partner (including same sex domestic partner), another family member, or a friend Patient's right to change their mind at any time about who is allowed to visit them Patient's right to not have hospital restrict, limit, or otherwise deny visitation privileges on the basis of race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation and gender identity or expression. YOU ARE RESPONSIBLE FOR: Providing your health care provider, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to your health Reporting unexpected changes in your health conditions to your health care provider Reporting to your health care provider, whether or not you understand a possible plam1ed course of action and what is expected of you Following the treatment plan recommended by the health care provider Keeping appointments and, when you are unable to do so for any reason, for notifying your health care provider of health care facility Your actions and the resultant consequences if you refuse treatment or do not follow your health provider's instructions Assuring that your financial obliga t ions of your health care are fulfilled as promptly as possible Helping to facilitate the safe delivery of care by reporting any perceived risks in your care Following health care facility rules and regulations pertaining to patient care and conduct designed for your safety and the consideration of others FILING A GRIEVANCE OR COMPLAINT: If you have any concerns about patient care and safety at Baptist Health Care, please tell your nurse, the charge nurse, or the unit manager. You may also contact our Governance, Risk and Compliance Department (GRC) at (850) Or you may contact: Florida Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL The Joint Commission Office of Quality Monitoring One Renaissance Boulevard Oakbrook Terrace, IL complaint@jointcommission.org GeneralPublic/ Complaint BAPTIST HEAL TH CARE Patient Bill of Rights FM-0034 Page 2 of 2 (03/14) - T r I )-