Patient Medical Information Kendall L. Wise, MD (239) 261-5400 N.. Naples FL 34102 (239) 261-4387 A Division of 21 st Century Oncology, LLC 1044 Goodlette Road Today's Date: Patients Date of Birth: Patient Name (Legal): First Middle Last Allergies (Food or Drug) Please list all medications you are currently taking: (Include dosage and frequency) Medication Dosage & Frequency PATIENT MEDICAL HISTOKY Renal Cancer Prostate Cancer Bladder Cancer He~naturia Diabetes Ulcer Arthritis Cancer Renal Failure Stones Recurrent UTI Prostatitis Stroke Asthma COPD Pulmonary Embolism Headaches PATlENT SURGICAL HISTORY Colitis Gallbladder Problems Ulcer Congest i~ e Heart Failure Myocardial Infarction (Heart Attack) Cardiac Problems-list type: Arrhythmia High Blood Pressure Diverticulitis Seizure Depression Hepatitis Liver Problems Anemia leukemia Thyroid Disease PLEASE INDICATE "L" (Left)"Rt'(Right)OR "BI" {bilateral-both sides) and approximate date L R Bi Cataract Appendectomy Lung Arthroplasty Heart Kidney Stone Bladder Prosthesis Incontinence Colon Removal of Gallbladder Hernia FAMILY HISTORY Relationship to you (exarnp1e:brother) Cancer-List Type: Prostate- Cancer Stones Heart Disease Diabetes Strokes Hypertension MALE Prostate Testis Vasectomy FEMALE Ovarian Syndrome Uterine Surgery Breast Surgery # of Pregnancies Cesarean Section Hysterectomy EEI SOCIAL HISTORY Language Race White Black or African American American Indian or Alaska Native English Spanish French German Portuguese Russian Chinese lapanese Italian Other Eskimo Hispanic or Latino Asian Native Hawaiian or Pacific Islander Unknown Other Ethnicity Non-Hispanic or Latino Hispanic or Latino MARITAL STATUS Single SMOKING HISTORY No History Currently Smoke Former Smoker # Of Packs Smoked/Day Widowed Divorced Married Spouse Name: ALCOHOL USE YES Types of alcohol consumed: Drinking Habits: REVIEW OF SYSTEMS Constitutional Symptoms: Chills Fever Weight Loss Eyes: Blurred Vision Double Vision Cataracts Ear/lVose~hroat/Mouth: Nasal Stuffiness Hearing Loss Sore Throat Curdiuvrrscular: Chest Pain Irregular Heartbeat Swollen Ankles Respiratory: Shortness of Breath Wheezing Cough PATIENT SIGNATURE: CAFFEINE How many caffeinated beverages per day? I I NOTANY MORE Beer Light social NEVER Wine Other Moderate Excessive Gastrointestinal: Abdominai Pain Nausea /Vomiting Change in Bowels Genitourinaty : Blood In Urine Incontinence Painful Urination Musculoskeletal: Chronic Back Pain Chronic Neck Pain Sore Muscles Neurologicrrl: Dizzy Spells Numbness/Tingling Hematologic/Lymphatic: Abnormal Bleeding Swollen Glands Transfusions New Patient Information Sheet (239) 261-5400 KendalI L. Wise, MD 1044 Goodlette Road N.,Naples FL 34102 (239) 261-4387 A Division of 2lst Century Oncology, LLC TODAY'S DATE: i PRIMARY CARE PHYSICIAN: REFERRING PHYSICIAN: HOME #: ( 1 CELL#: ( ) NAME First Last Middle DATE OF BIRTH: / 1 SOC. SEC. # ADDRESS Street City State Zip City State Zip OUT OF AREA ADDRESS Street GENDER: (cirde one) MARITAL STATUS; {circle one) Male I Female Married I Single / Divorced I Widowed ETHNICITY: (circle one) HispaniclLatino / Other I Not RepofiedlRefused RACE: (circle one') White (Caucasian) / BlacWAfrican American / Asian / Native American American IndianlAlaskan Native / Native Hawaiian I Pacific Islander Asian Pacific American / Subcontinent Asian American I Hispanic Caucasian Non-Hispanic / Black Non-Hispanic / More than 1 race / Other Race PHARMACY INFORMATION Pharmacy Name: Pharmacy Location: Pharmacy Pbone # PRIMARY 1NSURANCE INFORMATION Name of Company: Group: Insured's/Guarantor Name: Guarantor Date of Birth: SECONDARY INSURANCE INFORMATION Name of Company: Group: Insured'y/Guarantor Name: Guarantor Date of Birth: ADDITIONAL 13RD)INSURANCE INFORMATION Name of Company: Croup: Insured'slGuarantor Name: Guarantar Date of Birth: Use this form during patien1 r e g ~ s t r a t ~ aton dbcument any patient requests to authorize and r e s t r ~ c thow [her health informath is disclosed to frcends/farnily memberstothers. Use also to document any {€quests fw c o n f i d e n t i a l cornmunrcationa Patient Authorization for Genetal Disctosure andlor Request for Restrictions of Protected Health Information and Request for Confidential Communications 1 hereby request the fo~lowrnguse cr disclosure of m f health infcfmaticn as descfibeo below Patlent M a m t I h.le0;sal Rec7rd Number Date of Binh ' I ioaress iSl(ee1. 21ir, Stale. I Telephone hurnDer Code) I 1 requesl that my heelb iniormal~onor m e d a l b~lhngrcord b1 -e~d16cl0scd - 1 . ~ 1 c i r ~or se . I Alrrhorrrd U I names ~ Irsted aelow 10 haw access to my medical Inf~rmar~on. These people may call and speak with Ihs nurseldocfn~ about m), case. I have Ihe right to terminate mi$ agreemen( el any time by infotmmg a (flpfssonlaliue of the physicran office 'bb NOT discuss or provide informalion lo Ihe fallowing individua,~ or enlirirs: Authorized Name i 'I requesl the use of ONLY lhe follawl~gaddress andlor phone numbtr(s) ro conlacl me regarding my health or bill~ngrnformation. Patient Rtghls: Your physiclvn office maxt permkt psllenls lo reque$[rtsirictiova oflheir protected hcallh ~nlorn,atrurh. Patlenls may teqUeSr reslriclion of UCRE and disclosures o i prolscled health inlorpalion to carry owl Irealment, payment, and healthcafe operations; discIosures lo a family member, OlhW relalive, dose personal friend. or any *!her person ident~tiedby Ihe palienl of pcotected heallh ~nfomaliondireclly releven( l o such person's 1nuolv6mentwth m e patlenl's care: and diislbzures uf protecied hcrlrh ~nl~rrrdalivn to notify or 3siis1 \nme not\dtation o( a family member, a personal rspresenlatrve or anotner parson r e ~ p o n s r ~tor l e Ihe care of me pallent or the pslien'z localion, general cundilion, or death. AH reqvesls for restrlcraons must be submitted in wrifino. Physlelan Ofi~ceR e s p ~ n s ~ b r l i t t sYour s : physicIan omce 13 nor requrred lo grant most re:lr~cliono and rs prscrrrded from granling restrictions Ihaf would vrolare [he law. H we agree ro the reslricllon, we wlil comply n l l n 11unlots ycu ask lo lerrnlnale the- rerlriction or w e nol~fyvou !hat wc I r e lermtnatina Ihe agreement. If you reqdrd ernstgenq treslment, we may release Ihe reslrided information wrlhout your consenl ifil Is rleeded 10 provide Iha~trealment. Dale jignature a i Patient or Legal Represenhh~e A It Signed I by Legal Reptasanlal~ve,Refallonshiplo Paltsnl ~ISQOSlTlOM of PATlEHf REQUEST: The above request fw r+str\clionof heakh m f m a t h n by the above-nar,edpatient has been' 'Granted 'If GRANTED, Opnitcl an Alen must be entered inlo all eleclr6ntc medlcal records and/or practrce management (billing) sysremis) Reason(s) for D e n ~ a tif, Applicable Physician Office Representative' - + Oale; I . -. - . --- - - Oncology LeelCollier Counties, Florida Market Patient Protection and Affordable Care Act of 2010 Patient Disclosure for Diagnostic MRI, PET or CT Services Dear Patient, If your physician determines that a referral for diagnostic MRI, PET or CT services is appropriate as a part or your medical evaluation and treatment; we may have these services available at one of our locations. We will provide you information about those options. You, however, have the freedom to choose the supplier for this service. To the best of our knowledge, the following providers furnish these services in the area Name: Radiology Regional Centers Address: 6100 Winkler Rd, Ft. Myers. FL 33919 Name: Advanced Radiology Imaging Associates, LLC Address: 13731 Metropolis Ave, Ft. Myers, FL 33912 Name: Florida Radiology Consultants Address: 6311 Southpointe Blvd, Ft. Myers, FL 33919 Name: Naples Diagnostic Imaging Center Address: 31 1 North Tarniami Trail, Ste 104, Naples, FL 341 02 Name: Radiology Regional Centers Address: 700 Goodlette Rd, Naples, FL 34102 1 have read and understand this notice Patient Name (Printed): Patient Signature: Form # RTMS 04 1 030 0 V . l Date: Date: 01/10/201 1 Kendall L. Wise, M.D. 1044 G d l e t t e Rd. N. Naples, FL 34102 Phone (239)261-5400 Fax (239)261-4387 AUTHORIZATIONS AND PAYMENT AGREEMENT When assignment is accepted, I hereby authorize payment directly to Kendall Wise, for benefiis (including Medicare benefits or Major Medical) payable under the terms of my insurance or governmental coverage for any sewices furnished me by Kendall Wise. (Void aft^ Decemher 31 of this calendar year on Medical Claims.) Upon receipt of a written request for release of medical information, I hereby authorize Kendall Wise to mlease information acquired in the course of my examination or treatment. I hereby authorize any physician, hospital, or medical facility to provide information on my medical history and treatment to Kendall Wise. I hereby authorize any holder of medical or other information about me to release to the Social Security Administration and/or the State of Florida or their intermediary or fiscal agent any information needed for Medicare or Medicaid claims. I hereby authorize Kendall Wise to receive "Explanation of Medicare Benefits" advisements for non-assigned Medicare claims on my behalf directed from the Medicare intermediary. I hereby certify that the information given by me in applying for payment under the Medicare or Medicaid programs is correct. I hereby authorize photocopies of this form to be as valid as the original. 1 hereby agree to be responsible for the payment of this patient's account. PATHOLOGY CONSENT: I hereby authorize the physicians of Kendall Wise to order any pathology testing they deem necessary in connection with off ice visits or surgeries. OUR PAYMENT POLICY* PLEASE NOTE You are responsible directly to the office for payment of your account, regardless of the status of medical or liability insurance claims. Mice charges should be paid on the date incurred. All other charges are payable within 60 days, unless you arrange an extended payment plan. A~countswith charges 60 days or older will be subject to a rebilling fee. The undersigned hereby obligates himherself to pay the account for medical sewices rendered. If this account is referred to an attorney or collection agency for coliection, the undersigned shall pay for reasonable attorney's fees, collection expenses, court costs and recording fees. Upon mquest, special consideration may be extended in the event of hardship. To avoid misunderstandings, we invite you to discuss problems with our practice manager. Standardized insurance forms are completed as a courtesy to you without c h q e . The office does not accept responsibility far collecting your insurance claims or negotiating settlement on a disputed claim. Theg&eiima% mguktbm andpokcras r e g d i n g ttm m d p t ofpayment Irwn M e d b or M e d M a m a@abk on my #&&m claim whwe the or daccepts ass&nmant of benem. If you haw a question or need tWw W t i o n rn ~ p a y m e n t spAwielet , us know. w M&&d OAT€: SIGNATUREOF PATIENTAND/OR G U M O R