Carlos R. Sarduy, MD Pablo E. Uribasterra, MD

Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP

301 NW 179th Avenue • Suite 102 • Pembroke Pines • FL 33029

Phone: 954-447-1446 • SignatureWHC.com • Fax: 954-241-4147

swhPTPortal

We are Happy to Announce

At Signature Women’s Healthcare, we have been listening to your concerns and have been working hard to improve the care we provide you. As part of our commitment to you, we are proud to announce our new Patient Portal, a convenient way for you to interact and communicate with our office!

As we continue in our efforts to provide you with the highest quality of care, we are constantly looking for methods of working together with you to ensure that you are not only aware of but also involved in the maintenance and improvement of your health.

To that end, we are proud to announce that our practice now offers you the opportunity to use the power of the web to track all aspects of your health care through our office. The Patient Portal enables our patients to communicate with our practice easily, safely, and securely over the Internet.

Patient Portal URL: https://mycw62.ecwcloud.com/portal8061/jsp/login.jsp

Please take this opportunity to log in to our site and activate your account… Only after activating your account will you be able to receive messages alerting you when your test results are available for viewing.

Through the Patient Portal, you will be able to

ask questions of doctors, nurses, and staff members request prescription refills and referrals set up appointments examine your current and past statements

… all from the comfort of your home, whenever it is convenient for you!

By using the Patient Portal you no longer have to call the office, leave a message, and wait for a response to get the results of your lab work; those results will be available to you on the Portal. You no longer have to call with a question or concern; you can send a message to the office through the Portal and expect a prompt reply.

Begin today to take an active role in managing your health care.

By supplying my home phone number, mobile phone number, email address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach & messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, balances due, lab results, or any other healthcare related function. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events and to leave a detailed message on my voice mail, answering system, or with another individual, if I am unavailable at the number provided by me.

Signature: ___________________________________________ Date: _________________

Al proporcionar mi número de teléfono, número de teléfono móvil, dirección de correo electrónico y cualquier otra información de contacto personal, autorizo a mi proveedor de atención médica a utilizar un sistema automatizado de mensajería y extensión para utilizar mi información personal, el nombre de mi proveedor de atención médica , la hora y el lugar de mi cita programada, y otra información limitada, con el propósito de notificarme de una cita pendiente, una cita perdida, un examen de bienestar vencida, saldos debidos, resultados de laboratorio o cualquier otra función relacionada con la atención médica. También autorizo a mi proveedor de atención médica a revelar a terceros, que pueden interceptar estos mensajes, información de salud protegida limitada con respecto a mis eventos de atención médica y dejar un mensaje detallado en mi correo de voz, contestador automático o con otra persona si no estoy disponible en el número proporcionado por mí.

Firma: ___________________________________________ Fecha: _________________

NEW PATIENT INFORMATION

PRIMARY CARE DOCTOR: _________________________________________________________________ PCP # _______________________________________ FAX # ___________________________________ PATIENT NAME: _________________________________________________________________________________________________________ BIRTHDATE: ________/________/________ AGE: _____________ SOCIAL SECURITY # __________________________________________________________________________________ MARITAL STATUS: ( ) S ( ) M ( ) W ( ) D HOME TELEPHONE # _______________________________________________ CELLULAR # _________________________________________ RELIGION: ____________________________________________ STREET ADDRESS: _________________________________________________________________________________________________________________________________ APT. # _______________________ CITY: ______________________________________________________________________________________________ STATE: ________________________________ ZIP: ______________________________

PATIENT EMAIL ADDRESS: _________________________________________________________________________________________________________________________________________________________ DRIVER’S LICENSE: _____________________________________________________________________________________________________________________ DRIVER’S LICENSE STATE: _________________ EMPLOYER/SCHOOL: __________________________________________________________________________ TITLE: __________________________________ PHONE # _________________________________ STREET ADDRESS: ______________________________________________________________________________ CITY: ______________________________________ STATE: _______ ZIP: _________________ SPOUSE NAME: ___________________________________________________________________________________________________________ CONTACT TEL. # ________________________________________ TRANSLATOR NEEDED ( ) YES ( ) NO PRIMARY LANGUAGE SPOKEN: ___________________________________________________ REFERRED BY: ___________________________________________

*****************************************************************************************************************************************************************

EMERGENCY CONTACT NOT LIVING WITH YOU:

NAME: __________________________________________________________________________ PHONE # __________________________________________ RELATIONSHIP: _____________________________ ADDRESS: ________________________________________________________________________________ CITY : ______________________________________ STATE: _________ ZIP: ___________________

****************************************************************************************************************************************************************

IF PATIENT IS A MINOR, PLEASE COMPLETE THE FOLLOWING:

MOTHER’S NAME: _______________________________________________________________________ FATHER’S NAME: ______________________________________________________________________ EMPLOYED BY: __________________________________________________________________________ EMPLOYED BY: _______________________________________________________________________ PHONE # ________________________________________________________________________________ PHONE # _____________________________________________________________________________

****************************************************************************************************************************************************************************** PRIMARY INSURANCE INFORMATION: SECONDARY INSURANCE INRORMATION: INSURANCE CO. ______________________________________________________ INSURANCE CO. _____________________________________________________________ ADDRESS: ___________________________________________________________ ADDRESS: _________________________________________________________________ CITY/STATE/ZIP: _______________________________________________________ CITY/STATE/ZIP: _____________________________________________________________ PHONE # _____________________________________________________________ PHONE # ____________________________________________________________________ I.D. # ________________________________________ GRP # __________________ I.D. # ___________________________________________________ GRP # ______________ INSURED’S NAME OR # _________________________________________________ INSURED’S NAME OR # ________________________________________________________ IS THIS AN EMPLOYER PLAN ( ) YES ( ) NO IS THIS AN EMPLOYER’S PLAN ( ) YES ( ) NO INSURED’S SOCIAL SEC. # ______________________________ DOB: __________ INSURED’S SOCIAL SEC. # ____________________________________ DOB: ___________ RELATIONSHIP TO INSURED: SELF HUSBAND WIFE CHILD OTHER RELATIONSHIP TO INSURED: SELF HUSBAND WIFE CHILD OTHER

GUARANTEE OF PAYMENT AND RESPONSIBILTY I fully understand that I am directly responsible for payment to the physicians in this office for all medical services (consultations, evaluations, follow-up, procedures, treatment, etc.), and/or rendered supplies (IUD, Essure, Implanon, vaccines, etc.). I also understand that all bills are payable and become due at the time services are rendered, unless other arrangements have been made or covered by the insurance plan. Patients with no insurance coverage (Self-Pay) are responsible for all laboratory services (specimens, blood work, general testing, etc.). Patient will be billed directly by the laboratory, Genpath (BioReference), LabCorp, Quest Diagnostic, etc. I agree to pay all collection costs including reasonable attorney’s fees and costs in the event it becomes necessary to file suit to effect payment. I authorize payments to be made directly to my doctor. AUTHORIZATION TO RELEASE INFORMATION I hereby authorize the Physicians in this office to release any information acquired in the course of my examination or treatment to my insurance, disability or FMLA company for the purpose of processing any insurance or disability claim. NOTICE OF PRIVACY PRACTICES I acknowledge that I have received the Notice of Privacy for Signature Women’s Healthcare, LLC. The NPP is required to be provided to me under the Health Insurance Portability and Accountability Act of 1996. ASSIGNMENT OF INSURANCE BENEFITS If insurance claims are filed by this office on my behalf, I hereby authorize direct payment of any payment of any benefits to the physicians in this office for medical or surgical treatment rendered to me. In these circumstances, I understand that I am financially responsible for any charges, services or supplies not covered by insurance. I permit a copy of the authorization to be used in place of the original. PERSONAL INFORMATION CONFIRMATION I confirm that all of the above Information is current and accurate, and I consent to all of the above specifications.

SIGNATURE (Patient’s parent if minor): _____________________________________________________________________________________ DATE: ________ /________/________

Signature Women’s Healthcare, LLC - 301 NW 179th Avenue, Suite 102, Pembroke Pines, FL 33029 *** 6175 NW 153 Street, Suite 332, Miami Lakes, FL 33014 - Tel. # 954-447-1446 - Fax # 954-241-4147 - SignatureWHC.com swh30A

PREFERRED PHARMACY

NAME OF PHARMACY: __________________________________________________________________________

ADDRESS: _____________________________________________________________________________________

TELEPHONE # __________________________________________________________________________________

AUTHORIZATION TO DISCUSS PROTECTED HEALTH INFORMATION*

I, __________________________________________(Patient name), authorize Signature Women’s Healthcare, LLC to

release or discuss information related to my medical condition (including information related to my treatment plan,

medication information and/or billing information) to the following named person(s)*

1) ______________________________________ Relationship: ____________________

2) ______________________________________ Relationship: ____________________

3) ______________________________________ Relationship: ____________________

****************************************

* PLEASE BE ADVISED THAT ANY PERSON NOT REFERRED TO ON THIS

LIST WILL NOT BE GIVEN ANY INFORMATION RELATED TO YOUR CARE,

INCLUDING BILLING INFORMATION. YOU MAY CHANGE, RESTRICT OR

EXPAND THIS LISTING AT ANY TIME.

* YOU ARE NOT REQUIRED TO LIST ANY NAME IF YOU DO NOT CHOOSE.

******************************************

Please list any additional phone numbers where you would like us to contact you for:

* Results – Lab, X-ray, Ultrasounds, Mammograms, etc.

* Reminder notices

* Changes on scheduled appointments

1. __________________________________________ 2. ____________________________________________

ADVANCE DIRECTIVE

Do you have an Advance Directive / Living Will? ( ) YES ( ) NO

If yes, please provide us with a copy for our records.

If no, please let us know if you require information.

Patient Signature: _______________________________________ Date: _____/_____/_____

I was referred to Signature Women’s Healthcare, LLC by:

Friend Relative Physician Insurance

Reputation of LLC’s Physician(s) Existing Patient Other

Signature Women’s Healthcare, LLC

Carlos R. Sarduy, MD Pablo E. Uribasterra, MD Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP Swh30B

Carlos R. Sarduy, MD Pablo E. Uribasterra, MD

Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP

301 NW 179th Avenue • Suite 102 • Pembroke Pines • FL 33029

6175 NW 153 Street • Suite 332 • Miami Lakes • FL 33014

Phone # 954- 447-1446 • SignatureWHC.com • Fax: 954-241-4147

swh15A

PATIENT FINANCIAL CONSENT

Your care often requires the use of laboratory studies, imaging studies, or pathology evaluation.

These studies are not performed at our practice. If your care does require the use of any of these

modalities, you will receive a separate bill from the laboratory, physician, or center providing

that specific service. Please understand that we do not control these costs. If you have any

questions regarding these costs, please ask your physician prior to your procedure.

If you have a health insurance plan, your insurance policy is a contract between you and the

insurance company. It is an agreement that your insurance will pay for covered medical

services. They may not pay for every bill or services. It is very important that you know which

medical treatments they will pay for and which expense they will not cover. Please note,

verification of benefits is NOT a guarantee of payment. We recommend you contacting your

health insurance plan for questions regarding covered benefits under your plan.

Please do not hesitate to contact any of our staffed employees to assist you with any questions.

I acknowledge that I have read and fully understand that I am directly responsible for any and all

services provided.

___________________________________________________

Patient Name

___________________________________________________

Patient Signature

ID #_________________________________

Date: _______/_______/_______

03/04/15

Carlos R. Sarduy, MD Pablo E. Uribasterra, MD

Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura J. Paris, CNM, ARNP

301 NW 179th Avenue • Suite 102 • Pembroke Pines • FL 33029

6175 NW 153 Street • Suite 332 • Miami Lakes • FL 33014

Phone: 954-447-1446 • SignatureWHC.com • Fax: 954-241-4147

swhA1

ACKNOWLEDGEMENT OF RECEIPT

OF NOTICE OF PRIVACY PRACTICES

By signing below, I acknowledge that I have received the Notice of Privacy Practices for

Signature Women’s Healthcare, LLC. The Notice of Privacy Practices is required to be provided

to me under the Health Insurance Portability and Accountability Act of 1996.

Effective Date of Notice: April 14, 2003

Patient: _____________________________________ Date: _______/_______/_______

Or

Patient’s Representative: _______________________ Date: _______/_______/_______

Relationship to Patient: ________________________

FOR USE BY SIGNATURE WHC STAFF ONLY:

_____ Patient refused to sign.

_____ Patient unable to sign.

_________________________

Signature Women’s Healthcare Employee’s Initials

_______/_______/_______

Today’s Date

Carlos R. Sarduy, MD Pablo E. Uribasterra, MD

Monica Companioni, MD Jenny Arango-Longo, MD Alvin Martinez, DO Laura Paris, CNM, ARNP

301 NW 179th Avenue • Suite 102 • Pembroke Pines • FL 33029

6175 NW 153 Street • Suite 332 • Miami Lakes • FL 33014

Phone: 954-447-1446 • SignatureWHC.com • Fax: 954-241-4147

swh02e

NICA INFORMATION

I have been furnished information by Signature Women’s Healthcare, LLC prepared by the

Florida Birth-Related Neurological Injury Compensation Association, and have been advised

that Dr. Carlos R. Sarduy, Dr. Pablo E. Uribasterra, Monica Companioni, MD, Jenny Arango-

Longo, MD, and Alvin Martinez, DO are participating physicians in the program, where in

certain limited compensation is available in the event certain neuro-logical injury may occur

during labor, delivery or resuscitation. For specifics on the program, I understand I can contact

the Florida Birth-Related Neurological Injury Compensation Association (NICA), 1435

Piedmont Drive East, Suite 101, Tallahassee, FL 32312. 1-800-398-2129. I further acknowledge

that I have received a copy of the brochure prepared by NICA.

DATED this _________ day of _______________________________ ,20_____.

_______________________________________________________

Signature

______________________________________________ Name of Patient

______________________________________________ Social Security

Attest:

______________________________________________ Witness

_______/_______/_______ Date

SEE SECTION 766.316, FLORIDA STATUES