Jeffrey I. Mechanick, M.D. Elise M. Brett, PATIENT INFORMATION Name:_<) € FREY Ec. EPS TEIN Social Security # street:_ 4 Eas ae abl S- Date of Birth: An. 20 i City: NY State: WY) Zip:/002Z\ Sex: @ ¥ Marital Status: ©M D W Partnered Spouse’s Name: viome Phone: SNR — Cell Phone: Occupation: BANIKER. Employer: EINLAN Q AL TRUST Business — lr nc le Fax: Address Primary Care Physician: Phone: _ Emergency Contact: Relationship: Le) iD ; . Home Phone: Business Phone:___~ Referred by: DX. EVA An DERSS EN Phone:_ Heacih PLAN RIMARY INSURANCE 4 roicy + I _ cro Doral E epren Insurance Co:_( 4A) JTED pte Ate CMH CALE Relationship to Patient SELLE Address: “PO BO Yate RO o Date irth: a City: ATLANTA tate: GA Zip: 3034+- SS# OF OO SECONDARY INSURANCE Policy: Group # Insured _ _ Insurance Co: Relationship to Patient__ _ Address: Date of Birth City: State Zip: SS#: _ Lhereby authorize Jeffrey 1. Mechanick, M.D. and Elise M. Brett, M.D. to furnish information concerning my illness and treatment to my insurance carriers. I authorize payment of medical benefits to Jeffrey 1. Mechanick, MD. and Elise M. Brett, M.D. I understand that | am responsible for any part of the charges that are not covered by medical coverage. Signed:____ Date: (Parent or Guardian if patient is a minor) Sel td AJJJITOPATATAIO1 dota ISR PTA OW WTNHHIAW AFN449P:WOs4 BC:CT TIA@-AT-19N EFTA00310781

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SAMPLE HIPAA PRIVACY NOTICE 1S NOTICE DESCRIBES HOW MEDICAL INFORMATION asOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. INTRODUCTION jinsect the name of the Practice} understands that your medical uvformation ss private and confidential Further, we are required by law to mamiain the privacy of “protected health information.” “Protected health information” meludes any individually identifiable information that we obtain from you or others that relates to your past, present oF future physical or mental healih, the health care you have received, of payment for your health care As required by law, this notice provides you with information about your rights and our legal dunes and privacy practices with respect 10 the powacy of protected health information. This notice also discusses the uses and disclosures we will make of your protected health information Ve must comply with the provisions of this notice as currently an effect, although we reserve the right to change the terms of this notice from ume to time and to make the rewssed notice effective for all protected health information we maintain You can always request a written copy of our most current privacy notice from the Practice’s Privacy Officer or you can access Ht On Our website ot (Note: The referenct to the website should be included only if the Practice has 2 ite.) MITTEO AND DISCLOSURES We can use of disclose your protected health information for purooses of Irentment, payment und health care operations. For cach of these culegories of uses and disclosures, we have provided a description and an cxamp-e below However, notevery particular use or disclosure in every category ‘wall be listed : Treqiment means the provision, coordination of management of your health care, including consultations between health care providers regarding your care and referrals for health care from SAMPLE ACKNOWLEDGMENT one health carc provider to anuther. For example, a doctor ircating for 3 broken leg may need to know if you have diabetes bec diabetes may slow the healing process. In addition, the doctor may! to contact a physical theraprst to create the exercise eginyen approp 10 your care ° Payment means the activities we undertake ty obtain rermbursemer the health care provided to you, including billing. collections, ¢! management, determinations of chigibility and coverage and utrlrzi review activities. For example, prior to providing health care serv we may need to provide information to your Third Party Payor a your medical condition to determmnc whether the proposed cour treatment will be covered. When we subsequently bill the Thitd | Payor for the services rendered to you, we can provide (he Therd Payor with information regarding your carc if necessary to © payment. Federal or State law may require us fo obtyin a written re from you prior to disclosing certain specially protected & information for payment purposes, and we will ask you 10 sign a r¢ when necessaty under applicable law ° Health care operations means the support functions of our pri related to treatment and poyment, such 9S quality assurance act" case management, receiving and responding (0 patent commen! complaints. physician reviews, compliance programs. audits, bu planning, development, management and adminisirative actsitie example, we may use your protected health information to cealu: performance of our staff when caring for you. We may also co health information about many pationts to deerde what ad! services we should offer, whut scrvices ure not nevded, and w certain new treatments are effective fn addition, we may 1 information that identifies you from your potent information § others can use the de-sdentified information to study health ca health care delivery without learning who you arc CTED HE ND__ DISCLOSURE: P IN ATION In addition to using and disclosing your raformation for treé payment and health care operations, we may use your protected health infor in the following ways: I, , acknowledge that I have been provided with a copy of [Insert nai Practice]’s privacy notice. Date. , 200 —_— i [Note: As discussed in the Step 7 of the Privacy Guide, the privacy regulations require health care provid with direct treatment relationships to make a good faith effort to obtain an individual’s writteo acknowledgement of his/her receipt of the Practice’s ept in emergencies). This sample acknowledgmen 279853 2 £-2'd 62222 TSeT2ATS:O1 privacy notice at the time of the first service delivery t is included for tbe Practice’s use for this purpose.| © 2002 - Garfunkel, Wild & Travis, PC 4£te TE8 ete OW WOINGHDSW ASedsSL W044 ES:ST TI@2-8t-190 EFTA00310782

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Date. HEALTH HISTORY ~ please check symptoms you currently have or have had since your last visit here. General ___ Unexplained weight loss / gain ___ Unexplained fatigue / weakness ___ Fall asleep during day when sitting ____ Fever, chills ___ No problems Skin ___ New or change in mole __. Rash / itching ___ No problems Breast ___ Breast lump / pain / nipple discharge ___No problems Ears/Nose/Throat ___ Nosebleeds, trouble swallowing __. Frequent sore throat, hoarseness __ Hearing loss / ringing in ears ___ No problems Eyes ___ Change in vision / eye pain / redness ___ No problems Cardiovascular ___ Chest pain / discomfort __ Palpitations (fast or irregular heartbeat) ___No problems Respiratory ____ Cough / wheeze ____ Loud snoring / altered breathing during sleep ____ Short of breath with exertion ___ No problems Gastrointestinal ___ Heartburn / reflux / indigestion ____ Blood or change in bowel movement ____ Constipation ___No problems Genitourinary ___ Leaking urine ____ Blood in urine ___ Nighttime urination or increased frequency ____ Discharge: penis or vagina ____ Concern with sexual function ___ No problems Musculoskeletal ___ Neck pain ___ Back pain ____ Muscle / joint pain ___No problems Endocrine __ Heat or cold sensitivity ___ No problems Hematologic/Lymphatic ___ Swollen glands ___. Easy bruising ___ No problems Neurological ___ Headache Memory loss Fainting Dizziness Numbness / tingling Unsteady gait Frequent falls ___ No problems LLL Allergic/immune ___ Hay fever / allergies ___ Frequent infections ___ No problems Psychiatric ___ Anxiety / stress / irritability ___ Sleep problem ___ Lack of concentration ___No problems Women only ____ Pre-menstrual symptoms (bloating cramps, irritability) ___ Problem with menstrual periods _— Hot flashes / night sweats ___ No problems Men only ____ Errection problems Lump in testicle Prostate cancer Enlarged Prostate No Problems To the best of my knowledge, the above information is complete and correct. I understand that is my responsibility to inform my doctor if I, or my minor child ever have a change in health. J assign directly to Dr. Elise M. Brett and Dr. Jeffrey I. Mechanick at 1192 Park Avenue, all insurances rendered. I understand I am financially responsible for all charges, I also authorize the disclosure of medical records to other providers for the management of my care in the extent permitted by law. I request payment to be made directly to Dr. Elise M. Brett and Dr. Jeffrey I. Mechanick at 1192 Park Avenue on my behalf. Signature re Print E-f"d 62122 TS2TeTe:oL DOB 2£T2 TE8 ate QW WOINKHIAW AAN444Pr:wWo44 AGICT TIAP-AT-17N EFTA00310783