Welcome to University Family Healthcare, PA.

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Welcome to University Family Healthcare, PA. We re delighted that you have chosen us as your primary care providers. We work hard to earn your trust and to see that you have the best healthcare possible. Good health is the result of a partnership of providers and patients. WHAT WE EXPECT OF YOU: 1. You signed a contract with your insurance provider; should understand what your particular insurance plan covers and how services must be obtained. What local hospitals participate with your insurance? Can you go to an urgent care? Do you need referrals to see specialists? 2. We Require that you have a Complete Physical Exam with us each year, and at least one other Wellness visit. If you have a chronic condition, you may need to see us as many as four or six times per year. 3. If you are of Medicare age, the Centers for Medicare Services (CMS) require that we provide preventative care. When we ask you to have a mammogram, a colonoscopy, or a diabetic eye exam, please understand that we are required by Medicare to see that you have these services. 4. Take the medications we prescribe and follow the care plan we develop with you. There may be long-term consequences of not managing your health conditions. It is critical to follow your care plan to see its full benefits in your health. 5. Keep your appointments and arrive a few minutes early. We have a ten minute grace period for office visits, after which, we have to reschedule your appointment. Please inform us right away if you are unable to attend an appointment. WHAT YOU CAN EXPECT OF US: 1. For emergency services, a provider is available to you via phone, 24/7. You can reach our staff via phone, day or night. (941-351-2020) We also have an online portal so you can keep track of your appointments and labs, and ask questions during office hours. We do our best to see sick patients within 24 hours of the first call. Our goal is to see you promptly and give you the best care possible. 2. We will listen to you. No one knows your body like you do. We need your input to get a complete picture of your health and develop the best plan of care for you. 3. We order and monitor the results of tests and radiology, and will call you if there is cause for concern. You can always call us for results. Be aware that some results cannot be given over the phone because our providers need to explain them and help you consider treatments. 4. We continually update our skills and knowledge to provide you with the best practices in Primary Care Medicine. We regularly update our offerings to reflect state-of-the-art medical treatment, such as joint injections, stem cell treatments, and laser treatments. 5. We only prescribe medications and treatments that research shows have the best record of improving your condition. It is important that you follow through with medications that are prescribed. Our diligence and your compliance with treatment are the basis for our mutual trust. Patient signature Date

Acknowledgement of Receipt of Notice of HIPAA Regulations and Authorization for Release of Medical Records Printed Name of Patient I have read the HIPAA regulations posted on the waiting room wall at University Family Healthcare and have been offered a copy to take home with me. I give the following permissions that University Family Healthcare may: Send or call appointment reminders to my home: Y N Send or call test results of lab or X-rays to my home: Y N Send or call billing messages to my home: Y N Leave above messages at home or cell: Y N Give my spouse the above information: Y N Give the above information to:, Relationship, Relationship I authorize University Family Healthcare to send or receive records to or from the following physicians: 1. 2. 3. 4. I understand that my records and information may be shared with a specialist to whom I have been referred or in an emergency, to a physician attending me in the hospital. I understand that my medical records may contain information about but not limited to: alcohol and or drug treatment, mental health or psychiatric care and or HIV / AIDS information. I understand that if I choose to change this form in any way after it is signed, I must redo the entire form. I understand that certain records are sent by fax and I relieve University Family Healthcare and its employees or agents from any liability resulting from any mis-transmission of a fax. I understand that a photocopy of this authorization shall have the same effect as the original. Signature of Patient Date Signed Witness

Patient Name Date of Birth / / Medical Information University Family Healthcare, PA Medications: please list medications below or check this box if you do not take any medications Name Strength How do you take this medication/dosage? Social History: Please circle answers Tobacco Use: Never smoker Current Smoker: (interested in quitting? Yes No ) Former Smoker (approximate quit date: ) Alcohol Use: Never Occasional Daily Illegal Drug Use: Never Occasional Daily Caffeine Use: Never Occasional Daily Occupation: Are you under a lot of pressure at work? Yes No Home Environment: Private Home Assisted Living Other (Please describe): Is anyone hurting you at home? Yes No Medical History: Please list all chronic problems Females only: Are you pregnant, planning a pregnancy or nursing a child (circle answer)? Yes No Surgeries and Recent Hospitalizations Date Allergies: (Environmental, food, and medication) Reaction:

Patient Name: Date of Birth / / Recent Immunizations Date Names of last doctor and any current specialists Any contact information you have available for these doctors such as phone number, fax number, and/or address: Family History: Please check your answers within the table provided Father Mother Sister Brother Aunt Uncle Daughter Son Deceased High Blood Pressure Heart Disease Stroke Kidney Disease Obesity Genetic Disorder Alcoholism Depression Cancer, Specify Type: Other: I certify the above information is correct to the best of my knowledge. Signature: Printed Name: Date: / /

4 TOPICS WE SOMETIMES DO NOT HAVE TIME TO DISCUSS Mood and Overall Functioning 1. Do you feel down, depressed, or hopeless? 2. Appetite changed? Overeating or not wanting to eat? 3. Sleep patterns changed? Too sleepy or unable to sleep? 4. Trouble concentrating? Hard to read or watch TV? If you answered yes, we can discuss treatment options that may help you feel better, sleep better, and be more alert. Exercise Do you regularly do any form of exercising? If you do not, we should discuss ways to increase your mobility. If you do, there may be opportunities to safely increase what you are doing. Balance and Falls Have you fallen in the last 12 months? Yes No Do you feel unsafe walking or changing position? Yes No Do you frequently lose your balance or feel dizzy? Yes No If you do, we can discuss things to help you be safe and prevent falls. Bladder Control Are you... Going too Frequently? Yes No Unable to control the urge? Yes No Painful urination? Yes No

Patient Name: Date of Birth Address: Phone: Cell: Screenings and Medical Services in the last year Please check the boxes for services you have had in the last 12 months. (Approximate dates will do but we need doctors names!) Annual Eye Exam (with Glaucoma Screening): date Colonoscopy: date and doctor Mammogram: date and doctor DEXA Bone Density Scan: date Falls or Fractures in the last year? If you have Diabetes, have you had: A Diabetic retinal eye exam? A Cholesterol test? A prescription for a blood pressure medication? An A1C test (blood test) When and where? What specialists have you seen in the last year?

APPOINTMENT POLICY Increases in population and recent legislation have created an increased demand for the services of primary care providers. Further, Medicare and other insurers are placing greater demands on primary care physicians, which require that we see patients more often. Making the best use of our appointment time with patients is increasingly critical. We have a significant waiting list of patients who wish to join our practice and be seen for both preventative care and illnesses. Our office operates by APPOINTMENTS ONLY. Effective January, 2003, any person who fails to keep an appointment, set by this office at a patient s request, may be charged a $50.00 MISSED APPOINTMENT FEE. If you are unable to keep your appointment, you must notify this office PRIOR TO YOUR SCHEDULED APPOINTMENT and the $50.00 fee will be waived. We will gladly set a new appointment at that time if you desire one. If we are notified in advance, another patient can be scheduled during that appointment time. Please be courteous. MISSED APPOINTMENTS We do not charge missed appointment fees for normal fifteen minute appointments unless there have been repeated no-shows. WE DO CHARGE no-show fees for all thirty minute appointments, such as Complete Physical Exams (CPEs) surgeries, or other special procedures. I you do not come for a 30 minute appointment, you have just wasted the time that could have been used by two other patients. ARRIVING LATE FOR APPOINTMENTS We make every effort to see our patients at their scheduled appointment time. It is our policy that if you are more than 10 minutes later for an appointment, you will be asked to reschedule. We understand that there may be good reasons for patients being late, but we cannot ask our other patients to wait for extended times or have our physicians sit idle while waiting to accommodate late patients. ACKNOWLEDGEMENT Patient signature Date

University Family Healthcare, PA 2415 University Parkway, Suite 111, Sarasota FL 34243 ph (941)351-2020 fax (941)3601362 MEDICARE PATIENTS MEDICARE NUMBER: MEDICARE DISCLAIMER I FULLY UNDERSTAND AND AGREE that if MEDICARE SHOULD DENY PAYMENT for ANY NONAPPROVED SERVICE RENDERED, that I WILL BE FINANCIALLY RESPONSIBLE for ANY REMAINING BALANCE except for that portion that is designated to be assignment by Medicare. MEDICARE PATIENT S SIGNATURE I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO: UNIVERSITY FAMILY HEALTHCARE, P.A. for any and all claims submitted to a third party due to the practice of medicine by Dr. LOREN CARLSON (My Physician) and/ or his employees AND I ALSO REALIZE THAT I WILL BE FINANCIALLY RESPONSIBLE TO PAY IN FULL FOR ANY CHARGES NOT COVERED BY MY INSURANCE PLAN. I HEREBY AUTHORIZE THE AUTOMATIC RELEASE OF MEDICAL INFORMATION TO: MY INSURANCE COMPANY, MY PHYSICIAN, AND ANY PHYSICIAN TO WHOM I MAY BE REFERRED by Dr. Carlson and/or his designated employees. SIGNATURE: ALL PATIENTS or GUARDIANS MUST SIGN HERE ACKNOWLEDGEMENT AND CONSENT TO TREAT: I consent to any or all treatment as deemed necessary or desirable for the care of myself, the patient, or my minor child or dependant, named above, including but not restricted to whatever drugs, performance of surgical procedures, laboratory testing, Xrays or other studies or procedures may be used or recommended by Dr. Loren or Brian Carlson, Dr. Workman and/or their Nurse Practitioners, Physician s Assistants, qualified medical assistants, or other designate. (If the patient is a minor or a dependant, Guardian must sign below) ALL PATIENTS or GUARDIANS MUST sign here: DATE: Circle relationship to PATIENT: SELF PARENT GUARDIAN

HIPAA AUTHORIZATION FOR RELEASE OF PATIENT RECORDS I, Print Patient Name Date of birth SS Number hereby authorize University Family Healthcare PA to RELEASE RECEIVE my medical health records, including a copy of my entire health record, all records of my care and treatment including psychiatric, drug information, HIV/AIDS status, treatment and testing, emergency room records, nursing notes, laboratory and X-ray results, pathology reports, all consent forms and a copy of my bill for services. TO: FROM: Physician Healthcare Entity Name: Address City, State, and Zip If any of the information includes psychiatric or drug abuse information, this release will serve as my written release of that information. I understand that a separate release is required for the transfer of psychotherapy notes. I understand that I may wish to refuse to grant consent for psychiatric or Drug abuse information unless disclosure is necessary for treatment or required by law. Records requested: [ ] ALL or [ ] specifically: [ ] History and Physical [ ] Lab and Xray [ ] Consultation reports [ ] Physical therapy [ ] Immunizations [ ] Other: This authorization is valid unless revoked by me in writing and properly presented to the records office of the provider from whom the records are requested. I may inspect any information released under this authorization. I understand that if the person or entity receiving the information is not a healthcare provider or health insurance plan covered by the federal privacy act, the information described above may be redisclosed and is no longer covered by those regulations. I understand that Florida law allows a copy charge of $1.00 each page for the first 25 pages and $0.25 for every page 26 and above. 20 Patient signature/ or Printed Patient Name if Minor or Ward Date signed Printed Name of Guardian/ Parent or Representative and Title Signature

WEB PORTAL ACCESS TO OUR PATIENTS: Would you like to be able to check on your next appointment date and time? Would you like to be able to look up your last A1C or cholesterol level without having to call the office? Would you like to be able to print out a copy of your current meds to take with you to another doctor s office or surgery center? You can do all of that and more when you sign up for access to our Patient Portal! Our renewed web site, www.univfamhc.com, will be functional beginning January 1, 2015, providing information and access to our present and incoming patients. You can learn about our practice and providers, discover the services we provide, and even download new-patient paperwork and educational information. In addition, you ll be able to access our patient portal through the web site. It will help you keep track of your data and learn more about staying healthy. How do you get access? The patient portal requires that you have an e-mail address and that you sign up with us for access. Anyone at the front desk can help you create a patient portal account. Then you can access the portal and your health information from your home computer or other electronic device. Just go to our web site, click the link, and put in your user e-mail and the password we give you. You can also go directly to the portal by putting this address into your internet browser: https://drconnect.com/ufh/. My Name My e-mail address My Initial Password

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