O to-laryn goyo gy Associates ENT & Face, Head & Neck Plastic SUrgery www. olola r; 'II. com

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Naomi Owen
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I AUTHORIZE PAYMENT OF MEICAL BENEFITS IRECTLY TO THE PHYSICIAN FOR SERVICES PROVIE. I AUTHORIZE THE RELEASE OF THE ABOVE PATIENT'S MEICAL RECORS TO THE PHYSICIANS INVOLVE IN THE CARE VIA FAX OR MAIL.

1 O to-laryn goyo gy Associates ENT & Face, Head & Neck Plastic SUrgery www. olola r; 'II. com M/R RELEASE, MESSAGES, FINANCIAL POLICY I AUTHORIZE THE RELEASE OF THE ABOVE PATIENT'S MEICAL RECORS TO THE INSURANCE CARRIER(S) VIA FAX OR MAIL. I AUTHORIZE PAYMENT OF MEICAL BENEFITS IRECTLY TO THE PHYSICIAN FOR SERVICES PROVIE. I AUTHORIZE THE RELEASE OF THE ABOVE PATIENT'S MEICAL RECORS TO THE PHYSICIANS INVOLVE IN THE CARE VIA FAX OR MAIL. I FURTHER AUTHORIZE OTOLARYNOLOGY ASSOCIATES TO LEAVE THE RESULTS OF THE ABOVE PATIENT'S EXAMINATIONS AN TESTS, INCLUING MESSAGES, APPOINTMENT REMINERS, LABORATORY TESTS AN X-RAYS ON THE ANSWERING MACHINENOIC AT THE PHONE NUMBER PROVIE. I AM RESPONSIBLE FOR ALL FINANCIAL OBLIGATIONS OF THE HEALTH SERVICES FOR THE ABOVE PATIENT, AN FOR REIMBURSEMENT AN PAYMENT OF CLAIMS FROM THE INSURANCE COMPANY. I UNERSTAN THE OCTOR'S CHARGE MAY EXCEE THE INSURANCE CARRIER'S PAYMENT AN IF THE CHARGE IS MORE THAN SUCH PAYMENT, I WILL BE RESPONSIBLE FOR THE IFFERENCE IF FOR ANY REASON THE ABOVE PATIENT'S ACCOUNT SHOUL BECOME ELINQUENT, I AGREE TO PAY FOR ALL COLLECTION, ATTORNEY FEES, AN COURT COSTS. ACKNOWLEGEMENT OF RECEIPT OF PRIVACY NOTICE By signing below, I acknowledge that I have received Otolaryngology Associates, LLC* Notice of Privacy Practices ("Notice"). * This includes Whisper Hearing Centers, Biggerstaff & Associates and Balance Point PRESCRIPTION MEICATION HISTORY CONSENT I agree that Otolaryngology Associates, LLC may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payers for treatment purposes. Signature (Patient or Authorized Representative) Printed (Patient or Authorized Representative) Printed Patient Name BC1

M I F (CIRCLE ONE) ----- ------ ------ ------- EMAIL ARESS (FOR PATIENT PORTAL ACCESS) RACE: 0 Asian 0 Native Hawaiian 0 Other Pacific Islander 0 Black/African American 0 American Indian/Alaska

2 OTOLARYNGOLOGY ASSOCIATES PHYSICIAN ~F~O~R~O~FF~IC~E~U~SE~O~N~L~ PATIENT NAME PATIENT ARESS INITIAL (MILE) CITY STATE ZIP ~==~ ===~ PRIMARY ) ~ SECONARY ( ) ~ OTHER ( ) SOCIAL SECURITY NUMBER 0 SINGLE 0 MARRIE0 SEPARATE 0 IVORCE 0WIOWEC ATE OF BIRTH I AGE SEX: M I F (CIRCLE ONE) ARESS (FOR PATIENT PORTAL ACCESS) RACE: 0 Asian 0 Native Hawaiian 0 Other Pacific Islander 0 Black/African American 0 American Indian/Alaska Native 0 White 0 More than one race 0 Unreported/Refused to report ETHNICITY: 0 Hispanic/Latino 0 Not Hispanic/Not Latino 0 Unreported/Refused to report LANGUAGE: SPOUSE CHIL'S MOTHER/GUARIAN CHIL'S FATHER/GUARIAN (LAsn ARESS IF IFFERENT THAN PATIENT'S REFERRING M.. FAMILY M.. (FIRsT) (s.s.#) cs.s #) (s.s.#) (ATE OF BIRTH) I I (ATE OF BIRTH) I (ATe OF BIRTH) NOTIFY IN CASE OF EMERGENCY =="""'"'==="""'=---PHONE (RELATIONSHIP) PHARMACY LOCATION PHONE REASON FOR BEING SEEN TOAY ANY HEARING CONCERNS: 0 YES 0 NO O YOU HAVE ANY IZZINESS: 0 YES 0 NO (ARESS) (ARESS) ANY PROBLEMS WITH ALLERGIES: 0 YES 0 NO.,.THIS SECTION MUST BE COMPLETE IN FULL, EVEN IF CAR IS COPIE** PRIMARY INSURANCE CO_ Employer: I# GROUP# POLICY HOLER'S ATE OF BIRTH I I POLICY HOLER'S NAME PATIENT 0 SPOUSE 0 FATHER 0 MOTHER 0 STEPPAREN1 SECONARY INSURANCE CO~ ; Employer: I# GROUP# POLICY HOLER'S ATE OF BIRTH POLICY HOLER'S NAME PATIENT 0 SPOUSE 0 FATHER 0 MOTHER 0 STEPPAREN1 BCS

0 Allergies 0 Epilepsy 0 Asthma 0 Eye isease 0 Bleeding Tendencies 0 Gastroesophageal 0 Bronchitis Reflux 0 Cancer - Tumors 0 Glaucoma Type 0 Gout 0 Chicken Pox 0 Heart isease 0 epression/anxiety 0

3 HEALTH HISTORY ATA SHEET (Complete this form In Ink) Please Pri nt O to-laryn got'o gy Associates ENT & Face, Head & Neck Plastic Surgery www. otolat)ltt. com Provider HEIGHT WEIGHT FAMILY PHYSICIAN CHECK (-i) BELOW ANY ILLNESSES YOU HAVE HA. 0 Allergies 0 Epilepsy 0 Asthma 0 Eye isease 0 Bleeding Tendencies 0 Gastroesophageal 0 Bronchitis Reflux 0 Cancer - Tumors 0 Glaucoma Type 0 Gout 0 Chicken Pox 0 Heart isease 0 epression/anxiety 0 Hemorrhoids 0 iabetes 0 Hepatitis 0 iverticulosis Type. _ 0 Eczema 0 Hernia 0 Emphysema 0 High Blood Pressure 0 Irritable Bowel Syndrome 0 Kidney isease 0 Liver isease 0 Measles 0 Mumps 0 Mononucleosis 0 Neuritis 0 Obstructive Sleep Apnea 0 Osteoarthritis 0 Pancreatitis 0 Polio 0 Rheumatic Fever 0 Sexually Transmitted isease 0 Stroke 0 Thyroid 0 Tuberculosis 0 Ulcers (Leg) 0 Ulcers (uodenal) List Other Illnesses MEICATIONS Are you currently taking any medications? Please Print List Below Yes 0 No Are you currently taking any vitamins, herbal supplements or over the counter medications? 0 Yes 0 No Please Print List Below OPERATIONS Please Print TYPE MONTH - YEAR NAME OF HOSPITAL FRACTURES Please Print ALLERGIES 0 Penicillin 0 Sulfa 0 Codeine 0 emerol CHECK (.J) BELOW IF YOU ARE ALLERGIC TO: Aspirin Please Print Other rug Allergies Not Listed On The Left Morphine Latex 0 NO ALLERGIES BC3

O to-laryn golb gy Associates ENT & Face, Head & Neck Plastic Surgery www.otolti'j'ii.com FAMILY HEALTH HISTORY ATA SHEET Physician: FAMILY HISTORY {CHECK.

..-- AIIergies Bleeding Tendencies Blood isease Bone isease Cancer or Tumors Cardiovascular isease {Heart) Congenital eformities iabetes Gastrointestinal isease Kidney isease Mental isease Pulmonary

4 O to-laryn golb gy Associates ENT & Face, Head & Neck Plastic Surgery FAMILY HEALTH HISTORY ATA SHEET Physician: FAMILY HISTORY {CHECK.J BELOW IF ANY OF THE CONITIONS HAVE OCCURRE ON EITHE"'"R_S I E_O F P_A--T--IE,.,... N--T-- 'S F,..,. A.,..M-- IL.,..Y),...-- AIIergies Bleeding Tendencies Blood isease Bone isease Cancer or Tumors Cardiovascular isease {Heart) Congenital eformities iabetes Gastrointestinal isease Kidney isease Mental isease Pulmonary isease Thyroid isease Tuberculosis List Any Other Illnesses o you have a pacemaker? No Are you HIV positive? Yes No Smoking Status: 0 Never Smoker Current every day smoker Current someday smoker 0 Former smoker Heavy tobacco smoker Light tobacco smoker 0 Smoker, current status unknown o you use alcohol? 0 Unknown if ever smoked Start : Quit : No Amount per day o you use illegal substances? Have you or anyone in your family had problems with anesthesia? No No Attend ay Care: No ROS (CHECK.J BOX IF YOU HAVE HA THESE SYMPTOMS IN THE PAST YEAR) Constitutional: Weight Loss Fatigue Fever Eyes: 0 ouble or Blurry Vision 0 Blindness Red Eyes Cardiovascular: Chest Pain 0 Shortness of Breath on Exertion Cyanosis 0 Ankle Edema Frequent Urination at Night Respiratory: 0 Shortness of Breath 0 Cough Coughing Blood 0 Wheezing 0 Use Oxygen Gl: 0 ifficulty Swallowing 0 Nausea Vomiting 0 Vomiting Blood 0 iarrhea Indigestion GU: Blood in Urine Burning Urinary Infections Musculoskeletal: Muscle Weakness Pain Tenderness Joint Swelling Skin: 0 Rash Lumps 0 Sores 0 Loss of Hair Neuro: Headaches Blackouts Paralysis Numbness Head Injury Psychiatric: 0 Nervousness Anxiety 0 Memory Loss 0 Sleep isturbances Hematology/Lymphatic: Anemia Bruise Easy Enlarged Lymph Nodes Endocrine: Excessive Thirst 0 Intolerance of Heat or Cold High Blood Sugar Allergy/Immunologic: Inhalant or Food Allergy Itchy 0 Frequent Infections Have you ever taken Cortisone? No VACCINATIONS (Please select the ones you have had) Orally Injection Mumps 0 Tetanus 0 Rubella lnfluenza If yes, Month Year Print Please Month ;... Year Month Year Pneumococcal Hepatitis BC2

Health Information (Protected Health Information would include your name, diagnoses, test results, dates of service as described in the Notice of Privacy Practices).

5 O to.jaryn gofo gy Associates ENT & Face, Head & Neck PJaslic Surgery www. otolary n. com OA Physician: Contact Information for Protected Health Information I, (patient's name) OB: request that the following methods be adhered to for the disclosure of my Protected Health Information (Protected Health Information would include your name, diagnoses, test results, dates of service as described in the Notice of Privacy Practices). Please check any or all of the three options that apply: Option A: 0 OA may disclose information by telephone to people designated below. This document does not allow the people listed below to receive medical records. For OA to allow non patients to receive medical records, a release of Information form must be signed by the patient or their power of attorney. Name Phone Number Relationship Option 8 : 0 You may leave Protected Health Information on my answering machine/voic at this phone number:...l ' Option C: O Other ocument is good for one year from date signed. Patient's Printed Name Social Security Number Patient's Signature (or Guardian if a minor) Witness (optional) BC6

Summer Youth Musical Theatre Workshop Application Form

Office Use Only: Date Rec d Full payment Rec d 2016 Summer Youth Musical Theatre Workshop Application Form PLEASE READ THIS APPLICATION CAREFULLY Please complete the entire application and mail it along