Race: Decline Other: Ethnicity: Hispanic or Non-Hispanic

Asian Black Hispanic White Preferred Language:

Our preferred method to contact you is texting. If you would like to opt

out of texting, please indicate here and you will be contacted by phone.

Contact by phone (specify number)

How did you hear about us? : Website Family/Friend Physician Referral Other:

PATIENT INFORMATION

INSURANCE INFORMATION (Please present all insurance cards and a photo ID to the receptionist.)

Patient’s Last Name First Middle Initial Marital Status: Married Single

Widowed Divorced

Name Address Relationship

Social Security #

Patient/Guardian Signature Date

By signing here, I attest that the above information is true and accurate to the best of my knowledge.

Birth Date Social Security Number Gender: Male Female Other

Email Address (required for access to Patient Portal)

Cell/Mobile Phone Work Phone Home Phone

Referring Provider (Full Name) Primary Care Provider (Full Name)

Phone Number Phone Number

Occupation Employer

Emergency Contact & Number Relationship

Preferred Pharmacy Name Preferred Pharmacy Number

Primary Insurance Member ID# Group ID#

Subscriber’s Name Relationship DOB

Subscriber’s Social Security #

Secondary Insurance Member ID# Group ID#

Subscriber’s Name Relationship DOB

Subscriber’s Social Security #

Street Address Apt# City State Zip Code

RESPONSIBLE PARTY (If same as patient, do not complete this portion.)

_ _

_ _ _ _ _ _

Effective Date: November 2016

_ _ _ _

_ _

_ _

_ _

_ _

_ _

NEW PATIENT MEDICAL HISTORY

Please list the medications that you are currently taking (including herbal supplements). Please include those with and without a prescription.

Medication Dose Frequency Reason for taking medication

MEDICATIONS

Why are you seeing the doctor today? ________________________________________________________________________________________

Have you been treated for this problem in the past? Yes No

If yes, please explain ______________________________________________________________________________________________________

Have you had any recent radiology or laboratory studies? Yes No

If yes, please indicate where, when, and type of study __________________________________________________________________________

REASON FOR VISIT

Are there any other medical problems that we should be aware of? ______________________________________________________________

Do you exercise or participate in sports? Yes No Type and frequency: __________________________________________________

Females Only:

Are you currently pregnant or could you possibly be pregnant? Yes No Date of Last Menstrual Period ____________________

MEDICAL HISTORYPlease indicate if you have received treatment for the conditions below, or if you are currently receiving treatment.

Yes No Yes No Yes No Alzheimer’s Gallbladder Problems Obesity Anemia Gout Osteoporosis Arthritis Heart Disease/Heart Attack Phlebitis Asthma Hepatitis Peripheral Vascular Disease Attention Deficit Disorder HIV/AIDS Polio Birth Defects High Blood Pressure Pulmonary Embolism Bladder Problems High Cholesterol Rheumatoid Arthritis Bleeding or Bruising Intestinal/Bowel Problems Sexually Transmitted Disease Cancer Type Kidney Problems VRE/MRSA/Staph Infection ___________________________________ Liver Disease Stroke/TIA Diabetes Lung Problems Tuberculosis DVT/Blood Clots Mental Illness Thyroid Epilepsy Migraine Ulcer

DOB Height Weight

Patient Name Date

In an effort to help us keep track of your important vaccinations and health screenings, we collect the following information in order to deliver the best healthcare.

Effective Date: November 2016

HEALTH QUESTIONNAIRE

NEW PATIENT FORMS

/ /

Date of Last Tetanus Shot

Type : Tdap TD

Location: Physician Office Place of Work Other

/ /

Date of Last Pneumococcal Vaccine

Type : Tdap TD

Location: Physician Office Place of Work Other

/ /

Date of Last Influenza (Flu) Shot

Location: Physician Office Place of Work Other

/ /

Date of Last Colonoscopy / /

Females Only:

Date of Last Mammogram

Date of Last Pap Smear

/ // /

Type of Surgery/Reason for Hospitalization Date Hospital Name/Surgical Center

I have not had any surgeries or been hospitalized

SURGERIES AND/OR HOSPITALIZATIONS

FAMILY HISTORY

Please indicate if your mother, father, grandparents, brothers, or sisters have been treated or are currently receiving treatment for the conditions listed below and indicate which family member.

Condition Family Member Condition Family Member Condition Family Member Alzheimer’s ________________ Heart Disease ________________ Stroke ________________ Cancer ________________ Hypertension ________________ Sudden Death ________________ Diabetes ________________ Osteoporosis ________________ Thyroid ________________ Gout ________________ Rheumatoid Arthritis __________ Other ________________

SOCIAL HISTORY

Do you use tobacco products? Yes No Former

If Yes/Former: Number _________ Packs per day for _________ years. Type of Tobacco: _________________________________________

Do you consume alcoholic beverages? Yes No Amount and frequency: __________________________________________________

Do you use recreational drugs? Yes No Type and frequency: ___________________________________________________________

Other _______________________________________________________________

Please list any present or past allergies (including medication, food, metal, or environmental).

Allergy Reaction How reaction was/is treated

ALLERGY

Reviewed By Date

FOR OFFICE USE

NEW PATIENT FORMS

Effective Date: November 2016

Patient Name Date

Signature of Patient / Guardian Date

Name of Guardian Date

HEALTH QUESTIONNAIRE

REVIEW OF symptOms/cOmplaInts

Do you CURRENTLY have any problems related to the following systems?

constitutional

Fatigue

Fever

Chills

Night Sweats

Marked Weight Change

Loss of Appetite

Other: ___________________

Eyes

Double or Blurred Vision

Excessive Tearing

Dry Eyes

Sensitivity to Light

Eye Pain

Other: ___________________

Respiratory

Cough

Spitting up Blood

Shortness of Breath

Wheezing

Oxygen Use

Other: ____________________

Ears/nose/mouth/throat

Hearing Loss

Ear Pain

Post Nasal Drip

Loss of Taste

Loss of Smell

Nose Bleeds

Dental Problems

Bleeding Gums

Sore Throat

Hoarseness

Difficulty Clearing Ears

Painful/Swollen Lymph Glands

Other: _____________________

cardiovascular (central/peripheral)

Chest Pain

Heart Palpitations

Heavy Sweating

Difficulty Breathing or Exertion

Swelling in Legs

Leg Pain When Walking

Difficulty Breathing When Lying Down

Other: ______________________

Gastrointestinal

Bowel Incontinence

Change in Bowel Habits

Abdominal Pain

Difficulty Swallowing

Indigestion

Yellow Skin

Nausea/Vomiting/Diarrhea

Blood in Stools

Constipation

Loss of Appetite

Hemorrhoids

Acid Reflux

Other: ____________________

sOcIal HIstORy

Marital Status: Single Married Divorced Widowed

Children: Yes No If yes, how many? ________________________

Occupation: ______________________________________________________________________________________________________________

Do you consume caffeine products? Yes No Type and frequency: ______________________________________________________

Cultural, Religious, or Language Concerns: ___________________________________________________________________________________

Financial Concerns: _______________________________________________________________________________________________________

Unable to Care for Self Suspected Abuse or Neglect Support Systems Lacking

Food, Clothing, or Shelter Needs Transport Concerns Object to Blood Products

Noted misuse of patient’s money, food, clothing, housing and/ of denial of medical care

Notes: ___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

DOB Height Weight

Patient Name Date

REVIEW OF systEms

Effective Date: May 2016

constitutional

Cachexia

Malignant Hyperthermia

Malnourished

Sleep Apnea

Eyes

Cataracts

Glaucoma

Optic Neuritis

Retinopathy

Ears/nose/mouth/throat

Barotrauma

Dysphagia

Myringotomy

Pharyngitis

Sinusitis

Tinnitus

Tube Placement

Respiratory

Abnormal Chest X-ray

Acute Respiratory Distress Syndrome (ARDS)

Aspiration

Asthma

Chronic Bronchitis

Chronic Obstructive Pulmonary Disease (COPD)

Emphysema

Lung Transplant

Pneumonia

Pneumothorax

Positive TB Test

Tuberculosis

Upper Respiratory Infection (URI)

Integumentary (Hair/skin/nails)

Alopecia

Fungal Infection

Malignancy

Onychomycosis

Scleroderma

neurological

Amyotrophic Lateral Sclerosis (ALS)

CNS Trauma Injury

Head Injury/LOC

Multiple Sclerosis

Neuropathy

Transient Ischemic Attack (TIA)

psychiatric

Dementia

Depression

Psychosis

Under Psychiatric Care

Endocrine

Adrenal Disease

Cortisone Treatment

Gestational Diabetes

Type I Diabetes

Type II Diabetes

Hematological/lymphatic

Anemia

Lipidemia

Lymphadenopathy

Lymphedema

Sickle Cell Anemia

allergic/Immunological

Aids

Epidermolysis

HIV Positive

Immune Deficiency

Lupus

Polyarteritis

Pyoderma Gangrenosum

Raynaud’s Disease

Rheumatoid Arthritis

past mEdIcal and suRGIcal HIstORy

REVIEW OF systEms

Patient Name Date

Signature of Patient / Guardian Date

Reviewed By Date

FOR OFFIcE usE

Effective Date: May 2016

CONSENT FOR TREATMENT

1. GENERAL CONSENT FOR TREATMENT. I hereby authorize employees and agents of Virginia Hospital Center Physician Group and Virginia Hospital Center Urgent Care, including physicians, physician assistants, nurse practitioners, nursing and other staff members to render medical evaluations and care to the patient indicated below.

I acknowledge that according to Virginia state law, I shall be deemed to have consented to the testing for infection with Human Immunodeficiency virus (HIV), Hepatitis B, Hepatitis C viruses should any healthcare provider, or any person employed by or under the direction and control of a healthcare provider, by directly exposed to my body fluids in connection with rendering care to the patient, in a manner which may, according to the current guidelines of the Center for Disease Control, transmit HIV, Hepatitis B, or Hepatitis C viruses. Test results may be released to the person exposed.

2. E- PRESCRIBING CONSENT. The Medicare Modernization Act (MMA) of 2003 listed standards that have to be included in an ePrescribe program. These include:

• Formulary and benefit transactions – Gives the prescriber information about which drugs are covered by the drug benefit plan.

• Medication history transactions – Provides the physician with information about medications the patient is already taking to minimize the number of adverse drug events.

By signing this consent form you are agreeing that this office can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.

3. OTHER CONSENTS. Virginia Hospital Center participates in an affiliated teaching program; physicians may be assisted in patient care by residents and/or medical students. I understand I have the right to refuse residents or medical students’ involvement in my care and will notify my care provider(s) of any such decision.

I agree to receive a survey from a premier polling company. The surveys are used to assess the quality of care delivered to our patients and ensure that we are providing the best care possible.

4. PATIENT INFORMATION. I authorize the practice to provide _____________________________________________________________________

with information (including both medical and billing information). This release will remain active in your electronic health record, and will not be cancelled unless there is written authorization from the patient to do so on file.

5. PATIENT PORTAL. The Virginia Hospital Center Physician Group and Virginia Hospital Center Urgent Care utilize a web portal as the preferred method of communication to send patient information via email, including but not limited to test results and visit summaries. Patients must provide a current and valid email address to the office and complete the user registration process through eClinical Works to receive updates. I understand that I may decide to opt out of participation at any time either in writing or by completing the VHC Physician Group Patient Portal opt-out form.

• The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in the case of an emergency.

Patient Name (please print) Date

Signature of Patient, Parent or Legal Guardian Date

Relationship, if GuardianContact Information If Minor:

Family Address

Guardian’s Telephone: Cell/Mobile Home Work

Our primary method of contacting you will be through the Patient Portal and via text. If you would like to opt out of texting,

indicate here and you will be contacted by phone.

Contact by Phone: Cell/Mobile Home Work

Provider Representative Signature/Witness Date

(List All Names / Relationships)

_ _ __ _ _

Effective Date: November 2016

NEW PATIENT FORMS

PRESCRIPTION REFILL POLICY

All Virginia Hospital Center (VHC) Physician Group providers (physician, nurse practitioner or physician assistant) participate in electronic prescribing directly to your local and mail order pharmacies. Our goal is to assist patients with prescription requests in an efficient manner. In order to process your request as quickly as possible, please see the details of our prescription policy.

• Prescription refills require close monitoring by your physician, nurse practitioner, or physician assistant to ensure the safe continuation of the appropriate dose, frequency and term of that medication. Your provider will prescribe the appropriate number of prescription refills to last you until your next scheduled appointment.

• It is the patient’s responsibility to schedule your next appointment in advance and with adequate time to receive a prescription refill.

• As prescriptions are prescribed with the amount of refills needed until the next appointment, almost all requests for prescription refills between regularly scheduled appointments will require a appointment in the office prior to authorization. The clinician will review the request from the pharmacy, as well as the patient’s medical record, to determine appointment needs. The patient will be contacted by the staff to schedule such appointment, if necessary.

• In the event that you require an emergency refill, prescriptions refill requests should be electronically submitted from the pharmacy directly to the office. If approved by your provider, an appropriate refill will be submitted to your local pharmacy. If your prescription refill is not approved, please contact your provider’s office to schedule an appointment.

• Patients requesting new prescriptions or antibiotics must be seen for an appointment by a clinician. They are not prescribed over the phone.

• Urgent Care will not refill prescriptions.

• Maintaining current pharmacy information is the responsibility of the patient. Please confirm with our practice that your correct local pharmacy address and phone number or mail order pharmacy information is on file. Prescription refill requests will be submitted electronically to your pharmacy. Your local pharmacy will contact you when your prescription is ready.

• Our practice will always order generic prescriptions whenever available unless brand is medically necessary. Each insurance plan outlines a detailed classification for medications which could impact which medication, generic or brand, is prescribed and the cost to you. Contact your insurance plan for details.

• Prescriptions classified as controlled substances are not processed after hours or on the weekends.

• Our providers participate in the Virginia Prescription Monitoring program, and prior to prescribing controlled substances, our office will access the VPM database.

• Please allow 48–72 hours to process prescription requests. Medications requiring pre-authorization may require additional time to process. Please plan ahead for refills during holidays and when traveling.

REFERRAL POLICY

The Virginia Hospital Center (VHC) Physician Group must adhere to guidelines as outlined by the contracts we have with your insurance company. As a patient, you have a responsibility to understand and follow the requirements of your plan. In order to best accommodate your needs please be mindful of the following policy:

• Requests for referral(s) must be authorized by your primary care provider and may require an appointment.

• A minimum of 72-hours is needed to process non-emergency referral requests. Emergency referrals will be handled as quickly as possible.

• It is your responsibility to make sure that you have complied with the referral policy guidelines of VHC Physician Group and have met the requirements of your health plan. You must have an approved and completed referral form or authorization number in hand prior to testing or an examination by a specialist. Referrals may be picked up at your primary care provider’s office or mailed to your home if time allows. Referrals will not be emailed nor faxed.

• No retroactive referrals will be issued. If you are seen by a specialist or facility without the proper referral, your insurance carrier will likely deny coverage and you will be responsible for charges incurred. If you receive treatment in a hospital emergency room or urgent care facility during a weekend, a holiday, or after hours, you must report this to our office on the first business day following the date of service, so we can provide proper authorization to that facility.

• If a referral to another VHC Physician Group provider was given to you at the time of your visit, the VHC Physician Group’s specialist’s office will reach out to you within 48-hours. If a referral to a specialist outside the VHC Physician Group is given to you at the time of your visit, it is your responsibility to contact the specialist to schedule an appointment. You will need to bring your referral to your appointment.

INSTRUCTIONS FOR OBTAINING A REFERRAL:

1. Your primary care provider or a designated staff member will give you the name of a specialist or group to whom you are being referred. Call the specialist’s office. Verify that the specialist accepts your insurance plan. If so, make an appointment. Please be sure you give yourself at least 72-hours prior to the appointment so you can obtain a referral.

2. Once the appointment is made, immediately call your primary care office and provide the following information (in some offices a voice mail option is available):

• Your name and date of birth (please spell your last name).

• A phone number where you can be reached or where a message can be left.

• Name and phone number of the specialist you will be seeing (please give the address if you have it available including the zip code).

• The reason for your visit to the specialist, the date and time of your appointment.

• Please state whether you will be picking up the referral from the front desk or if you prefer it mailed to your home.

Effective Date: November 2016

PATIENT FINANCIAL RESPONSIBILITY FOR SERVICES

The providers and staff of the Virginia Hospital Center (VHC) Physician Group and Virginia Hospital Center Urgent Care are committed to providing you with the best possible care and to help you receive your maximum allowable insurance benefits. We are here to help and are happy to answer any questions you may have about billing for our services. While the filing of insurance claims for contracted insurance carriers is our obligation, all fees are ultimately your responsibility. We recommend that you be completely familiar with your individual coverage, benefits, limitations, and exclusions. All questions in this regard should be addressed to your insurance carrier directly.

Please be aware of the following important financial responsibilities:

• It is your responsibility to keep all insurance and demographic information up to date.

• You must make all co-payments and outstanding balances at the time of your visit, as well as payments for any deductibles, co-insurance, or non-covered services.

• If referral is required for your visit, it is your sole responsibility to arrive for your appointment with your required referral. If you do not have the required referral at the time of your appointment, you will be required to pay the full appointment fee at the time of service.

• It is your responsibility to notify the office of any appointments to be rescheduled or canceled, and must be addressed no less than 48 hours prior to the scheduled appointment time. Patients with greater than 3 late cancellations and/or no shows per calendar year will be notified in writing of the absences. Patients with continued occurrences following written notice may be subject to the Virginia Hospital Center Physician Group Patient Dismissal from Care Policy (R-001).

• If you do not have insurance or receive treatment for a non-covered service, you must pay for services in full at the time of the visit. In most cases, we are able to give you a discount for payment given in full at the time of service. There is a separate fee schedule for cash services.

• You may pay in the form of cash, money order, check and credit card in most cases. We will assess a fee of $30.00 for returned checks.

• If your account becomes delinquent, we will submit the account to our attorneys, at which time you will be responsible for all collection costs including attorney fees, court costs, and all civil penalties as provided by the Code of Virginia.

I hereby authorize Virginia Hospital Center Physician Group to apply for benefits for services rendered to me. I certify that the information that I have provided with regard to insurance coverage is correct. I further authorize the release of any necessary information, including medical information, for any related claim to my insurance carrier or to CMS (Centers for Medicare and Medicaid Services) and its agents in order to determine these benefits or benefits payable for related services. I request that payment of authorized benefits due under my insurance plan, including Medicare if applicable (assigned charges), be made payable directly to Virginia Hospital Center Physician Group or any individual provider, on my behalf.

In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier. This assignment will remain in effect until revoked by me in writing.

I understand that I am financially responsible for the total charges for services rendered which may include non-covered services. I agree that all amounts are due upon request and are payable to Virginia Hospital Center Physician Group. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. I further understand should my account become delinquent; I shall pay the reasonable attorney fees or collection expenses of Virginia Hospital Center Physician Group.

I have read the above Patient Financial Responsibility for Services and have provided true and correct insurance and demographic information. I will promptly notify you of any changes to my health insurance carrier, including new ID #’s with my current carrier.

Effective Date: November 2016

Reviewed By Date

ACKNOWLEDGEMENT OF RECEIPT OFVIRGINIA HOSPITAL CENTER (VHC) PHYSICIAN GROUP POLICIES

By signing here, I attest to the following Virginia Hospital Center (VHC) Physician Group Policies which I have reviewed.

PATIENT FINANCIAL RESPONSIBILITY FOR SERVICES

I have read and understand the Patient Financial Responsibility for Services and have provided true and correct insurance and demographic information. Per the policy, I will promptly notify the VHC Physician Group practice of any changes to my health insurance carrier, including new ID number(s) with my current carrier.

PRESCRIPTION REFILL POLICY

I have read and understand the Prescription Refill Policy including that the VHC Urgent Care Center does not refill medications.

REFERRAL POLICY

I have read and understand that VHC Physician Group must adhere to guidelines as outlined by the contracts in place with my insurance company. I acknowledge that I have a responsibility to understand my plan’s requirements and follow to them.

I attest that all submitted information is true and accurate to the best of my knowledge and that I have read, understand and

agree to compliance with the aforementioned VHC Physician Group policies.

Patient Signature Printed Name Date

Signature of Legal Representative Printed Name Date

OFFICE USE ONLY

Effective Date: November 2016

NEW PATIENT FORMS

For Health Care Operations: We may use and disclose health information about you for our health care operations purposes. These uses and disclosures help us run our facilities and to make sure that all of our patients receive quality care. For example, we may use health information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine health information about many patients to decide to evaluate the need for new services or treatment. We may also disclose information to physicians, nurses, technicians, medical students, and other Virginia Hospital Center Arlington Health System facility personnel for review and educational purposes. We may also combine the health information we have with that of other hospitals for comparisons that will help us make decisions on improvements. We may remove information that identifies you from this set of health information to protect your privacy. Business Associates: There are some services provided in our organization through contracts with business associates. For example, certain laboratory tests may be sent out for processing, and a copy service is used to make copies of your health record. When services are contracted, we may disclose your health information to our business associate so that they can perform the job that we have asked them to do for us. To protect your health information, however, we share with our business associates only the minimum amount of information necessary for them to assist us, and require them to safeguard the information we do share according to contractual agreement.Hospital Directory: We may include certain limited information about you in the Virginia Hospital Center directory while you are a patient at Virginia Hospital Center. This information may include your name, location in Virginia Hospital Center, your general condition (e.g. fair, stable, etc.), and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in Virginia Hospital Center and generally know how you are doing. If you do not want to be included in the facility directory, you will need to notify the admission staff at the time of each admission. If emergency circumstances prevent us from asking you about the directory, we will use our professional judgment to determine what is in your best interest until there is a reasonable opportunity for you to object.For Contacting you about Services: We may use your health information to contact you to:

• Give a reminder that you have an appointment for treatment or medical care at a Virginia Hospital Center Arlington Health System facility.

• Tell you about possible treatment alternatives• Tell you about health-related benefits or services• Assess your satisfaction with our services• As part of our fundraising efforts, we may use, or disclose to a business associate or

institutionally-related foundation, certain health information about you, such as your name, address, phone number, e-mail information, dates you received treatment or services, treating physician, outcome information, and department of service (for example cardiology or orthopedics), so that we or they may contact you to raise money on our behalf. The money raised will be used to expand and improve the services and programs we provide the community. You are free to opt out of fundraising solicitation, and your decision will have no impact on your treatment or payment for services. Any fundraising materials that you may receive will tell you how you can opt out of receiving any further fundraising communications from us. Please note that we will promptly process your request to be removed from our fundraising list, and we will honor your request unless we have already sent a communication prior to receiving notice of your election to opt out.

Individuals Involved in Your Care or Payment for Your Care: We may release health information about you to your personal representative or a designated family member who is involved in your medical care. We may also give information to someone who helps pay for your care. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. We may require your written permission to release such information, however, if you are incapacitated or otherwise unavailable, we will use our professional judgment to determine whether to make any such disclosure.Research: Under certain circumstances, we may disclose your health information for research consistent with our legal obligations, for example, when an institutional review board has reviewed the research proposal, established protocols to ensure the privacy of your health information, and approved the research. As Required or Authorized by Law: We may disclose health information about you when required or authorized by law to do so to the following types of entities, including but not limited to:

• The Food and Drug Administration (FDA), or an entity regulated by the FDA, to report an adverse event or a potential defect related to a drug or medical device.

• Public Health or Legal Authorities (such as Child Protective Services, Human Rights Advocate/Board, Mental Health Advocate/Board) to:

- Prevent or control disease, injury or disability;- Report births and deaths;- Report suspected abuse, neglect, or domestic violence;- Report reactions to medications or problems with products;- Notify people of recalls of products they may be using;- Notify a person who may have been exposed to a disease or may be at risk for

contracting or spreading a disease or condition.• Correctional Institutions• Workers Compensation Agents• Organ and Tissue Donation Organizations• Military Command Authorities• Health Data Registries including Tumor and Trauma Registries• Funeral Directors, Coroners and Medical Directors• National Security and Intelligence Agencies• Protective Services for the President and Others

VIRGINIA HOSPITAL CENTERARLINGTON HEALTH SYSTEM

NOTICE OF PRIVACY PRACTICES

Effective Date: September 23, 2013

101440 (9/13)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET

ACCESS TO THIS INFORMATIONThe confidentiality of your health information is very important to us. Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by and as part of the care furnished to you in a Virginia Hospital Center Arlington Health System facility or through a Virginia Hospital Center Arlington Health System service, whether made by Virginia Hospital Center Arlington Health System personnel, agents of Virginia Hospital Center Arlington Health System and its affiliated facilities including hospitals, clinics and other health care providers that Virginia Hospital Center Arlington Health System operates, as well as any health care facility or physician practice now or in the future controlled by or under common control by Virginia Hospital Center Arlington Health System, or by your personal physician. Your personal physician may have different policies or notices regarding the physician’s use and disclosure of your medical information created in the physician’s office or clinic.Our Responsibilities This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of health information. We are required by law to:

• Make sure that health information that identifies you is kept private.• Give you this notice of our legal duties and privacy practices with respect to health

information about you.• Follow the terms of the notice that is currently in effect.

Contact InformationAfter reviewing this notice, if you need further information or want to contact us for any reason regarding the handling of your health information, please direct any communications to the following contact person:

Privacy OfficialHealth Information Department

Virginia Hospital Center1701 N. George Mason Drive, Arlington, VA 22205

Phone: 703.558.6116; Toll Free: 855.816.2446

Organized Health Care ArrangementVirginia Hospital Center Arlington Health System’s facilities, including but not limited to Virginia Hospital Center, deliver care in clinically integrated settings in which individuals typically receive care from more than one health care provider including Virginia Hospital Center Arlington Health System’s workforce, physicians and allied health practitioners who are in private practice and have clinical privileges at Virginia Hospital Center, hospital-based physician groups such as anesthesia, radiology, pathology and emergency medicine, department chairs and medical directors. These are all part of Virginia Hospital Center Arlington Health System’s organized health care arrangement and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment, and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect current and future care that we provide to you. Neither this joint notice nor participation in an organized health care arrangement create an employer-employee relationship between Virginia Hospital Center Arlington Health System and a medical staff member where none otherwise exists.How We May Use and Disclose Health Information About YouThe following categories describe different ways that we use and disclose health information.For Treatment: We may use health information about you to provide you with medical treatment or services. We may disclose health information about you to physicians, nurses, technicians, medical students, or other facility personnel who are involved in taking care of you at the facility. For example: a physician treating you for a broken leg may need to know if you have diabetes, because diabetes may slow the healing process. Different departments of the Virginia Hospital Center Arlington Health System facility also may share health information about you in order to coordinate the different things you may need, such as prescriptions, lab work, and x-rays. In addition, we may disclose your health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician. We also may provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you once you are discharged from a Virginia Hospital Center Arlington Health System facility.For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company, or a third party payer. This may include certain activities that your health insurance plan may undertake before it approves or pays for health care services we recommend for you such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provide to you for medical necessity, and undertaking utilization review activities. For example, we may need to give your health information about a surgery you received at the hospital, so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may also provide your physician or other medical personnel involved in taking care of you at Virginia Hospital Center Arlington Health System facility or their billing agents with information so they can send bills to your insurance company or to you.

Health Oversight Activities: We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.Lawsuits and Disputes: We may disclose health information about you in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process, but only if like notice has been given to you or your attorney in accordance with applicable law. Law Enforcement: We may release certain health information to law enforcement authorities for law enforcement purposes, such as:

• As required by law, including reporting certain wounds and physical injuries;• A court order; subpoena, warrant, summons or similar process;• A need to identify or locate a suspect, fugitive, material witness, or missing person;• A need for information about the victim of a crime, if, under certain limited

circumstances, we are unable to obtain the person’s agreement;• A death we believe may be the result of criminal conduct;• Investigation of criminal conduct at the facility;• In emergency circumstances to report a crime; the location of the crime or victims; or

the identity, description or location of the person who committed the crime.To Avert a Serious Threat To Health or Safety: We may use and disclose health information about you when necessary to prevent a serious threat to the health and safety of the public, to you, or to another person. Any disclosure, however, would only be to someone able to help prevent the threat.Minors: If you are an unemancipated minor under Virginia law, there may be circumstances in which we disclose health information about you to a parent, guardian, or other person acting in loco parentis, in accordance with our legal responsibilities.Parents: If you are a parent of an unemancipated minor, and are acting as the minor’s personal representative, we may disclose health information about your child to you under certain circumstances. For example, if we are legally required to obtain your consent as your child’s personal representative in order for your child to receive care from us, we may disclose health information about your child to you. In some circumstances, we may not disclose health information about an unemancipated minor to you. For example, if your child is legally authorized to consent to treatment (without separate consent from you), consents to such treatment, and does not request that you be treated as his or her personal representative, we may not disclose health information about your child to you without your child’s written authorization.Deceased Individuals. Following your death, we may disclose health information to a coroner or to a medical examiner as necessary for them to carry out their duties and to funeral directors as authorized by law. In addition, following your death, we may disclose health information to a personal representative (for example, the executor of your estate), and unless you have expressed a contrary preference, we may also release your health information to a family member or other person who acted as a personal representative or was involved in your care or payment for care before your death, if the health information is relevant to such person’s involvement in your care or payment for care. We are required to apply safeguards to protect your health information for 50 years following your death. Incidental Uses and Disclosures. There are certain incidental uses or disclosures of your information that occur while we are providing service to you or conducting our business. For example, after surgery the nurse or physician may need to use your name to identify family members that may be waiting for you in a waiting area. Other individuals waiting in the same area may hear your name called. We will make reasonable efforts to limit these incidental uses and disclosures.Health Information Exchange. We participate in one or more electronic health information exchanges, which permits us to exchange health information about you with other participating providers (for example, physicians and hospitals) and their business associates. For example, we may permit a physician providing care to you to access our records in order to have current information with which to treat you. In all cases, the requesting provider must verify that they have or have had a treatment relationship with you, and, if required by law, we will ask the provider to obtain your consent before accessing your health information through the health information exchange. Participation in a health information exchange also lets us access health information from other participating providers and health plans for our treatment, payment and health care operations purposes. We may in the future allow other parties, for example, public health departments, that participate in the health information exchange, to access your protected health information for their limited uses in compliance with federal and state privacy laws, such as to conduct public health activities. Your Health Information RightsAlthough your health record is the physical property of the Virginia Hospital Center Arlington Health System facility, you have the following rights regarding the health information we maintain about you:Right to Inspect and Copy: You have the right to inspect and copy health information we maintain about you that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. If we maintain the information electronically and you ask for an electronic copy, we will provide the information to you in the form and format you requested, assuming it is readily producible. If we cannot readily produce the record in the form and format you request, we will produce it another readable electronic form we agree to. We may charge a cost-based fee for producing copies, including the cost of retrieving, copying, mailing, and use of supplies associated with your request. We may deny your request to inspect and copy in certain, very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional, chosen by Virginia Hospital Center Arlington Health System, will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Virginia Hospital Center

Arlington Health System facility. You must provide a reason for your request. We may deny your request for an amendment. If this occurs, you will be notified in writing of the reason for the denial, and of your right to submit a statement (of reasonable length) disagreeing with the decision, which will be added to your records.Right to An Accounting of Disclosures: You have the right to request an accounting of disclosures of your health information. This is a list of the disclosures we made of health information about you. The accounting will not include certain disclosures, such as those made for treatment, payment, or health care operations and certain other types of disclosures, for example, as part of a facility directory or disclosures in accordance with your authorization. We will provide you the accounting free of charge, however if you request more than one accounting in any 12 month period, we may impose a reasonable, cost-based fee for any subsequent request. Your request should indicate the period of time in which you are interested (for example, “from May 1, 2003 to June 1, 2003”). We will be unable to provide you an accounting for any disclosures made before April 14, 2003, or for a period of longer than 6 years. Requests must be in writing. You may contact the Privacy Official to obtain a form to request an accounting of disclosures. Right to Request Restrictions: You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations or to persons involved in your care or payment for your care. We are not required to agree to your request, with one exception explained in the next paragraph, but we will let you know whether we have agreed to your request. We are required to agree to your request that we not disclose certain health information to your health plan for payment or health care operations purposes if (1) you pay out-of-pocket in full for all expenses related to that service either at the time of service or within timeframes specified by our written policies and (2) the disclosure is not otherwise required by law. Such a restriction will only apply to records that relate solely to the service for which you have paid in full. If we later receive an authorization from you dated after the date of your requested restriction which authorizes us to disclose all of your records to your health plan, we will assume you have withdrawn your request for restriction.You must make a separate request to each covered entity from whom you will receive services that are involved in your request for any type of restriction, including physicians and allied health practitioners who are in private practice and have clinical privileges at Virginia Hospital Center, hospital-based physician groups such as anesthesia, radiology, pathology and emergency medicine. Contact the Privacy Official if you have questions regarding which providers will be involved in your care.Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes.Notice in the Case of Breach. You have the right to receive notice of an access, acquisition, use or disclosure of your health information that is not permitted by HIPAA, if such access, acquisition, use or disclosure compromises the security or privacy of your Protected Health Information (we refer to this as a breach). We will provide such notice to you without unreasonable delay but in no case later than 60 days after we discover the breach. Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to paper copy of this notice. You may obtain a copy of this notice at our website: www.virginiahospitalcenter.comTo exercise any of your rights, please obtain the required forms from the Privacy Official and submit your request in writing.CHANGES TO THIS NOTICEWe reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice on our website at www.virginiahospitalcenter.com. The effective date will be on the first page of the notice. In addition, each time you register or are admitted for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.COMPLAINTSIf you believe your privacy rights have been violated, you may file a complaint with the Virginia Hospital Center Arlington Health System Privacy Official (contact information appears on page 1 of this Notice), or with the Secretary of the U.S. Department of Health and Human Services. All complaints to Virginia Hospital Center Arlington Health System must be submitted in writing. You will not be penalized for filing a complaint.

USES AND DISCLOSURES REQUIRING YOUR AUTHORIZATION.There are many uses and disclosures we will make only with your written authorization. These include: Uses and Disclosures Not Described Above. We will obtain your authorization for uses and disclosures of your health information that are not described in the notice above. Psychotherapy Note. These are notes made by a mental health professional documenting conversations during private counseling sessions or in joint or group therapy. Many uses or disclosures of psychotherapy notes require your authorization.Marketing. We will not use or disclose your protected health information for marketing purposes without your authorization. Moreover, if we will receive any financial remuneration from a third party in connection with marketing, we will tell you that in the authorization form.Sale. We will not sell your protected health information to third parties without your authorization. Any such authorization will state that we will receive remuneration in the transaction. If you provide authorization for the disclosure of your health information, you may revoke it at any time by giving us notice in accordance with our authorization policy and the instructions in our authorization form. Your revocation will not be effective for uses and disclosures made in reliance on your prior authorization.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

By signing this form you acknowledge receipt of the Notice of Privacy Practices for Virginia Hospital Center Arlington Health System and its affiliated medical groups. Our Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change.

OFFICE USE ONLY

We attempted to obtain written acknowledgement of patients’ receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained from the patient for the following reason:

Patient Refused to Sign

Patient Representative Refused to Sign

Patient/ Patient Representative Refused Copy of Notice of Privacy Practices

Emergency Situation Prevented Signature

Other (please specify) ____________________________________________________

MRN

Signature of Patient / Patient Representative Date

Name of Patient / Patient Representative (please print) Relationship to Patient

Provider Representative Signature Date

Effective Date: November 2016

NEW PATIENT FORMS

Patient Rights & Responsibilities

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At Virginia Hospital Center, we pledge to treat each patient with dignity, respect and compassion. We recognize that all patients have fundamental rights. As early as possible in the care process, we will inform patients of their rights and are committed to honoring those rights throughout a patients’ stay at Virginia Hospital Center. Likewise, we have a right to expect reasonable and responsible behavior from patients, their families, representatives and friends.

During your stay we encourage you to ask questions, be proactive and take an active part in your care plan. If you have questions or concerns, please discuss them with your doctor or any staff member, or contact the Hospital’s Patient Relations Department (703.558.6195) or Nursing Supervisor (703.558.5000).

The following summary of rights and responsibilities serves as the foundation for our partnership with you and your family (and/or representative) as we collaborate on your healthcare. Patient Rights and Responsibilities and additional useful information may be found in Virginia Hospital Center’s “Patient & Visitor Information Guide” given to inpatients upon admission. Outpatients can request copies by calling 703.558.6195.

The Patient has the right:Safety

To receive care in a safe setting To be free from mental, physical, sexual and verbal abuse, neglect, exploitation, harassment or corporal punishment To be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience or retaliation by

staff. (Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time)

To safe implementation of restraint or seclusion by trained staff To prompt resolution of grievances To access protective and advocacy services To be informed of unanticipated outcomes of her/his care

Respect and Dignity To every consideration for her/his privacy To the confi dentiality of her/his identifi able health information To receive visitors designated by the patient, including but not limited to, a spouse, a domestic partner (including same-sex

domestic partner), another family member or a friend (this includes the patient’s right to withdraw or deny such consent at any time)

To be informed of the Hospital’s practice that allows for the presence of a support individual unless it interferes with the rights of others, or is not recommended for medical reasons

To respectful medical and nursing care that recognizes personal dignity, diversity and religious or other spiritual preference, and that is administered regardless of ability to pay

PATIENT RIGHTS & RESPONSIBILITIES

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Consent To give informed consent prior to care and treatment, except for emergencies To say “yes” or “no” to experimental treatments and to be advised when a physician is considering her/him to be part of a

medical research or donor program To appoint someone else to make decisions for her/him if she/he becomes unable to do so, and have that person approve

or refuse care, treatment or services

Quality Care and Pain Management To participate in the development and implementation of her/his plan of care To have pain assessed and managed appropriately To be told what she/he needs to know about her/his health condition upon Hospital discharge To emergency care and procedures which are implemented without unnecessary delay To receive care regardless of age, race, color, national origin, culture, ethnicity, language, socioeconomic status, religion,

physical or mental disability, sex, sexual orientation, or gender identity or expression, or manner of payment To quality care from competent professionals To care provided 24 hours/day, 7 seven days/week by credentialed medical professionals To have a family member, representative of choice and physician to be notifi ed of her/his admission To knowledgeably refuse any drugs, treatments or services To ask for a change of provider or second opinion To request that ethical issues related to her/his care be referred to the Bioethics Committee for discussion

Information To make advance directives (such as living will and durable power of attorney for healthcare) and have them followed (For

more information on the Code of Virginia regulations on when advance directives do not apply and Virginia Hospital Center limitations, please see the Patient Rights section in the Virginia Hospital Center Patient & Visitor Information Guide which can be requested by dialing 6112 or 703.558.6195 )

To receive information in understandable terms concerning diagnosis, treatment and anticipated outcomes To make informed decisions regarding care, including being informed of health status, being involved in care planning and

treatment, and being able to request or refuse treatment To know the names and professional titles of her/his caregivers To know the rules regulating her/his care and conduct To access information contained in her/his medical records within a reasonable time frame To know that Virginia Hospital Center is a teaching hospital and that some caregivers may be in training To ask caregivers if they are in training To have her/his wishes followed concerning organ donation, when she/he makes such wishes known in accordance with

law and regulations To have bills explained and receive information about charges that she/he may be responsible for To inquire about fi nancial assistance in paying her/his Hospital bill and help in fi ling her/his insurance forms

Communication To effective communication To an interpreter and/or interpretive devices, for patient or patient representative, when English is not spoken or is not the

patient’s preferred language To have access to sign language and oral interpreters, and assistive telecommunication devices, if needed

As a patient at Virginia Hospital Center, you have the responsibility to: Cooperate with caregivers and ask questions if you don’t understand Inform staff about the medicines you are taking

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By signing this form I acknowledge receipt of the Hospital’s Patient Rights and Responsibilities and that I’ve had the opportunity to ask questions.

Patient Signature Print name Date

Be respectful and considerate of others Safeguard your personal items you choose to bring with you Maintain your recommended treatment Abide by Hospital rules, including no smoking on the Hospital campus Provide a copy of your advance directive Provide for prompt payment of your bill

Addressing Complaints or GrievancesIf you or your representative has a complaint or grievance about any aspect of your care at Virginia Hospital Center, we urge you to let us know so we can resolve it promptly. This reporting will in no way negatively impact your care. We consider your comments opportunities for us to improve care and service.

To address complaints or grievances you can: Speak to your physician, nurse and/or caregiver Speak to the manager of the department where your concern(s) arose Speak to the Nursing Supervisor or the Administrator on Call (703.558.5000) Speak to a Patient Relations Department (703.558.6195) or in writing to: Patient Relations Department 1701 N. George Mason Dr. Arlington, VA 22205 Email: patientrelations@virginiahospitalcenter.com

Once a complaint or grievance is received and assessed, Patient Relations will inform the appropriate staff and establish a contact person for the patient, family or representative. Patient Relations will respond in writing and within seven (7) calendar days.

If your grievance cannot be resolved, or at anytime, you have the option to submit a verbal or written complaint to the following:

Joint CommissionOne Renaissance Blvd.Oakbrook Terrace, IL 60181Phone: 800.994.6610Email: complaint@jointcommission.org

Virginia Department of HealthOffice of Licensure and Certification9960 Mayland Drive, Suite 401Henrico, VA 23233-1819Phone: 800.955.1819Email: OLC-Complaints@vdh.virginia.gov