AcknowledgementandConsents

FinancialAgreementandAssignmentofBenefitsIauthorizePacificMedicalGrouptoreleaseinformationacquiredinthecourseofmedicalservicestomyinsurancecompanytofileandexpeditepayment.Iauthorizepaymentofbenefitsdirectlytotheclinic.Iagreetobefinanciallyresponsibleforthebalanceleftafterprocessingbymyinsuranceandfornon-coveredservices.Allnon-coveredorpartiallycoveredchargesareduein30daysfromthedateofservice.IfIamunabletopayinfull,Iunderstandthatapaymentplanmaybeestablished.IacknowledgeIhavereceivedacopyofPacificMedicalGroup’sCreditandPaymentPolicy.NoticeofUsesandDisclosuresofProtectedHealthInformationIunderstandthatPacificMedicalGroupwilluseanddisclosehealthinformationaboutme.Iunderstandthatmyhealthinformationmayincludeinformationbothcreatedandreceivedbythepractice,maybeintheformofwrittenorelectronicrecordsorspokenwords,andmayincludeinformationaboutmyhealthhistory,healthstatus,symptoms,examinations,testresults,diagnoses,treatments,procedures,prescriptions,andsimilartypesofhealth-relatedinformation.IunderstandandagreethatPacificMedicalGroupmayuseordisclosemyprotectedhealthinformationto:

• Makedecisionsaboutandplanformycareandtreatment;• Referto,consultwith,coordinateandmanagemycareandtreatmentwithotherhealthcareproviders;• Determinemyeligibilityforinsurancecoverage,andsubmitbills,claimsandotherrelatedinformationtoinsurance

companiesorotherswhomayberesponsibletopayforsomeorallofmyhealthcare;• Performvariousoffice,administrativeandbusinessfunctionsthatsupportmyprovider’seffortstoprovidemewithquality,

cost-effectivehealthcare.IunderstandthatIhavetherighttoreceiveandreviewawrittendescriptionofhowPacificMedicalGroupwillhandleinformationaboutme.ThiswrittendescriptionisknownasaNoticeofPrivacyPracticesanddescribestheusesanddisclosuresofhealthinformationmadeandtheinformationpracticesfollowedbytheprovidersandstaffofPacificMedicalGroup,andmyrightsregardingmyhealthinformation.IunderstandPacificMedicalGroupreservestherighttochangetheNoticeofPrivacyPractices,andthatIamentitledtoreceiveacopyoftherevisedNoticeofPrivacyPractices.PacificMedicalGroupwillpostanyrevisedNoticeofPrivacyPracticesinitsofficeandontheirwebsiteat:http://www.pacificmedicalgroup.com.IunderstandthatIhavetherighttoaskthatsomeorallofmyhealthinformationnotbeusedordisclosedinthemannerdescribedintheNoticeofPrivacyPractices,andIunderstandthatPacificMedicalGroupisnotrequiredbylawtoagreetosuchrequests.oBysigningbelow,IacknowledgethatIhavereceivedacopyofPacificMedicalGroup’sNoticeofPrivacyPractices.oBysigningbelow,IacknowledgethatIwasofferedacopyofPacificMedicalGroup’sNoticeofPrivacyPracticesandIhavedeclinedtotakeacopyatthistime.

8.26.2015

PatientName DateofBirth

PatientorLegalGuardianSignature Date

PatientorLegalRepresentativeSignature Date DescriptionofRepresentative’sAuthority:

� Beaverton � Canby � North Portland � Oregon City � Tigard 4510 SW Hall Blvd. 1185 S Elm St. 6445 N Greeley Ave. 1001 Molalla Ave., Ste 100 13200 SW Pacific Hwy.

Beaverton, OR. 97005 Canby, OR. 97013 Portland, OR. 97217 Oregon City, OR. 97045 Tigard, OR. 97223

503.644.1171 503.723.4660 503.285.6607 503.656.5273 503.598.2000

503.643.7443 fax 503.266.6649 fax 503.285.3195 fax 503.650.4828 fax 503.639.0920 fax

Authorization to Release Medical Information

Patient Name _____________________________________ Other Name ___________________________

Birthdate ____________________________________ Social Security # ____________________________

Current Address _________________________________________________________________________

________________________________________________________________________________________

Daytime Phone # _____________________________

I AUTHORIZE INFORMATION RELEASE FROM:

___________________________________________________

Name of Facility

___________________________________________________

Name of Provider

___________________________________________________

Address

___________________________________________________

City, State, Zip Phone / Fax #’s

INFORMATION TO BE RELEASED TO:

________________________________________________

Facility to Receive Information

_______________________________________________

Title (Provider, Healthcare Facility, etc.)

_______________________________________________

Address

________________________________________________

City, State, Zip Phone / Fax #’s

Type of Information to be Released � Specific Information Only Please � Chart Notes � Immunization Records � Other:

� Laboratory Results � Medications Records ___________________________________

� X-Ray Reports/Films � Physical Therapy

� Most Recent Visit* � Medical records from __________ to ___________* � Last 2 years only* Note: If checkbox is not selected, entire record will be copied/printed. THERE MAY BE FEES FOR PROVIDING COPIES.

*Records more than 25 pages must be mailed not faxed

Protected or Sensitive Information

If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use

and disclosure of the information may apply. I understand and agree that this information will be disclosed if I place my initials in the

applicable space next to the type of information.

______ HIV / AIDS information Initials

______ Mental health information Initials

______ Genetic testing information Initials

______ Drug / Alcohol diagnosis, treatment, or referral information Initials

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be

protected under federal law. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS

information, mental health information, genetic testing information, and drug/alcohol diagnosis, treatment or referral

information. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain health care services or reimbursement for

services. The only circumstance when refusal to sign means I will not receive health care services is if the health care services are solely for the purpose of providing

health information to someone else, and the authorization is necessary to make that disclosure. My refusal to sign this authorization will not adversely affect my

enrollment in health plan or eligibility for health benefits unless the authorized information is necessary to determine if I am eligible to enroll in the health plan. I may

inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of.

I understand that I may revoke this authorization in writing at any time, except: to the extent that action has been taken in reliance upon this authorization. If I revoke

my authorization, the information described above may no longer be used or disclosed for the purposes described in this authorization. Unless revoked earlier, this

authorization will expire 24 months from the date of signing or on (insert applicable date or event) _______________________________________________________.

_____________________________________________________________________________ ________________________________

Signature of Patient or Patient’s Legal Representative Date

_____________________________________________________________________________ ________________________________

Print Patient’s Name or Name of Patient’s Legal Representative (if applicable) Relationship to Patient

� Patient’s or Legal Representative’s Personal Identification Verified ____Associate Initials Revised 3.2012

REASON FOR RECORD

� Personal

� Medical Care

� Benefits

� Litigation

� Workman’s Comp

� Permanent Transfer

� Other: _____________

� Beaverton � Canby � North Portland � Oregon City � Tigard.

4510 SW Hall Blvd 1185 S Elm St 6445 N Greeley Ave 1001.Molalla Ave, Ste 100 13200 SW Pacific Hwy

Beaverton, OR 97005 Canby, OR 97013 Portland, OR 97217 Oregon City, OR 97045 Tigard, OR 97223

503.644.1171 503.723.4660 503.285.6607 503.656.5273 503.598-2000

CREDIT AND PAYMENT POLICY

We are pleased that you have chosen Pacific Medical Group, P.C. as your Primary Health Care Provider. Our goal is to provide you with the highest

level of professional medical care possible, while keeping medical costs to a minimum. In an effort to provide quality medical services, we have

established the following credit and payment policies.

If you have insurance:

We submit claims on your behalf to your primary and secondary insurance carriers. If you have questions or concerns about your insurance

coverage, please call your carrier. Your insurance contract is between you and your carrier. Any remaining patient balance is due within 10 days of

the date you receive your statement.

Non-Covered Services: Payment in full is required at the time of treatment for services not covered by your insurance. Co-payments: Co-payments

are due at the time of service. If you are unable to pay, your appointment may be rescheduled.

Medicare:

Pacific Medical Group, PC accepts Medicare assignment. We will submit your claim directly to Medicare and will bill your secondary insurance

after Medicare has paid their portion. You are responsible for any allowed amount that is not paid by Medicare and/or your secondary insurance.

Any remaining patient balance is due within 10 days of the date you receive your statement.

Oregon Health Plan:

To receive treatment, you must currently be covered by the Oregon Health Plan and assigned to this clinic or to a Primary Care Provider at this

location. You must be assigned to a health plan this clinic participates with. Proof of coverage is required at each time of service.

Workers Compensation:

Please notify the registration desk at each appointment if your visit is due to an injury covered by Workers Compensation. To file a Workers

Compensation claim, you will need the name of your workers compensation insurance carrier, the date of your injury, the name and address of your

employer at the time of the injury, and the claim number (if available). If you have questions or concerns about your insurance coverage, please call

your carrier. We cannot accept responsibility for negotiating a disputed claim.

Motor Vehicle or Other Liability Claims:

Pacific Medical Group, P.C. requires payment within 30 days from the date of service, for visits related to motor vehicle/personal liability injury.

The patient is required to provide accurate complete billing information at the time of service when applicable.

Pacific Medical Group, P.C. requires a $50.00 deposit at the time of service for each visit regarding a motor vehicle accident or personal liability

injury.

In the event that your claim is disputed or a suit is established against another party, Pacific Medical Group, P.C. cannot accept the responsibility of

collecting on these cases or negotiating settlements. Patients will be asked to work with our business office to establish a suitable payment plan to

pay the balance of your medical charges. While we understand that settlement of these cases can take months, we do not feel that suit against another

party is reason for non-payment of your medical charges.

If you do not have insurance:

We require self-pay (uninsured) patients to pay a deposit at time of treatment. In circumstances where unexpected major medical expenses are

incurred, we will help you arrange a payment schedule.

Broken and Canceled Appointments:

Our clinic requests that you notify us 24 hours in advance when canceling a scheduled appointment. We reserve the right to charge a fee for any

appointment canceled or broken without reasonable notice.

Financial Responsibility:

Patients are financially responsible for all services rendered. If you are required to pay for treatment at the time of service, but are unable to do so,

your appointment may be rescheduled. A fee will be assessed for checks returned for insufficient funds. Failure to meet financial responsibility will

result in legal action.

Effective January 1, 2011, a rebilling charge of $5 will be added to all accounts with unpaid patient responsibility balances over 60 days.

Exceptions to these policies will not occur unless you make prior arrangements with our business office.

Agreement:

I have read and understand the Pacific Medical Group, P.C. Credit and Payment Policy. My signature below indicates that I accept this policy and

agree to abide by the terms for my treatment with Pacific Medical Group, PC.

______________________________________ ______________________________________________ ______________________

PRINT PATIENT NAME Patient Signature or Legal Guardian, if patient is a minor Date

We accept: Cash, Personal Checks, Money Orders and Most Major Credit Cards Rev06.2011

rev2.2016

Genetic Privacy Notice

NOTICE OF YOUR RIGHT TO DECLINE PARTICIPATION IN FUTURE ANONYMOUS OR CODED GENETIC RESEARCH

Pacific Medical Group is required by Oregon law to provide this notice to you regarding use of your health information or biological samples for genetic research (OAR 333-025-0100 – 333-025-0165). State laws protect the genetic privacy of individuals and give you the right to decline to have your health information or biological samples used for research.

A biological sample may include a blood sample, urine sample, or other material collected from your body. You can decide whether to allow your health information or biological samples to be available for genetic research. Your decision will not affect either the care you receive from your health care provider, or your health insurance coverage.

Research is important because it gives us valuable information on how to improve health, such as ways to prevent or better treat heart disease, diabetes and cancer. Under Oregon law, a special team reviews all genetic research before it begins. This team makes sure that the benefits of the research are greater than any risks to participants. In anonymous research, personal information that could be used to identify you, such as your name, Social Security number or medical record number cannot be linked to your health information or biological sample. In coded research, personal information that could be used to identify you is kept separate from your health information or biological sample, making it very difficult to link your personal information to your health information or biological sample. Your identity is protected in both types of research. If you want to allow your health information and biological sample to be available for anonymous or coded genetic research, you don’t have to do anything . If you make this choice, your health information or biological sample may be used for anonymous or coded genetic research without further notice to you. If you do not want to have your health information and biological sample available for anonymous or coded genetic research, you must tell your health care provider by:

• Requesting and completing the Genetic Privacy Opt-Out form from the clinic front desk, and

• Giving or mailing the form to your health care provider. The Genetic Privacy Opt-Out form can be obtained from your health care provider at the clinic’s front desk. No matter what you decide now, you can always change your mind later by completing a form and returning it to your health care provider. Your new decision is effective on the date your health care provider receives the Genetic Privacy Opt-Out form, and will apply only to health information or biological samples collected after your health care provider receives the form. If you have questions about genetic research, please call the Oregon Genetics Program at 971-673-0271.

rev2.2016

Genetic Privacy Opt-Out

GENETIC PRIVACY – OPT OUT STATEMENT

□ I have read and understand the Genetic Privacy Notice and I DO NOT WANT to have my health information and/or biological samples available for anonymous or coded genetic research,

Patient’s Name (Print): _ _ Today’s Date:

Patient’s Signature: _ _ _ _ _

Patient’s Date of Birth: _ _ _ _ _

Personal Representative’s Name (Print): _ _

Personal Representative’s Signature: _ _ _ _

Describe authority and relationship to Patient: _ _ _

Regardless of your decision now, you may change your decision at any time by completing a new Genetic Privacy Notice form and returning it to your health care provider. Your new decision is effective on the date that your health care provider receives your new Genetic Privacy Notice and will apply only to health information or biological samples collected after your health care provider receives your new directive. If you have questions about genetic research, please call the Oregon Genetics Program at 971-673-0271.

This directive will be retained in your medical chart throughout your relationship with Pacific Medical Group.

OTHER FAMILY MEDICAL HISTORY:______________________________________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY

FAMILY HISTORY

Cancer:

Heart Attack:

Diabetes:

High Blood Pressure:

High Cholesterol

Kidney Disease:

Stroke:

Seizure Disorder:

Depression:

Alcoholism:

Bleeding Disorder:

Mental Health:

Other:

Alcohol Trouble

Anxiety

Asthma

Back Trouble

Bleeding Disorder

Cancer

Chicken Pox

Depression

Diabetes

Epilepsy

Fainting Spells

German Measles

Glaucoma

Heart Disease

Heart Murmur

Hepatitis

High Blood Pressure

High Cholesterol

Kidney Trouble

Lung/Respiratory Disease

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

Lung Trouble

Measles

Memory Loss

Migraine

Mononucleosis

Mumps

Nervous Breakdown

Peptic Ulcer

Polio

Rheumatic Fever

Scarlet Fever

Sexual Diseases

Stomach Ulcer

Stroke

Thyroid Trouble

Tuberculosis (T.B.)

Urinary Tract Infection

Whooping Cough

Other Illnesses

If Yes, please describe:

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

Accidents/Fractures

If yes, please describe:

Appendectomy

Back

Breast

Cataract

Colon or Intestine

Ear Tube Replacement

Gallbladder

Hernia

Heart

Hysterectomy

Prostate

Tonsillectomy

Other Surgeries

If yes, please describe:

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

Tobacco

Alcohol

Drugs

Caffeine

Exercise

HABITS:yes

yes

yes

yes

yes

ALLERGIES: Describe

How much? SOCIAL HISTORY yesMarried yesSingle

CURRENT MEDICATIONS: (List by name, including over the counter)

PERSONAL HISTORYILLNESSES: Please fill in “yes” for all that you have been treated for. SURGERIES:

Date of Birth: Gender: M F Other Date:

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

yes

Date of Previous Screening Tests:(If applicable)

PAP smear

Mammogram

Bone Density

Colonoscopy

Name:

pmg med hx 03/16

Widowed yes Divorced yes Partnered yes

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Immunization Dates: (If applicable)

Pneumococcal

Flu Tetanus

Ophthalmologist Visit :(If applicable)

Date:

Name:

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Non-CoveredEntityAuthorization Revised 4.2010

Authorization to Use/Disclose Protected Health Information **Release by Pacific Medical Group to a Third Party (Non-Covered Entity)**

------------------------------------------------------------------------------------------------------------------------------------------------------------------ THIS AUTHORIZATION MUST BE COMPLETED IN FULL FOR IT TO BE VALID.

Patient Name (Print) ___________________________________________________ DOB _____________________________ I authorize Pacific Medical Group to disclose my protected health information to: ______________________________________________________________________________________________________

Please Print (Name, phone # and address of recipients) for the purpose(s) of: ______________________________________________________________________________________________________

Please Print (Describe each purpose of the use/disclosure)

______________________________________________________________________________________________________

______________________________________________________________________________________________________

My protected health information includes medical records, emergency and urgent care records, billing statements, diagnostic imaging reports, transcribed hospital records, clinical office chart notes, laboratory reports, pathology reports, physical therapy records, hospital records (including nursing records and progress notes), and any personal or medical information related to the purpose of this Authorization. Information obtained with this Authorization will be used solely for the purpose defined above and will be limited to the minimum necessary information to achieve that purpose. If the information to be disclosed contains any of the types of records or information listed immediately below, additional laws relating to use and disclosure of the information may apply. I understand and agree that such information will be disclosed if I place my initials in the applicable space next to the type of information to be included with the disclosure: ______HIV/AIDS test or result information and related records

______Mental health information

______Genetic testing information

______Drug/alcohol diagnosis, treatment, or referral information

I have the right to revoke this authorization by sending a written statement to the Clinic Manager at Pacific Medical Group or other specified person at Pacific Medical Group ______________________and state that you are revoking this authorization. If you revoke your authorization, the information described above may not longer be used or disclosed for the purpose described in this written authorization. Any use or disclosure already made with your permission cannot be undone. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and may not longer be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS test or result information, mental health information, genetic information and drug/alcohol diagnosis, treatment or referral information. Unless revoked, this Authorization shall be in force and effective until the following (must give DATE or EVENT, check one):

□ Date: ______________________________________________________________ -OR-

□ Event: _____________________________________________________________________

at which time this Authorization to use or disclose this protected health information expires. Further, this Authorization is null and void 24 months from the date of signature.

I have reviewed and I understand this Authorization.

- OR -

By: _______________________________________________ Date:_____________________ (Individual)

By: _______________________________________________ Date:_____________________ (Individual’s representative) Relationship to patient: □Parent □ Other ____________________________________________________________

(List Relationship) □Legal guardian* □Holder of Power of Attorney*

*Please attach legal documentation if you are the legal guardian or Holder of Power of Attorney

Today's Date:

Patient Legal Last Name First Name Middle Init Preferred Name

Address Gender o Male Date of Birth

o Other o Female

City State Zip Email Address

Primary Phone Secondary Phone Other Phone

o Home o Cell o Work o Home o Cell o Work o Home o Cell o Work

Employer Name Marital Status

o Single o Marriedo Employed o Unemployed o Retired o Student o Partnered o Widowed

Guarantor Name (if other than patient) Patient Relationship to Guarantor Guarantor Date of Birth

o Spouse/Partner o Child o Other

Address (if different than patient) Phone Number

o Home o Cell o Work

Primary Insurance Company Secondary Insurance Company

Address Address

ID number Group Number ID number Group Number

Group Name or Employer Group Name or Employer

Subscriber Name (if other than patient) Subscriber Name (if other than patient)

Subscriber Relation to Patient Date of Birth Subscriber Relation to Patient Date of Birth

Name Phone Number(s) Relationship

How did you hear about Pacific Medical Group?

o Other Doctor o Online Search o Advertisement o Insurance Company

o Friend/Family Member --- Name ____________________________________ o Other _________________________________

Race? (Federal Statistics and Administration reporting for medical research purposes)

o I decline to answer o American Indian or Alaska Native o Asian o Two or more races

o Native Hawaiian or Pacific Islander o Black or African American o White

Ethnicity? (Federal Statistics and Administration reporting for medical research purposes)

o I decline to answer o Hispanic or Latino o Not Hispanic or Latino

Preferred Language ____________________________________________ o Interpreter Needed

Preferred Pharmacy Name & Location_________________________________________________________________________________

Insurance Information

Patient Registration

Emergency Contact

revised 8/2015

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