1111111111111111111111111CoxHealth

Springfield, MORegional Services

PATIENT REGISTRATION FORM

Patient Sticker

*FAC*

Patient's Legal Name: SSN#: Date: _

Address: City/State/Zip: _

Birth Date: __ ,__ ,___ Sex: 0 Male 0 Female Marital Status: o Single 0 Married 0 Divorced 0 Widowed

o Spanish 0 Other: _

o White 0 Native Hawaiian or Other Pacific Islander

Ethnicity: 0 Hispanic or Latino 0 Not Hispanic or Latino Language: 0 English

Race: 0 American Indian or Alaska Native 0 Asian 0 Black or African American

Please complete all fields and check the phone number you would prefer messages to be left regarding your health care.

o Home Phone: _ o Cell Phone: _ o Email: _

Name of Patient's Employer: Work Phone: _

Patient's Employer Address: City/State/Zip: _

Spouse Name: Spouse Work/Cell Phone: _

Emergency Contact and Relationship: _ Phone: _

INSURANCE INFORMATION

Is this visit related to an accident? 0 Yes 0 No If yes, please specify if AUTO or Other: _

Is this visit related to a work related accident? 0 Yes 0 No If yes, please provide Workman's Comp Ins.

+ PRIMARY INS: POLICY HOLDER NAME: _

Policy Holder's Employer: Policy Holder SSN#: _

Group #: Policy/ID #: Policy Holder DaB: _

Patient's Relationship to Policy Holder: 0 Self 0 Spouse 0 Child 0 Other (explain) _

+ SECONDARY INS: POLICY HOLDER NAME:

Policy Holder's Employer: Policy Holder SSN#: _

Group#: _ Policy/lD #: Policy Holder DaB: _

Patient's Relationship to Policy Holder: 0 Self 0 Spouse 0 Child 0 Other (explain) _

PARENT OR GUARDIAN INFORMATIONComplete for Patients who are Minors or Patients with Guardians ONLY

+ RELATIONSHIP: 0 Father 0 Mother 0 Guardian

Name: (First, MI, Last) SSN#: Date of Birth: _

Name: (First, MI, Last) SSN#: Date of Birth: _

Address: City/State/Zip: Home Phone: _

Employer: Work Phone: _. Cell Phone: _

+ RELATIONSHIP: 0 Father 0 Mother 0 Guardian

Address: City/State/Zip: Home Phone: _

Employer: Work Phone: Cell Phone: _

o Physician (Recommendation/Referral) (AP) 0 Website - CoxHealth (WS) D Wal-mart Clinic (WC) 0 Social Media (SM) 0 Email (EM)o Emergency Room/Urgent Care (UC) 0 Heathsense Magazine (HM) 0 Mailer/Postcard (MP) 0 Newspaper (PA) 0 Other (O'I)o Health Plan Directory/lnsurance Company (HP) 0 Billboard/Sign (BS) 0 Online Search (OS) 0 Radio (RT)o Friend/Relative/Neighbor (FR) 0 Cox INFO Line (IL) 0 Phone Book (PB) 0 TV (TV)

OVER - Please Read and Sign"A copy of this authorization shall be as effective and valid as the original. "Lawson 4918 (Orig.11-97 Rev.4-14 Ref:3028) Page 1

NEW PATIENTS ONLY· How did you hear about us?

1111111111111111111111111111111111111111AUTHOR

CoxHealthSpringfield, MO

Health Information Management

AUTHORIZATION, FINANCIALOBLIGATION and CONSENT

Patient Sticker

Authorization to Release Information. I authorize thedisclosure of any or all information in my medical oraccounting record, including information regarding thediagnosis or treatment of HIV, AIDS, mental illness, orsubstance abuse, to any person, corporation or agencyresponsible for determining the necessity, appropriateness,payment or other matters related to CoxHealth treatment orservices. This includes, but is not limited to, insurancecarriers and companies, managed care plans, healthmaintenance organizations, preferred provider organizations,workers' compensation carriers, welfare agencies, Medicaid,or Medicare and its intermediaries and carriers, or myemployer, which may be necessary to process any claimrelated to this hospitalization or outpatient service. I furtheragree that if my injury is work-related, I authorize the'disclosure of my medical record related to my work-relatedinjury to my employer or employer's representative.Assignment of Benefits. I assign to CoxHealth or theCovered Entities listed below the benefits due to me forCoxHealth services from my insurance carrier or company,managed care plan, health maintenance organization,Medicaid, or Medicare and its intermediaries and carriers.

Medicare Beneficiaries. I authorize CoxHealth to obtain informationfrom the Social Security Administration regarding my entitlement tobenefits and my health insurance claim numbers.Financial Obligation. I agree that I am financially responsible forpayment of all amounts due for services provided by CoxHealth andthe physicians. I further understand that I am responsible to pay forsuch services regardless of whether I have insurance coverage orwhether other parties may also be responsible for paying for my care. Iwill not be responsible to pay for such services rendered if my financialobligation is waived by contractual agreements between CoxHealthand my insurer, or if prohibited by applicable state or federal laws orregulations. I agree to pay interest at the legal rate as defined by§408.020 RSMo., if the amount for which I am responsible is not paidwithin ten (10) days of receipt of the bill. In the event of collection, Iauthorize Cox Health or any of its collection agencies attempting tocollect any unpaid balance on my account to contact me at any numberI have provided as contact information using any manner they choose,including using an auto-dialing device. I agree that the cost ofcollection, including reasonable attorney's fees and court costs, will beincluded as part of my financial obligation to CoxHealth and the entitieslisted below. This agreement shall be governed by Missouri law, and Ihereby waive venue and agree that venue shall be appropriate inGreene County, Missouri.

Covered Entities. This Authorization, Financial Obligation and Consent Form applies to Lester E. Cox Medical Centers ("CoxHealth")facilities, departments and clinics including SNI Imaging, Ferrell-Duncan Clinic as well as its affiliated entities including OxfordHealthcare; Cox HPS of the Ozarks, Inc.; Cox-Monett Hospital, Inc.; Ozark Neuro Rehab; Cancer Research for the Ozarks, (all entitiescollectively referred to as "Cox Health") and the following hospital-based independent provider groups as applicable: Ozark AnesthesiaAssociates, Inc.; Litton & Giddings Radiological Associates, Inc.; Pathology Services of Springfield, Inc.; Emergency Physician ofSpringfield, Inc.; EJW Anesthesia, Inc.; and Visionary Imaging, Inc. (all entities and hospital based groups collectively referred to as"Covered Entities")I UNDERSTAND I MAY RECEIVE SEPARATE BILLS FROM EACH ENTITY NAMED IN THIS PARAGRAPH.

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Consent for Treatment. I agree, request and authorize the employees or, contractors of CoxHealth and its Covered Entities to providehealthcare services to me and further consent to any examination, tests or procedures that may be advisable or necessary for routinediagnostic purposes or to diagnose or treat my medical condition. I realize that among those who attend to patients at CoxHealth and itsCovered Entities are medical, nursing and other healthcare personnel in training who may be present and participating in my care aspart of their education. I authorize the taking of photographs or other images of me or parts of my body for use in medical evaluationand education. I am aware that the practice of medicine is not an exact science and understand that no promise, guarantee or warrantyhas been made regarding the results of the examination or treatment I receive. I understand that the employees and contractors ofCoxHealth and the Covered Entities do not routinely test patients for hepatitis or human immunodeficiency virus (HIV). I agree to havemy blood tested for hepatitis or HIV infection, if my physician determines that it is necessary or if an employee, provider, volunteer orcontractor of CoxHealth or its Covered Entities is exposed to my blood or bodily fluids. If my blood indicates infection, my physician willbe notified as well as any other individual, entity or agency required by law.

Release of Responsibilitv for Valuables. I understand that CoxHealth strongly recommends that all personal belongings andvaluables be sent home or placed in CoxHealth's security for safekeeping until I am discharged. I understand that Cox Health will not beliable for loss or damage to any personal property I may choose to keep with me and will not replace any personal items if they are lostor stolen.The CoxHealth Notice of Privacy Practices and The Notice of Patient Rights regarding my health care visit has been provided to me.The Notice of Privacy Practices was revised October 2013 and is available upon request.

I certify that I have read all parts of this Authorization, Financial Obligation and Consent Form, accept all its terms and conditions, that allrepresentations made by me are true, and that a copy of this form is effective and valid as the original. I further acknowledge that I havebeen informed of the Patient Bill of Rights and Responsibilities. This Authorization, Financial Obligation and Consent Form expires(unless expressly revoked at an earlier date) one (1) year after the date indicated below.

Patient parent if minor child, or guardian, Date(If Patient unable to sign, Representative name and Relationship)

_ Primary insured if different from patient_ Secondary insured if different from patient_ Guarantor if different from patient

Date

Witness DateLawson 4918 (Orig.11·97 RevA-14 Ref:L4863) Page 2

Upon request these individuals have access to my financial and/or protected health information (PHI). This may includeverbal and/or written medical information.

111111 1111111111CONSNT

CoxHealthSpringfield, MO

www.coxhealth.comPatient Sticker

ANNUAL PERMISSIONTO SHARE INFORMATION

Purpose: Many patients want their healthcare provider to share medical and/or billing information with specific familymembers, friends, or others participating in their care. The purpose of this annual authorization is to communicate withyour healthcare provider regarding who may have access to this information. Please be aware that you will be asked tosign this document annually at each of the CoxHealth clinics.

Patient Name: _ Date of Birth:__ /__ / _

I authorize the release of financial and protected health information (PHI) from the following:

The entire Cox system, which includes, but not limited to CoxHealth, Lester E. Cox Medical Centers, Cox-MonettHospital, CoxHealth Regional Services, Ferrell Duncan Clinic, and Springfield Neurological and Spine Institute.

Do not disclose information from the following entity(s)

I do not authorize communication with anyone.

I authorize communication with the following individuals:

Name: __ ---:--:- -:-:----:-:-:--:--:-_----:-:-__ Phone: Relationship: __ Any aspect of my care _ Health information only _ Billing (may include medical information and copies of bills)

Name: Phone: Relationship: __ Any aspect of my care _ Health information only _ Billing (may include medical information and copies of bills)

Name: __ -:---:- :-:----::-::-:--:-_--:-;-__ Phone: Relationship: _,--_--,- __ Any aspect of my care _ Health information only _ Billing (may include medical information and copies of bills)

Covering the following time frames. If NOT marked, all past, present and future encounters is the default.

_ All past, present, and future encounters/visits OR Other: _

By signing this authorization form, I understand that:

• PHI may include records relating to psychiatric, psychological care, communicable diseases, HIV/AIDS, treatment ofalcohol abuse, drug abuse, and other sensitive information.

• I have the right to revoke this authorization at any time. Revocation must be made in writing and presented to eachclinic in which services have been rendered.

• Unless otherwise revoked, this authorization will expire on the following date/evenUcondition:If I fail to specify an expiration date/evenUcondition, this authorization will expire one year from the date signed.

• Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.• Any disclosure of information carries with it the potential for unauthorized redisclosure and the information may not

be protected by federal confidentiality rules.• I may receive a copy of this authorization

Lawson 4918 (Orig,11-97 RevA-14 Ref:7191.01) Page 3

PatienUAuthorized Representative Signature: __ '---- Date: Time: _

Printed Name of Authorized Representative: _ Relationship to patient: _

Witness Signature: Date: Time: _

Covering the following time frames. If NOT marked, all past, present and future encounters is the default.