Hello Patients and Families! We are a team of Doctors and Nurse Practitioners that bring primary care to you. Our motto is “Extending Care to Meet Your Needs” and we are passionate about that! We see patients in their own Homes, Independent Living Facilities, Assisted Living Facilities, Adult Day Care Centers, Personal Care Facilities and Skilled Nursing Facilities. We are excited that we are now your primary care doctor/nurse practitioner. 1300 Clear Springs Trace, Suite 4 Louisville KY, 40223 Phone: 502-356-4377 Fax: 888-959-2460 Email: housecalls@echp2u.com Web: www.echp2u.com Office Hours: Mon to Fri 8:00am - 4:30 pm If you have an urgent issue that cannot wait till normal business hours call 502-356-4377 press option #1 and you will be connected to an on-call provider. If it is a TRUE emergency call 911 immediately. BILLING ADDRESS: 3903 Vantage Place Louisville KY, 40299 Phone: 502-565-4355 Email: billing@vocisinc.com Office Hours: Mon to Fri 8:00am - 4:30 pm

Thank You, ECHC Family

Frequently Asked Questions:

1. How often will you see me? We will see you as your medical needs arise. We find that most patients are seen monthly to manage their medical needs. Your medical provider will arrange your follow up visit at the end of your current appointment. If there is a change in your medical condition call 502-356-4377. If you have a medical emergency always call 911 first then notify us.

2. Do I have to leave for labs, xrays, pulmonary treatment or other testing? We work with companies that will come to you that include labs, xrays, nebulizers, oxygen, sleep studies, tube feedings, coumadin monitoring, non-invasive ventilation...

3. Do you work with other companies? Yes, we work with nursing, physical therapy, speech therapy, occupational therapy that have many programs focusing on falls, CHF, COPD, etc.. We also work with companies that provide oxygen, pulmonary medications, durable medical equipment that will deliver to your home.

4. What are your office hours? Monday through Friday 8am to 4:30pm and closed major holidays. Call us anytime at 502-356-4377 and if we are closed or the line is busy our answering service will connect you to our on call provider and they will help you. If you have an urgent issue that cannot wait till normal business hours call 502-356-4377 press option #1 and you will be connected to an on-call provider. If it is a TRUE emergency call 911 immediately.

5. Do you bill my insurance? Yes. We bill as if you were seeing us in an office. There are no extra fees for us coming to you. It is the same as if you went into doctor's office.

6. Can I still see my specialist? Yes you can. We are your primary care doctor/nurse practitioner. You may still need to see your specialist.

7. What insurance do you take? We accept MOST insurances except Wellcare. 8. Will you call me with the results of labs and tests? Your primary care provider will call

you the results OR a representative from the office will OR we discuss it with you at your next visit.

9. How else can I contact you? You can email us at housecalls@echp2u.com ; accessing the patient portal is accessible too.

What to do If and When to Call:

1. If you do not feel well: fatigue, nausea, vomiting, diarrhea or any

symptom out of your normal: Call us immediately so we can get

treatment started and get your provider out to see you.

2. If you have weight gain or loss: Call us immediately so we can get

you evaluated.

3. If you feel short of breath or have a cough or congestion: Call us

immediately so we can get a nurse specialized in the lungs and

heart to evaluate you as well as your doctor/nurse practitioner to

come see you.

4. If you begin falling: Call us immediately and we can get a falls

program started with you right away.

5. If you go to the Hospital/Emergency Room/Immediate Care Center

let them know that we are your doctor/nurse practitioner-

Extended Care House Calls. And Call us and let us know you are

there.

6. After your hospital stay please call us and let us know you are

home.

7. If you have an urgent issue that cannot wait till normal business

hours call 502-356-4377 press option #1 and you will be connected

to an on-call provider. If it is a TRUE emergency call 911

immediately.

Phone: 502-356-4377; Fax 888-959-2460 referrals@echp2u.com

Referred BY/ Facility: ________________________________

Today’s Date: ____________________ SSN#____________________

Patient Name: ________________________ DOB: _______________

Pharmacy Name and #______________________________________

Primary INS Name and ID#___________________________________

Secondary INS Name and ID#_________________________________

Address: __________________________________________________

Primary Phone Contact Name/#_______________________________

Emergency Contact Name/#__________________________________

BILLING ADDRESS (Where do we send invoices and address any

insurance issues?)

__________________________________________________________

Recent Hospital

Stay?/FormerPCP/Specialists?__________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

Past Medical History: _______________________________________

_________________________________________________________

Past Surgeries: _____________________________________________

Allergies to Medications: _____________________________________

Provider/Facility to obtain Copies of Insurance Cards

Provider/Facility to obtain Copies of POA/Guardianship Papers

Provider/Facility to obtain copy of DNR if applicable

Provider/Facility to obtain Signed Consent to Treat from Patient/Guardian

Patient/Guardian/RP to Sign and Date Bottom Page Authorization to

Release Medical Records

Patient/Guardian/RP to Sign and date whom we areallowedto talk to on

the Patient Authorization to Release Information to Family and Friends

To the best of my knowledge, the information I have provided in my

patient profile is complete and correct. I understand that it is my

responsibility to inform my doctor if I ever have a change in health.

I certify that I and/or my dependent(s) have insurance coverage with

the carriers listed, and assign directly to Extended Care House Calls,

PLLC , all insurance benefits, if any, otherwise payable to me for

services rendered. I understand that I am financially responsible for all

charges, whether or not paid by insurance. I authorize the use of my

signature on all insurance submissions. ECHC, PLLC and its officers may

use my health care information and may disclose such information to

my insurance comapnay(ies) and their agents for the purpose of

obtaining payment for services and determining insurance benefits or

the benefits ayable for related services.

___________________________ _________________

Patient/Guardian Date

Phone: (502)356-4377 Fax: (888)959-2460

housecalls@echp2u.com

www.echp2u.com

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

First Name:_____________________________Last Name:_______________________________

Date of Birth:__________________SSN:_______________Phone:_________________________

Address: City: State: Zip:_________________________________________________________

________________________________________________________________________________

***Please check one of the following***

I am authorizing Extended Care Health Professionals, PLLC to release records to another party

Or myself.

I am authorizing another Party to release records to Extended Health Care Professionals, PLLC

Please give details of the doctor & facility which we are releasing/ receiving records to/from below.

(A SEPARATE FORM IS REQUIRED FOR EACH DOCTOR’S REQUEST)

Doctor:____________________Facility:_____________________________________________

Address: City: State: Zip:________________________________________________________

Phone:_______________________ Fax:___________________________

We Request The Following Records Only:

Progress notes last 2 visits Most recent lab results Most recent radiology

Please Circle Reason for Disclosure:

Changing Physicians – Continuing Care – 2nd Opinion – Insurance/Legal – Other:

I understand that any alcohol, drug abuse, mental health, psychotherapy, and HIV/AIDS related information, if

present,will be disclosed with this authorization, unless excluded here: Note: If you are having your medical records printed yourself, and insurance company, or an attorney, there is a charge to have

Records printed. (If they are being sent to another doctor, you will not incur any charges.) The records are charged at $1.00 per page

for the first 25 pages, then $0.30 per pager thereafter. The processing time for medical records requests will vary depending on what

records are requested and the reason for request. Complete medical record request may take up to the legal 30 days allowed. By

Signing this release form you are agreeing to compensate ECHP, PLLC for all charges incurred in the printing of your medical records.

I understand that I may revoke this authorization, at any time, in writing, except to the extent that action has already been taken in

Reliance on this authorization and that this authorization shall remain in force for a 90 day period in order to effect the purpose for

Which it is given.

Patient (or Representative) Signature:_________________Date:______________________

Confidentiality Notice: This Facsimile transmission AND/OR the documents accompanying it may contain confidential information belonging

to the sender. The information is intended for the use of the individual or entity named above. If you are not the intended recipient, you are hereby

notified thatany reliance on the contents of this information is strictly prohibited. If you have received this transmission in error, please notify us

immediately and arrange the return of this document.

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

1. I hereby authorize Extended Care House Calls to use and/or disclose my protected health

information (“PHI”).

2. I understand that I or my legal Guardian or POA have the right to:

Get a copy of my records

Request limitations on the information ECHC shares

Get a copy of this privacy notice

Choose someone to act for you

Request confidential communication

Get a list of those with whom we share information

File a complaint if I believe my privacy right have been violated

3. I understand that ECHC may use and share my information for:

For medical treatment

Billing

Help with public safety and public health issues

Do Research

Comply with the law

Work with a medical examiner or funeral director

Address worker’s compensation and other government requests for business

Respond to lawsuits and legal actions

4. In addition to the authorization for release of my PHI, I authorize disclosure of information

regarding my billing, condition, treatment and prognosis to the following individual(s):

Name__________________________ Relationship______________

Name__________________________ Relationship______________

5. I understand I have the right to revoke this authorization, in writing to ECHC, PLLC. However,

the revocation will not apply to information that already has been released in reliance upon this

authorization. I also understand that this authorization is valid until further notice or written

revocation by me. I understand that it is my responsibility to advise ECHC, PLLC of changes to

my telephone numbers or contact information or my preferences.

___________________________ ________________

Patient/Guardian Signature Date

Phone: (502)356-4377 Fax: (888)959-2460

Email: housecalls@echp2u.com

www.echp2u.com

Today’s Date:________________ Medical Visit Summary : ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Appointment Card for f/u visit given____ Provider Signature: _________________________ Provider Name: (Circle) Pamela Alvey, APRN Kimberly Cashion, APRN Suresh Nair, MD Barry Klein, MD Melissa Patterson, APRN Felissa Williams, APRN Diane Sawyer, APRN Christopher Cooper, PA Angie Hocker, APRN

Portal Access to Review

Records:

If you would like portal access to review your records or your loved one's records contact us at the office and please provide us your full name, relationship and email. Once we receive the information GehriMed will email you the link with instructions. The link is provided through our Electronic Medical Records: GehriMed. Patient’s full name: _____________________________________ Guardian/Responsible Party/Family Member First and Last Name: ______________________________________________________ Email address: ___________________________________________ _____________________________________________________________ GehriMed is compatible with Windows, MAC or IPad. If you have any questions please feel free to call GehriMed Support at 855-829-2060.

NARCOTIC CONSENT FORM I _____________________________________AGREE TO ALL TERMS BELOW:

1) All Pain medicine/narcotics will be obtained from: PHARMACY: ____________________________ PHARM PH #__________________________

I WILL INFORM EXTENDED CARE HOUSE CALLS IF THERE IS A CHANGE OF PHARMACY 2) I WILL NOT SEEK PAIN MEDICINE/NARCOTICS FROM ANOTHER DOCTOR/PROVIDER.

3) I WILL ADHERE TO DOSING INSTRUCTIONS AS PRESCRIBED AND WILL NOT SELF INCREASE 4) I WILL NOT GIVE OR SELL MY PAIN MEDICINE/NARCOTICS TO FAMILY OR ANYONE ELSE. 5) I WILL NOT RECEIVE PAIN MEDICINE/NARCOTICS FROM ANYONE ELSE.

6) I WILL BE RESPONSIBLE AND KEEP PAIN MEDICINE/NARCOTICS SAFE AT ALL TIMES. 7) IN THE EVENT OF LOST, STOLEN OR ANY MISHAPS I WILL NOT REQUEST REPLACEMENT OF PAIN MEDICINE/NARCOTICS. 8) I WILL KEEP ALL SCHEDULED DR. APPOINTMENTS, TREATMENTS AND MEETINGS 9) I MAY BECOME DEPENDENT ON PAIN MEDICINE/NARCOTICS AND EVEN A SMALL RISK OF ADDICTION. I WILL SEE AN ADDICTION

EXPERT IF MY DOCTOR FEELS IT NECESSARY. I CAN ALSO CALL THE KENTUCKY HELP CENTER AT 1-833-859-4357. NATIONALLY, I CALL THE SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION AT 1-800-662-4357 24/7,365 DAYS A YEAR. 10) IF I STOP TAKING MY PRESCRIBED MEDICATION OR TAKE LESS THAN PRESCRIBED I COULD EXPERIENCE WITHDRAWAL. 11) I WILL BE COMPLIANT WITH BLOOD AND/OR URINE TEST FOR DRUG MONITORING WHEN ASKED BY MY PROVIDER OR WHEN

RANDOMLY SELECTED. 12) I WILL AVOID THE USE OF ANY MOOD ALTERING SUBSTANCE, SUCH AS TRANQULIZERS, SLEEPING PILLS, ALCOHOL OR ILLICIT DRUGS (SUCH AS CANNABIS(POT), COCAINE, HEROIN OR HALLUCINOGENS).

13) I WILL EXERCISE COMPLETE HONESTY WITH MY DOCTOR AND ANY OTHER HEALTH CARE PERSONS INVOLVED IN MY PAIN MANAGEMENT, SUCH AS PHARMACISTS, OTHER DOCTORS, EMERGENCY DEPARTMENTS, ETC. IN REPORTING ALL PAIN MEDICATION/NARCOTICS. 14) I UNDERSTAND I MAY BE CALLED IN FOR A RANDOM PILL COUNT, FAILURE TO COME IN FOR COUNT COULD BE GROUNDS FOR

DISMISSAL. 16) WE WILL OBTAIN KASPER REPORTS PER STATE LAW. 17) WE WILL CHECK THE STATE PHARMACY BOARD PERIODICALLY TO ENSURE YOU ARE NOT OBTAINING CONTROLLED

PRESCRIPTIONS FROM OTHER PROVIDERS OR USING MULTIPLE PHARMACIES. 18) FAILURE TO ADHERE TO THIS AGREEMENT COULD JEOPARDIZE MY DOCTOR/PATIENT RELATIONSHIP THUS STOPPING THE PRESCRIBING OF PAIN/NARCOTIC MEDICATIONS AND MAY EVEN RESULT IN MY DISMISSAL FROM THE PRACTICE.

PATIENT SIGNATURE: ____________________________ DATE________________________

Printed Name: _________________________________ Date of Birth___________________

WITNESS SIGNATURE: ____________________________ DATE_________________________

HIPAA PERMITS DISCLOSURE OF MOST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY M O S T

Medical Orders for Scope of Treatment This document is based on this person’s medical condition and wishes. Any section not completed indicates a preference for full treatment for that section.

Patient’s Last Name: Effective Date of Form: _ Form must be reviewed at least annually.

Patient’s First Name, Middle Initial: Patient’s Date of Birth:

Section A

Check One Box Only

Section B

Check One Box Only

Section

C

Check One Box Only

Section

D

CARDIOPULMONARY RESUSCITATION (CPR): PERSON HAS NO PULSE AND IS NOT BREATHING. Attempt Resuscitation (CPR) Do Not Attempt Resuscitation When not in cardiopulmonary arrest, follow orders in B, C, and D.

MEDICAL INTERVENTIONS: PERSON HAS PULSE OR IS BREATHING. Full Scope of Treatment: Use intubation, advanced airway interventions, mechanical ventilation, defibrillation or

cardioversion as indicated, medical treatment, IV fluids, and provide comfort measures. Transfer to a hospital if indicated. Includes intensive care. Treatment Plan: Full treatment including life support measures.

Limited Additional Intervention: Use medical treatment, oral and IV medications, IV fluids, cardiac monitoring as indicated, non-invasive bi-level positive airway pressure, a bag valve mask, and comfort measures. Do not use intubation or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care. Treatment Plan: Provide basic medical treatments.

Comfort Measures: Keep clean, warm and dry. Use medication by any route. Positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital unless comfort needs cannot be met in the patient's current location (e.g. hip fracture).

Other Instructions ANTIBIOTICS Antibiotics if indicated for the purpose of maintaining life Other instructions: Determine use or limitation of antibiotics when infection occurs. Use of antibiotics to relieve pain and discomfort. No Antibiotics (use other measures to relieve symptoms). MEDICALLY ADMINISTERED FLUIDS AND NUTRITION: the provision of nutrition and fluids, even if medically administered, is a basic human right and authorization to deny or withdraw shall be limited to the patient, the surrogate in accordance with KRS 311.629, or the responsible party in accordance with KRS 311.631.

Check One Box Only in

Each Column

Long term IV fluids if indicated IV fluids for a defined trial period. Goal:

No IV fluids (provide other measures to ensure comfort)

Special instructions

Long term feeding tube if indicated Feeding tube for a defined trial period. Goal: No feeding tube

Section E

Check The Appropriate

Box

Directions were

Patient Preferences as a Basis for This MOST Form: Basis for order must be documented in medical record.

Adult Patient with decisional capacity Parent/guardian of minor patient Surrogate per advance directive Judicially appointed guardian/durable power of attorney with power to make health care decisions

spouse Majority of patient’s reasonably available

adult children Parent Majority of patient’s reasonably available nearest living relatives of same relation

given: Orally Written

Patient does not have an advance medical directive such as a living will or health care power of attorney. Patient has an advance medical directive such as a living will or health care power of attorney in place. I certify this form is in accordance with the decisions in the current advance medical directive. Name: Printed: Position: Signature:

I agree that adequate information has been provided and significant thought has been given to decisions outlined in this form. Treatment preferences have been expressed to the physician (MD/DO). This document reflects those treatment preferences and indicates informed consent. If signed by a patient, surrogate or responsible party, preferences expressed must reflect patient’s wishes as best understood by that surrogate or responsible party. You are not required to sign this form to receive treatment. Patient, Surrogate or Responsible Party: Signature: Relationship:

Contact #: Health Care Professional Preparing Form: Print Name Health Care Professional Preparing Form: Signature Preferred Phone #: Date Prepared:

Physician Signature Physician (Print Name) Physician Contact Number

SEND FORM WITH PATIENT/RESIDENT WHEN TRANSFERRED OR DISCHARGED

INFORMATION FOR PATIENT, SURROGATE OR RESPONSIBLE PARTY OF PATIENT NAMED ON THIS FORM • The MOST form is always voluntary and is usually for persons with advanced illness. MOST records your wishes for medical

treatment in your current state of health. The provision of nutrition and fluids, even if medically administered, is a basic human right and authorization to deny or withdraw shall be limited to the patient, the surrogate in accordance with KRS 311.629, or the responsible party in accordance with KRS 311.631. Once initial medical treatment is begun and the risks and benefits of further therapy are clear, your treatment wishes may change. Your medical care and this form can be changed to reflect your new wishes at any time. However, no form can address all the medical treatment decisions that may need to be made. An advance directive, such as the Kentucky Health Care Power of Attorney, is recommended for all capable adults, regardless of their health status. An advance directive allows you to document in detail your future health care instructions or name a surrogate to speak for you if you are unable to speak for yourself, or both. If there are conflicting directions between an enforceable living will and a MOST form, the provisions of the living will shall prevail.

COMPLETING MOST

DIRECTIONS FOR COMPLETING AND IMPLEMENTING FORM

• MOST must be reviewed, prepared and signed by the patient’s physician in personal communication with the patient, the patient’s surrogate or responsible party.

• MOST must be reviewed and contain the original signature of the patient’s physician to be valid. Be sure to document the basis in the progress notes of the medical record. Mode of communication (e.g., in person, by telephone, etc.) should also be documented.

• The signature of the patient, surrogate or a responsible party is required; however, if the patient’s surrogate or a responsible party is not reasonably available to sign the original form, a copy of the completed form with the signature of the patient’s surrogate or a responsible party must be signed by the patient’s physician and placed in the medical record.

• Use of original form is required. Be sure to send the original form with the patient. • There is no requirement that a patient have a MOST.

IMPLEMENTING MOST • If a health care provider or facility cannot comply with the orders due to policy or personal ethics, the provider or

facility must arrange for transfer of the patient to another provider or facility. REVIEWING MOST This MOST must be reviewed at least annually or earlier if:

• The patient is admitted and/or discharged from a health care facility; • There is a substantial change in the patient’s health status; or • The patient’s treatment preferences change. • If MOST is revised or becomes invalid, draw a line through sections A – E and write “VOID” in large letters.

REVOCATION OF MOST This MOST may be revoked by the patient, the surrogate or the responsible party. Review of MOST Review Date Reviewer and Location

of Review MD/DO Signature (Required) Signature of Patient, Surrogate

or Responsible Party (Required)

Outcome of Review, describing the outcome in each row by selecting one of the following: No Change FORM VOIDED, new form completed FORM VOIDED, no new form No Change FORM VOIDED, new form completed FORM VOIDED, no new form

SEND FORM WITH PATIENT/RESIDENT WHEN TRANSFERRED OR DISCHARGED