JR., M.D. TELEPHONE 626 FIRST STREET J. STEPHEN M.D. (478) MACON, GEORGIA JEFFERY C. HINSON, JR., M.D. FAX (478)

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1 Eye Physicians' Association M.D. P.O. BOX 956 JR., M.D. TELEPHONE 626 FIRST STREET J. STEPHEN M.D. (478) MACON, GEORGIA JEFFERY C. HINSON, JR., M.D. FAX HOMER S. M.D., EMERITUS (478) fill out the following paperwork - By Mail - Drop it any -OR it with you at appointment it to our office 1) Paperwork Patient Information Sheet - 2pgs - Please fill date it at bottom of the second page. be sure to sign & 2) New Patient Medical History Questionnaire fill out history medications, the form and Form - 1pg Please medicines and vitamins.. iust circle "Brouaht b Own List" it for your chart. If you don't and write your name and pharmacy Medications." 4) Authorization to Disclose Health Information - 1 authorization you will a family member or friend who we can any of your care OR in case of an emergency. 5) - 1 Please sign this form to our Notice Privacy

2 INFORMATION LJ.LJ1o.UJLi PRINT) Appointment.I I Your is Dr wear: NAME ~~~------~=_~ ~ (Last) (Middle) / OSingle OMan'jed 0 all that apply): or Alaska Native or African American or Other or Latino DNot or Latino HAVE EVER BEEN TREATED AT OFFICE? ONo Soc. (1\umber and Street) (City) (State) (Zip) Phone '--_/ Would you like to your EPPA Statements through your One) Yes No Patient's Work Phone -'---_'-... DPARENTOR DPARENT If Patient a Minor: PARENT Date / / PARENT._

3 RESPONSIBLE FOR PAYMENT " ~~~~...~~...~~~~~~~~~~~~~~~~~~~~~~~_.. Phone (First) (Middle) (State) Refen"ed o (Physician Name & PRIMARY INSURANCE: INFORl\IATION (J.D. (Social Sec. Number) SECO:"lDARY INSURANCE: Number) (Social Sec. (Date FINANCIAL AGREEM ENT AND AUTHORIZATION FOR TREATMENT: I Authorize any holder of medical or other information about me to release to my insurance company or to the Social Administration or its intermediaries or carrier any information needed for this or related Medicare claim. of the and request payment of Medical insumnce Benefits either to to the part who accepts or Benefits I also request that payment under the Medical Insurance be made services furnished to me that for not covered A copy of this authorization be val id as the Date Signed

4 of Referring Physician Date of Eye Exam: Do currently have problems in areas? explain provided. Constitutional Systems Eyes I No I 1\0

5 Yes / Acuity Yes / Yes/ Nose, Mouth, Throat Cardiovascular Gastrointestinal

6 I Neurological I I Psychiatric I I Endocrine I Hemato oglca. IlL -,ympl h abc. Blood Lymph Nodes Swelling i\llerglc an d I mmuno OglC Head Allergy Symptoms Seasonal Allergies Hay Fever Symptoms Di\ILY MEDICi\ TIONS Do you take any Daily Medication? If yes. Please list them on the Medication and Allergy Form. i\llergies Do you have any allergies? If yes. Please list them on the l'v1edication and Allergy Form. Pi\ST HISTORY List All Major Illnesses and Injuries: List Any Surgeries And Hospitalizations You have had:

7 SOCIAL HISTORY Job (Occupation) Do you Drive? Do you have a problem with Night Vision? Have you ever tried to wear Contacts? Do you Currently Wear Glasses? If Yes, How long have you had the current pair? Do you Drink Alcohol? IfYes, How many glasses a day? Do you Smoke? Ifyes, How many packs a day? Have you ever been in contact with a person who had a sexually transmitted disease? Family and Social History: Do any medical or eye diseases run in your family? If YES, Please note relationship to patient. D Glaucoma D Diabetes D High blood pressure D Macular Degeneration D Other: Pa tient' s Signatu re: Date: Physicia n 's Signa tu re : Date:

8 Medication and Allergy Form PATIENT NAME: DOB: PHARMACY NAME AND ADDRESS: Circle One: BROUGHT OWN LIST OR NO DAILY MEDICATIONS OR Please list all your daily medications: Prescription, Non-Prescription, HerbaL Vitamins, etc. DOSAGE: HOW OFTEN: DOSAGE: DOSAGE: HOW OFTEN: HOW OFTEN: DOSAGE: HOW OFTEN: SAG E: DOSAGE: DOSAGE: HOW OFTEN : HOW OFTEN: HOW OFTEN: DOSAGE: HOW OFTEN: DOSAGE: 00SAGE: DOSAGE: HOW OFTEN: HOW OFTEN: HOW OFTEN: DOSAGE: HOW OFTEN: DOSAGE: HOW OFTEN: DOSAGE: DOSAGE: HOW OFTEN: HOW OFTEN: Please list any ALLERGIES you have Reaction: Reaction: Reaction: Reaction: Reaction: Reaction: Patient Signature: Date:

9 Eye Physicians' Professional Association P. Box 956 Fi Street GA lephone: (478) : (478) James I. Suit, M.D. William H. JR., M.D. J. en Ellis, M C. Hinson, J M.D. Physician Professional information to disclose billing. sname Signature Released Name Relationship Telephone Name Relationship

10 Eye Physicians' Professional Association P.o. Box First Street Macon, GA Telephone: (478) Fax: (478) James I. Suit, M.D. William H. Jarrard, JR., M.D. J. Stephen Ellis, M.D. Jeffery C. Hinson, JR., M.D. WRITTEN ACKNOWLEDGMENT FORM I hereby acknowledge receipt of Eye Physicians' Professional Association's Notice of Privacy Practices. Name : (Please Print) Signature: Date: OR (for Minor or Lega! Guardian) I am a parent or legal guardian of. I hereby acknowledge receipt of (Patient Name) Eye Physicians' Professional Association's Notice of Privacy Practices with respect to the patient. Name : (Please Print) Relationship to Patient: o Parent o Legal Guardian Signature: Date:

11 Eye Physicians' Professional Association JAMES I. SUIT, M.D. P.O. BOX 956 WILLIAM H. M.D. TELEPHONE 626 FIRST STREET J. STEPHEN ELLIS, M.D MACON, GEORGIA JEFFERY C. M.D. FAX HOMER S. NELSON, M.D., EMERITUS NOTICE OF PRlVACY PRACTICES THIS NOTICE DESCRlBES HOW MEDICAL fkforma TION ABOUT AND HOW GET TO THIS PLEASE READ IT CAREFULLY us In Health Insurance Portability & Accountability Act 1996 ("HIPPA") is a Federal medical and other individually identifiable health used or U''''vlV'''-U whether on or orally are properly This the right to understand and how your health ("PHI") is penalties As by HIPP A, we prepared explanation of how we are to the privacy health information and how we disclose personal only Treatment means providing, coordination, or one or more providers. An example of health care and related services would include you to a activities as activities, for example for your visit and/or verifying "rh,'a,'" prior to a Care assessments and customer include analysis, practice may also disclose your PHI we shall our best to assure law enl:0f(~en1en reasons We individually information. de-identified health information removing all to appointment reminders or to other out" about

12 NOTICE PRlVACY CONTINUED of PHI will made pursuant to us a of psychotherapy notes for marketing purposes, treatment a of under not described in this 10 to honor and abide that v"rritten extent that we have already You have the following rights with to your The to request on certain uses and disclosures of including those related to disclosures family close or any person identified you. are, not request restriction except in limited circumstances which we shall explain you If we do to restriction, we must abide it YOll writing to to to confidential communication of Information by alternative means or at locations. to copy your right to amend your to receive an accounting of disclosures of to obtain a of from lis upon advised if your unprotected PHI is intentionally or unintentionally If You have paid full, you PHI solely to those we accommodate your we are required law to We are required by your Protected Information to provide you of out with to September 2013 and it is out intention to abide by terms the Regulations currently reserve the to change terms our Notice Privacy and make new notice provision effective for all PHI that we maintain,. will post and YOll may request a written copy the revised Notice from our recourse if you feel that your protections been violated by our You have to the office and with Health and We will not you for filing a complaint. to contact Officer for more 10 or