Donald C. Lanza, MD 550 94th Avenue North

St. Petersburg, FL 33702

Office 727-573-0074

Fax 727-573-0076 Out of State 877-SNI-FLMD

www.sniflmd.com

SINUS & NASAL INSTITUTE OF FLORIDA, P.A.

EXCELLENCE IN PATIENT CARE, EDUCATION, & RESEARCH

Dear Thank you for your interest in the Sinus & Nasal Institute of Florida, P.A. There are 9 enclosures:

1. New Patient Questionnaire – signature required 2. Patient Registration Form – signature required 3. Consent to Care – signature required 4. Urgent Care when Dr. Lanza is out of the office – signature required 5. Insurance Coverage and SNI – signature required 6. Privacy Policy – signature required 7. Permission to Photograph and Publish – signature required 8. Contact information, directions, air travel/lodging information – for your files 9. SNI Brochure which describes our unique center – for your files

Please complete and return these forms to us prior to your appointment by mail or by sending them via fax to 727-573-0076. Additionally, if you have any of the following please try to obtain them prior to your appointment and either bring them with you or fax them to us:

• Hospital discharge summaries

• Operative reports from prior nasal or sinus surgery

• Sinus culture results

• Surgical pathology reports

• Sinus imaging studies (CT or MRI) – actual films are best but reports can be useful.

• Blood test results from last two years

• Allergy test results

• Breathing test results We encourage all new patients to learn more about our practice, our credentials, about what to expect during your office appointment and to learn more about nasal and sinus disorders by going to our website, www.sniflmd.com . As you are aware, we do not have contractual agreements with many insurers. Please check to see if you have “out-of-network” benefits and read the enclosure “Insurance Coverage & SNI”. Payment is due at the time of service. If we are not a participating provider, your insurance will typically reimburse you directly. As a service to you, we will offer to submit the charges to your insurance company. If you have any questions, please do not hesitate to contact our office. Sincerely,

Consent to Care

SINUS & NASAL INSTITUTE OF FLORIDA, P.A. Donald C. Lanza, M.D., F.A.C.S. Director 550 94

th Avenue North

St. Petersburg, FL 33702 PATIENT Name: DOB: PATIENT ACKNOWLEDGMENT AND CONSENT (Changes or alterations to this form are not permitted and are not binding on the Sinus & Nasal Institute of Florida, P.A.) (SNI) Financial Responsibility: Subject to applicable law and the terms and conditions of any applicable contract between The Sinus & Nasal Institute of Florida, P.A. and a third-party payer, and in consideration of all health care services rendered or about to be rendered to the patient named below, I agree to be financially responsible and obligated to pay SNI for its charges not paid under the "Assignment of Benefits" made below. Assignment of Benefits/ Third-Party Payers: In consideration of all health care services rendered or about to be rendered to me or the patient named below, I hereby assign to SNI all right, title, and interest in and to any third-party benefits due from any and all insurance policies and/or responsible third-party payers in an amount not to exceed SNI's regular and customary charges for the health care services rendered. I authorize such benefits to be paid directly to SNI. I agree to cooperate with SNI and/or its agents in their efforts to secure payments from my insurance carriers, third-party payers, and other third parties. I consent to any request for review or appeal by SNI to challenge a determination of benefits made by a third-party payer. Except as required by law, I assume responsibility for determining in advance whether the services provided to me are covered by my insurance or other third-party payer. Uses and Disclosures of Health Information: I acknowledge that I have received the Notice of Privacy Practices of SNI. I understand that the Notice of Privacy Practices explains how SNI may use and disclose confidential health information that identifies me. I consent to let SNI use and disclose health information about me as described in the Notice of Privacy Practices. In doing so I consent to the release of my health information and financial account information to all third-party payers and/or their agents that are identified by SNI, its billing agents, collection agents, attorneys, consultants, and/or other agents that represent SNI or provide assistance to SNI for the purpose of securing payment from all parties who are potentially liable for payment for my health care, including for substance abuse, psychiatric care, or HIV, if applicable. I can revoke my consent in writing at any time except to the extent that SNI has already relied on my consent. Teaching Facility/ Clinical Studies: I acknowledge that SNI is a teaching facility and that doctors and others in training may be involved in my health care. I also know that many SNI patients participate in clinical studies. I know I can ask my primary doctor questions about having health professionals in training involved in my care and about participating in clinical studies, and I can explain any views I have. All clinical studies at SNI go through a special process required by law that reviews patient safety and privacy. SNI patients usually consent in writing to participate in clinical studies. Sometimes family members or other surrogates are asked for consent when patients are not mentally able to give their own consent. Patients are encouraged to discuss how they feel about being research participants with family members so they will know the patients' wishes if asked. Valuables/ Limitation of Liability: I understand that I should not bring valuables (jewelry, money, irreplaceable documents, etc.) with me to SNI. I AGREE THAT SNI SHALL NOT BE RESPONSIBLE FOR VALUABLES. If I do not deposit my valuables, SNI is not responsible for them, even if I give them to other SNI personnel. Items in the SNI's Lost and Found are given to charity after 30 days. By signing below, I am indicating that I have reviewed and consent to the terms described above:

X _____________________________ Signature of Patient or Responsible Party Date: ______________________________ Print Name if not Patient): _____________________________________ Relationship to Patient: _____________________________________

Directions

Sinus & Nasal Institute of Florida, p.a. 550 94th Avenue North,

St Petersburg, Florida 33702 Tel: 727-573-0074 Fax 727-573-0076 www.sniflmd.com

As seen on the map below our old office is marked by the blue star and is situated 3.5 miles north and west of our new office located by the red star.

From the North & East (Tampa, Leesburg, Orlando, Daytona)

� From Orlando head west on I-4 towards Tampa/St Petersburg and follow signs to I-275 South (St. Petersburg). From Leesburg Take I-75 south to I-275 South (St. Petersburg).

� Once you cross the Howard Frankland Bridge exit I-275 (exit 32) heading south on 4

th Street North.

� At the second traffic light turn right onto Koger Blvd. N. Travel to the end of this road.

� At the stop sign you will see our new building directly in front of you. Turn left onto 94

th Ave. North

� Make an immediate right turn into our driveway at 550 94

th Ave. N.

Directions

Sinus & Nasal Institute of Florida, p.a. 550 94th Avenue North,

St Petersburg, Florida 33702 Tel: 727-573-0074 Fax 727-573-0076 www.sniflmd.com

From South (Downtown St. Petersburg, Sarasota, Naples, Miami)

� From Sarasota or South take I-75 north towards Tampa/ St. Petersburg and exit onto I-275 North towards St Petersburg.

� While heading north on I–275 take exit 28 (Pinellas Park, Seminole & Gandy, SR 694)

� Veer to the right off of the exit ramp onto Gandy Blvd (also known as SR 694 ) heading east.

� At the 1st traffic light (Frontage Road) turn right & then a make quick left turn onto 94

th Ave. N.

� Drive a bit more than ¼ of a mile past the next traffic intersection (Dr. Martin Luther King, Jr. St. North

aka 9th Street N) & turn right into our driveway at 550 94

th Ave. N.

From the Northwest (Clearwater, Tarpon Springs, New Port Richey)

� From Clearwater take Country Road 611 south (aka McMullen Booth Rd N ) across the Bayside Bridge to Ulmerton Road (RTE 688). Turn left (head east) onto Ulmerton Road (RTE 688).

� From Ulmerton Road (RTE 688), once you pass the Rally Gas Station at the corner of 34

th St N on the

right, veer to the right onto Roosevelt Boulevard (EAST 686 to SOUTH I-275). The right lane is an “exit only” lane.

� Travel to 3

rd traffic light and turn right onto Dr. Martin Luther King, Jr. St. North (also known as Pinellas

County Road 803 & 9th St. N.).

� Go south to the 5

th traffic light and turn left onto 94

th Ave. N. (BP gas station is on left corner)

� Just a bit more than ¼ of a mile turn right into our driveway at 550 94

th Ave. N.

From West (Largo)

� From Largo head east on Ulmerton Road (RTE 688).

� From Ulmerton Road (RTE 688), once you pass the Rally Gas Station at the corner of 34

th St N on the

right, veer to the right onto Roosevelt Boulevard (EAST 686 to SOUTH I-275). The right lane is an “exit only” lane.

� Travel to 3

rd traffic light and turn right onto Dr. Martin Luther King, Jr. St. North (also known as Pinellas

County Road 803 & 9th St. N.).

� Go south to the 5

th traffic light and turn left onto 94

th Ave. N. (BP gas station is on left corner)

� Just a bit more than ¼ of a mile turn right into our driveway at 550 94

th Ave. N.

Insurance Coverage & SNI Donald C. Lanza, MD

550 94th Avenue North St. Petersburg, Florida 33702

Office 727-573-0074

Fax 727-573-0076

Out of State 877-SNI-FLMD

SINUS & NASAL INSTITUTE OF FLORIDA, P.A.

EXCELLENCE IN PATIENT CARE, EDUCATION, & RESEARCH

Dear Currently we have contractual agreements with three insurers. We accept : Blue Cross/Blue Shield (inc. All plans) , Cigna, Evolutions, Great West, and Medicare. If you do not have one of these insurances, please check to see if you have out-of-network benefits (see below). We do offer to submit the charges to your insurance company but if we are not a participating provider, many insurers will reimburse you directly. Thus, payment for our service is due when the care is rendered. There are three options for patients who do not hav e insurance coverage for our services. 1. Out-Of-Network Benefits Variables affecting this type of coverage include:

a. Patient’s deductible b. Level of out-of-network level of coverage c. Although very helpful, there is still likely to be some out-of-pocket expense, since “out-of- network” benefits do not typically cover all the costs for your evaluation and treatment with “The Sinus & Nasal Institute of Florida”. You are welcome to discuss SNI charges with our office manager.

2. Request Permission for “Out-Of-Network Coverage” Patients without “out-of-network” benefits can sometimes obtain permission for an evaluation when a referring otolaryngologist and/or their primary doctor writes your insurance company with a “Letter of Necessity” on your behalf.

A. Elements for Physicians to include in the “Letter of Permission for Out-of-Network Evaluation and Care” • Patient name and insurance information (guarantor information if it applies) • Describe the complexity of the patient’s condition and diagnoses • Include a statement as to why you believe we may be better suited to handle the patient’s healthcare problems.

(Additional factual information regarding our center and the credentials of our director is available on our website www.sniflmd.com or in our enclosed brochure).

B. Patients are also encouraged to write their own letter to the insurer indicating why they believe they may need the

services of Dr. Lanza and The Sinus & Nasal Institute of Florida. The letter should include similar information described above. Occasionally requesting that your insurance company assign a case manager to your health care issues can be of benefit.

3. Out-of-Pocket Payment

a. Payment is anticipated at the time services are rendered. b. Payment plans for individuals can be established in advance.

By signing below, I am indicating that I have reviewed and understand the information and terms described above: X ____________________________________________________ Signature of Patient or Responsible Party Date: __________________________ Print Patient Name & Responsible Party’s Name: ________________________ ____________/X________________________________________ First Last First Last Responsible Party’s Relationship to Patient:_______ ________________________

PERMISSION TO PHOTOGRAPH AND PUBLISH

Patient: ____________________________________ DOB: ____________________________________ Date: ____________________________________ About Photographs & Video recording

The Sinus & Nasal Institute of Florida, P.A. requests your permission to use selected sinus CT images, MRI images, digital photographs and/or video of your medical condition for our electronic medical record. These will help identify you more readily so that your care can be improved when it is carried out by phone. Occasionally, we may videotape portions of your physical examination. This may be used for comparison at future visits to measure change in your condition, but also it can be used at a later time for the strict purposes of education or research.

Permission: In connection with the medical services that I am receiving from Donald C. Lanza, M.D., Director, Sinus & Nasal Institute of Florida, P.A. I consent that digital photographs and/or video may be taken of me, my imaging studies (CT or MRI Scans) or parts of my physical examination under the following conditions:

1) The photographs and/or video may be taken by my physician and/or an assistant of my physician. 2) I understand that I will be identified by name in the electronic medical record where this information

is stored. Should any of this information be used for purposes of education or research any identifying information, other than that which is an integral part of the photograph or video itself, will be removed. At no time will we display your facial appearance outside of the medical record, unless you separately consent to that.

3) The photographs, or prints and the video or any copies will be used for medical records, and may be used for medical research, educational or scientific purposes. They may be published and republished, either separately or in connection with each other in professional journals or medical books and used for any other lawful purpose that SNI may deem appropriate.

4) I understand that the photographs and/or video may be modified or retouched in any way by SNI. 5) I understand that the photographs and/or video are and will remain the exclusive property of SNI

and I will have no right, title or interest in them.

X__________________________________________

Signature of Patient

X _________________________________________

Witness Signature ___________________________________________ Witness Printed Name

Sinus & Nasal Institute of Florida, P.A. NOTICE OF PRIVACY PRACTICES

Dear Patient: Physicians have always protected the confidentiality of health information by locking medical records in file cabinets and refusing to reveal your health information. Today, state and federal laws also attempt to ensure the confidentiality of this sensitive information. The federal government recently published regulations designed to protect the privacy of your health information. This “privacy rule” protects health information that is maintained by physicians, hospitals, other health care providers and health plans. As of April 14, 2003, your physician will need to comply with the privacy rule’s standards for protecting the confidentiality of your health information. This new regulation protects virtually all patients regardless of where they live or where they receive their health care. Every time you see a physician, are admitted to the hospital, fill your prescription or send a claim to a health plan, your physician, the hospital and health plan will need to consider the privacy rule. All health information including paper records, oral communications and electronic formats (such as e-mail) are protected by the privacy rule. The privacy rule also provides you certain rights, such as the right to have access to your medical records. However, there are exceptions; these rights are not absolute. In addition we will be taking even more precautions in our office to safeguard your health information such as training our employees and employing computer security measures. Please feel free to ask your physician or our privacy contact about exercising your rights or how your health information is protected in our office. The Notice of Privacy Practices attached to this letter explains our privacy practices. It contains very important information about how your protected health information is handles by our office. It also describes how you can exercise your rights with regard to your protected health information. May we leave a message regarding your health or upcoming appointment on your answering machine or cell phone? _____ YES _____NO Please let us know if you have any questions about our Notice of Privacy Practices. You may contact our privacy contact at (727)573-0074, or discuss any questions you may have with your physician. I acknowledge I have received the “The HIPAA Privacy Rule” for the Sinus & Nasal Institute of Florida, P.A.. _________________________________________ Name of Patient (Print) __________________________________________ Signature of Patient Date I authorize disclosure of my protected health information to: ________________________________________ Name of Person / Relationship ________________________________________ Name of Person / Relationship ________________________________________ Name of Person / Relationship

File-02-23-09

PATIENT REGISTRATION FORM Patient Information Today’s Date Last name

First name

Marital Status S M W D

Date of Birth / Gender M / F

SS#

Local Street Address

City/State Zip Home Phone # ( )

2nd Address

City/State Zip 2nd Phone # ( )

Patient’s Employer Occupation

Business Phone # ( )

Employer’s Address Fax # ( ) Cell Phone # ( )

Pharmacy Name

Pharmacy Phone # ( ) Pharmacy Fax # ( )

Spouse’s Name (if applicable) Phone # ( ) 2nd Phone # ( )

Emergency Contact Relationship to Patient

Phone # ( ) 2nd Phone # ( )

Insurance Information Name of Policy Holder Relationship to Patient:

Insurance Company Name Policy # Group #

Insurer Address

City/State Zip Phone # ( )

Secondary Insurance Company Name

Name of Policy Holder Policy # Grp#

Secondary Insurer Address

City/State Zip Phone # ( )

Referring Physician _______________________________________________________________

Address ________________________________________________________________________

Telephone ( ) _____________________________ Fax ( ) ___________________________ Primary Care Physician ______________________________________________________________

Address ________________________________________________________________________

Telephone ( ) _____________________________ Fax ( ) ____________________________

Authorization: I hereby authorize the office of Donald C. Lanza, MD at the SNIFL to furnish my medical information to insurance carriers, and hereby irrevocably assign to the doctor all insurance payments for medical services rendered by this office. I understand that I am financially responsible for all charges whether or not covered by insurance. I understand that payment for office visits is required at the time service is rendered. Responsible Party Signature X _______________________________________________ Date ________________________

Please complete and return this form to us prior to your appointment by mail or via fax to 727-573-0076.