jns/FormWelcomeLetter/Rev.April2015

Welcome to our practice.

It is very important that you fill out the enclosed patient registration form, general consent form, and referring physician form completely, prior to your appointment. Please be sure to bring these forms and your current insurance card or cards with you to your appointment. We must get copies of your insurance cards to enable us to bill claims properly. Please do not mail paperwork to our office, bring it with you!

The anticipated cost of your initial visit can range. It is difficult for us to provide you with a precise cost estimate for your visit. However, you must pay your copay prior to being seen by the doctor.

Completion of Medical Forms: When requesting disability and FMLA forms to be completed we require a $25 payment for the initial form and a $10 payment for follow-up forms in advance of completion.

Some insurance plans require that you obtain a referral from your Primary Care Physician in order to see a Specialist. Please remember it is the patient’s responsibility to know their individual insurance plans, each plan has different coverage and networks. If your insurance company requires you obtain a referral we must have this prior to your appointment or you may bring it with you to your appointment. If you do not have your referral we cannot see you and your appointment will be rescheduled to our next available appointment date. There will be no exceptions!

Insurance plans that may require a referral include: Aetna HMO/Aetna MC/Aetna QPOS Cigna HMO/Cigna MC Essence HealthCare Humana HMO/Humana HMO-MBP Indiana Medicaid/Hoosier Healthwise Kentucky Medicaid/KENPAC Passport Tricare This is not an inclusive list; please check with your benefits administrator if you have any questions concerning referrals. Thank you for choosing our practice! We are here to help you in any way possible. Our office hours are Monday – Friday; 8:30 am to 5:00 pm. Our staff is happy to help you with any appointment needs. If you need to cancel, please call well in advance so that we may offer this appointment space to someone else in need.

Visit our websites at: www.usahandsurgery.com www.UofLPhysicians.com www.aboutlivertumors.com www.louisvillesurgery.com www.survivelivercancer.com www.aboutmelanoma.com www.uoflplastics.com www.aboutbreasthealth.com www.louisvillesurgonc.com www.colidoscope.com www.louisvilleotolaryngology.com

REG-01 Revised December 3, 2014

PATIENT INFORMATION FORM

Patient Information Name ______________________________________________ Also Known As ____________________

SSN __________________________ Date of Birth _________________ Sex Male Female

Marital Status Single Married Divorced Widowed Separated Preferred Language____________________

Special Needs Adult Sitter/Guardian Ambulates with Assistive Dev Hearing Impaired Sight Impaired Multiple Birth

Speech Impaired Wheelchair Interpreter Transportation Needs

Home Address________________________________________________________________________________________

City, St_______________________________________________County___________________ Zip Code ______________

Home Phone ______________________ Cell Phone________________________ Work/Other Phone __________________

Employment Status _________________________ Email _____________________________________________________

Employer Name ____________________________________________ Employer Phone Number _____________________

Employer Address_____________________________________________________________________________________

Employer City, St ____________________________________________________ Zip Code_________________________

Primary Physician _____________________________________________ Primary Physician Phone ___________________

Referring Physician ____________________________________________ Referring Physician Phone __________________

Preferred Pharmacy__________________________________ Pharmacy Phone ___________________________________

Pharmacy Address, City, St, Zip __________________________________________________________________________

Parent/Guardian(s) or Spouse Information Name_________________________________________________________

Relationship to Patient _____________________________ SSN ______________________ Date of Birth _______________

Address (If Different) ____________________________________________________ Zip Code_______________________

Employer _________________________________________________ Employer Phone Number ______________________

Employer Address ____________________________________________________ Zip Code_________________________

Home Phone ______________________ Cell Phone ______________________ Email ______________________________

Patient Race: Race – a human population considered distinct based on

physical characteristics.

American Indian Alaska Native

Asian Black or African American White Native Hawaiian or Other Pacific Islander

Other Declined

Ethnicity: Ethnicity a term which represents social groups

with a shared history, sense of identity, geography and

cultural roots which may occur despite racial difference.

Hispanic or Latino Not Hispanic or Latino

Religion ________________________________

REG-01 Revised December 3, 2014

Patient Name: _______________________________________ Patient DOB______________2.

Emergency Contact (someone other than a parent and who does not live with the patient or a parent)

Name ___________________________________ Relationship _____________________ Phone ______________________

Parent/Guardian #2 Name_____________________________________________________________________________

Relationship to Patient _____________________________ SSN ______________________ Date of Birth _______________

Address (If Different) ____________________________________________________ Zip Code_______________________

Employer _________________________________________________ Employer Phone Number ______________________

Employer Address ____________________________________________________ Zip Code_________________________

Home Phone ______________________ Cell Phone ______________________ Email ______________________________

Medical Insurance Info. Primary Insurance Secondary Insurance

Subscriber ID

Group or Plan Number

Plan/Program Code

Insurance Co. Name

Insurance Co. Phone Number

Patient Relation to Subscriber

Subscriber Name

Subscriber Street Address

Subscriber City and State

Subscriber Zip Code

Subscriber Date of Birth

Subscriber Sex

Subscriber Social Security #

Subscriber Employer

Co-pay Amount

Injury Related Information Work Related Auto Motorcycle Other Date & Time of Injury ___________________

State Where Injury Occurred ________________Contact Name ____________________________ Phone ______________

Claim # _________________________________ Insurance Co. ________________________________________________

Insurance Co. Address, City, St, Zip _______________________________________________________________________

______________________________________________________________________ _________________________

Patient/Parent/Legal Guardian/Legal Authorized Representative Signature Date

If Parent/Legal Guardian/Legal Authorized Representative, Print Name ___________________________________________

Patient’s Name:_______________________________________Today’s Date_____________________ Age:____ Birth Date: _____________ Race:_______________________SSN:____________________ Family Physician: Dr. _________________________ Referred by: Dr. _________________________ Other Physicians you see: ______________________________________________________________ Reason for Visit:______________________________________________________________________ Past Medical Problems: (check boxes that apply, describe below and list dates if possible) High Blood Pressure Diabetes Heart Disease/Heart Attack Kidney Disease Lung Disease/COPD Seizures Stroke Cancer Emotional/Psychiatric Problems Hepatitis _______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

List all Previous Operations/Procedures (for example, colonoscopy, cardiac stent, etc.) List reason,date, & MD ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Cancer Treatments: Have you ever had Chemotherapy or Radiation Therapy? If so when and by whom: _______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Medications: (List name, dose, & how often taken) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Do you take aspirin/ aspirin-containing products / any blood thinners? YES NO (if yes, please list) ____________________________________________________________________________________

Are you allergic to any medications? YES NO (if yes, please list) ALLERGIC to LATEX? YES NO _____________________________________________________________________________________

THIS BOX FOR MD USE ONLY Location Quality Severity Duration Timing Context Modifying Factors Associated Signs and Symptoms

Rev.Feb 2015

Social History

Single Married Separated Divorced Widowed Occupation______________ Do you use alcohol? YES NO How much and how often?________________________________ Do you use tobacco now? YES NO Did you ever use tobacco? YES NO

Describe tobacco use (for example, packs per day) _________________________________________ Heavy Sun Exposure in past? YES NO Blistering Sunburns in past? YES NO Tanning Bed Use? YES NO

Family History List diseases (including specific types of cancer) that run in the family, which relative was affected, and at what approximate age. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

ROS: List all symptoms that you are experiencing currently General Yes No Weakness _____ _____ Weight loss _____ _____ Fever/chills _____ _____ Night sweats _____ _____

Eyes Yes No Vision changes _____ _____ Double vision _____ _____

Head/Neck Yes No Headache _____ _____ Blackout spells _____ _____ Changes in hearing _____ _____ Changes in taste/smell _____ _____ Thyroid Problems _____ _____ Neck lumps _____ _____ Ear pain _____ _____

Hematologic Yes No Anemia _____ _____ Easy Bruising _____ _____ Clotting Problem _____ _____

Lung Yes No Lung problems _____ _____ Shortness of breath _____ _____ Cough up blood _____ _____ Wheezing/Asthma _____ _____ Pneumonia _____ _____ Tuberculosis _____ _____

Musculoskeletal Yes No New aches/pains in Bones/joints _____ _____ Arthritis _____ _____

Heart Yes _ No Chest Pain _____ _____ Heart Attack _____ _____ Irregular Heart Beat _____ _____ Heart Failure _____ _____ Swelling in Ankles _____ _____ Palpitations _____ _____

Gastrointestinal Yes _ No Abdominal pain _____ _____ Nausea/Vomiting _____ _____ Vomit Blood _____ _____ Difficulty Swallowing _____ _____ Heartburn /Indigestion _____ _____ Blood in Stool _____ _____ Black/Tarry Stool _____ _____ Change in stool size/color _____ _____ Constipation _____ _____ Yellow Jaundice _____ _____

Kidney Yes _ No Blood in Urine _____ _____ Kidney/bladder infection _____ _____ Kidney stones _____ _____ Painful urination _____ _____ Difficulty urinating _____ _____

Breast Yes _ No Lump _____ _____ Nipple discharge _____ _____ Pain _____ _____ Date Last Mammogram _____________

Reproductive History Yes No Age at 1st period _____________ yrs Age at menopause _____________ yrs # Pregnancies _____________ # Live births _____________ Age at 1st pregnancy _____________ yrs Breast Fed _____ _____ If yes, your age at the time _____________ yrs Last Menstrual period _____________ Last Pap Smear _____________ Currently use Hormone Replacement Therapy _____ _____ If yes, how long _____________ Previously used Hormone Replacement Therapy _____ _____ If yes, when stopped _____________

Neurologic Yes No Tingling _____ _____ Numbness _____ _____ Weakness _____ _____

Psychiatric Yes No Depression _____ _____ Anxiety _____ _____ Mood swings _____ _____

Skin Yes No Rash _____ _____ Skin cancer _____ _____ Change in mole _____ _____

FOR BARIATRIC PATIENTS ONLY: Diets used and weight lost: ______________________________________________________________________ Sustained weight loss: ______________ How long was weight lost? _____________________ How long over 100 lbs. overweight? _________________ How many times have you lost over 25 lbs? __________ How long have you been overweight? _______________years. Are you currently under a physician’s care for weight loss? YES NO Physician’s Name:__________________

PHYSICIAN COMMENTS:

____________________________________________________________________________________

Physician Signature: ____________________________________________ Date________________ (History Form Reviewed with Patient)

Rev. Feb 2015

Today’s Date: _____________________ Patient Name: ______________________________ DOB: _____________________ Chief Complaint: ________________________________________________________ Allergies: Latex Allergy No Yes Other Allergies No Yes, please list below __________________________________________________________ __________________________________________________________ Primary Care Physician: _________________________________________________ Other Physicians: _______________________________________________________ Name City, State

______________________________________________________ Name City, State

______________________________________________________ Name City, State

______________________________________________________ Name City, State

______________________________________________________ Name City, State

Pharmacy Name & Location: ______________________________________________ Pharmacy Phone Number: ________________________________________________ Medications:

Name Dose Frequency

RefPhysMedsFrontDesk/jns/forms/Rev.March 2015

REG-03 Revised September 16, 2014

GENERAL CONSENT FORM

PATIENT NAME: __________________________________________ Date of Birth: _____________________

Payment. I authorize University of Louisville Physicians, Inc. (UofL Physicians) to submit claims on my behalf directly to

Medicare/Medicaid/my private health insurance carrier. This means that UofL Physicians will direct payment for supplies

and services provided. I understand that I am financially responsible to the provider(s) for the charges not paid or payable. I

authorize you to release any information necessary to insurance carriers regarding illnesses and treatment to process

claims. Initials: ______________

Consent for Treatment. I consent for UofL Physicians to administer treatments, tests and/or diagnostic tests to treat my/the

patient’s injury/illness on an outpatient basis. I acknowledge there is no guarantee as to the outcome of any treatment I/the

patient receives. In compliance with state law, as part of the care to be given a test may be performed for human

immunodeficiency virus infection (HIV/AIDS), hepatitis, or other blood-borne infectious or communicable diseases if the

doctor, APRN, or Physician Assistant orders the test for diagnostic purposes because of my/the patient’s medical history,

symptoms, or conditions. Initials: ______________

Electronic Prescription. I understand UofL Physicians utilizes electronic prescribing technology and participates with

SureScripts. SureScripts operates the Pharmacy Health Information Exchange, which facilitates the electronic transmission

of prescription information between providers and pharmacists. SureScripts also provides prescription data on any

medications, known as medication history, which are prescribed to me/the patient. Initials: ______________

Cell Phone Calls. As a service to our patients, we provide a courtesy appointment reminder call and possibly other

important calls that may be placed using a prerecorded message. By providing your cell phone number, you consent to

receiving such calls at this number.

Involvement of Others in Care. I authorize UofL Physicians to provide and discuss my/the patient’s care and medical

needs with the following persons:

Name Date of Birth Relationship Phone

Patient Rights and Responsibilities

I acknowledge receipt of the Patient Rights and Responsibilities_____ Declined_____

Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices_____ Declined_____

Minor Patient Photograph

I consent for UofL Physicians to photograph the patient for identification purposes only_____ Declined_____

___________________________________________________________________ _________________________

Patient/Parent/Legal Guardian/Legal Authorized Representative Signature Date

If Parent/Legal Guardian/Legal Authorized Representative, Print Name _______________________________________

Did you know that your surgeon not only takes care of patients, but: • Is a Professor of Surgery at the University of Louisville School of Medicine? • Performs basic, translational, and clinical research to improve patient care? • Teaches students, residents and fellows who come from around the world to learn the latest

surgical procedures and participate in groundbreaking research? We want to tell you about some of the exciting research and educational programs that are underway in the Department of Surgery at the University of Louisville School of Medicine. We are proud to be nationally recognized for groundbreaking advances in: Cancer Detection and Treatment, Trauma and Critical Care, Minimally Invasive Surgery, Bariatric Surgery, Digestive Diseases, Endocrine Surgery, Vascular Surgery, Head and Neck Surgery, Plastic and Reconstructive Surgery, Hearing and Speech Disorders, Organ Transplantation, and Surgical Infections. A small sampling of our research includes: 1. The Sunbelt Melanoma Trial, a multicenter study that is the largest ever conducted in

melanoma with more than 3,600 patients registered. It was conceived, written and directed from the Department of Surgery.

2. Genetic research relating to colorectal cancer and inflammatory bowel disease, which

together affect hundreds of thousands of Americans every year. We have been using the latest technology such as gene chips to try to identify the cause of these disorders.

3. Minimally Invasive Parathyroid and Thyroid Surgery. We are one of the first centers to

develop and test the procedure of Minimally Invasive Radioguided Parathyroidectomy, which allows patients with parathyroid tumors to undergo a much less invasive yet curative procedure through a small incision. We have also developed techniques for minimally invasive endoscopic thyroid surgery.

4. Studies of sound perception and speech production in children and adults that have

undergone cochlear implant surgery 5. The University of Louisville Breast Cancer Sentinel Lymph Node Study, which involves

more than 4,000 patients from 79 institutions across the US and Canada. It is the largest study of its kind and is largely responsible for the acceptance of this minimally invasive procedure for patients with breast cancer around the world.

6. Basic research into the molecular basis for the response to trauma, shock, inflammation, and

infection. 7. New technologies for the treatment of liver tumors. Over the past decade, we have helped

develop and test new minimally invasive techniques for treatment of liver tumors. This allows many patients who previously were not candidates for surgery to eliminate cancer in the liver.

8. New gene therapy approaches to cancer as an alternative to chemotherapy. In the past decade, we have developed several new treatments of liver tumors, colon cancer, pancreatic and stomach cancer, melanoma, breast cancer, and cervical cancer.

9. Studies to evaluate rare endocrine tumors using artificial intelligence. 10. We were one of the first U.S. centers to pioneer the use of the Lap Band System™ and other

minimally invasive surgical treatments for obesity. We were the first center in America to perform an intragastric balloon and this was done in the setting of a clinical trial.

This is where you can help. Research is responsible for the development of new approaches to surgery and the treatment of a variety of conditions and diseases. We have made much progress, yet our work is far from done. With additional funding support, we feel confident we can bring some of these exciting results to our patients more quickly. Your investment in our research will bear dividends for years to come, helping others facing a diagnosis such as yours. Any amount helps, and you can specify where you would like your money to be used. If you are interested in investing in our research by making a donation or want to learn more, please contact Larissa Reece by email at lfreec01@gwise.louisville.edu or 502-852-8910 or 1-800-872-8033. She also may contact you following your treatment to gauge your interest and to discuss your experience with our office. In addition, you can discuss your interest with your surgeon or our office staff any time. You can also visit our Web site at louisvillesurgery.com. Thank you again for your confidence in our program. If you wish to have your name removed from the list to receive fundraising requests supporting the Department of Surgery, please make your wishes known in writing to: Department of Surgery, Development Office, 530 South Jackson Street; Louisville, KY 40202, and all reasonable efforts will be taken to ensure you will not receive any such communications from us in the future.

COMP-02 Revised July 9, 2013

KASPER CONSENT AND AUTHORIZATION

FOR TREATMENT WITH CONTROLLED SUBSTANCES/STIMULANTS

I/the patient understand and acknowledge that, to the extent medically necessary, I/the patient may be prescribed a

controlled substance, which may/may not contain Hydrocodone, while receiving medical care and treatment in order

to manage complaints of pain or other medical conditions. I have been fully informed of the risks, alternatives and

possible consequences involved in the use of controlled substances.

I understand that this agreement is contingent on compliance with ALL of the following patient and physician terms:

1. I understand that as required by KRS 218A a KASPER report must be obtained and reviewed by the provider(s) prior to dispensing all Schedule II drugs or Schedule III drugs with hydrocodone and every 90 days thereafter. KASPER tracks all controlled prescriptions written in the State of Kentucky.

2. I understand that I agree to receive stimulant medication prescriptions ONLY from the provider(s) in our practice.

3. I understand that a scheduled appointment may be required with the provider(s) prior to receiving any refills.

4. I understand this practice will not fill controlled substances or stimulants after hours, on holidays or weekends by the on-call provider.

5. I understand that my prescribing provider and/or staff may communicate and collaborate with any other health care provider(s) currently involved in my care, as well as, those previously involved in my care.

6. I understand that I must notify the provider(s) about any medication side effects I may experience.

7. I understand that if a serious side effect issue including withdrawal occurs after hours, on a holiday, or during the weekend, that I should immediately seek emergency assistance from the nearest emergency room.

8. I understand that I must take the medication as prescribed and I CANNOT change dosage amounts or alter the time schedule of the prescribed medication without being directed to do so by my provider(s).

9. I understand that these medication(s) must be kept in a safe place at all times and that I am responsible for the security of my medications. It has been thoroughly explained to me that the policy does not allow for replacement of misplaced, spilled, inaccessible, or lost medication(s) or prescription(s).

10. I understand that if my medication(s) or prescription(s) is/are stolen that I must deliver a police report to my provider(s) and the provider(s) will contact the police department for verification. A second event such as above may lead to termination of this contract.

11. I understand that if it appears to my prescribing provider(s) there are no demonstrable benefits to my daily function, academic performance, or quality of life from the medication(s), alternative medications, discontinuing or taper me off all stimulant medication(s) may be prescribed.

12. I will not hold my physician liable for problems caused by the discontinuation of medication(s).

13. I understand that I must submit to urine and/or blood tests to confirm the presence of the prescribed medications and to detect the use of non-prescribed medications or drugs at any time and without prior warning. If I test positive for non-prescribed medications or illegal substance(s), such as marijuana, speed, cocaine, etc. my treatment for chronic pain may be terminated. Failure to submit to drug testing will terminate this agreement.

14. I agree to actively participate in all aspects of the treatment plan recommended by my provider(s) to achieve increased function and improved quality of life. Failure to participate in all aspects of the treatment plan will result in termination of this agreement.

15. I understand that I must inform any provider(s) who may treat me for any other medical problem(s) that I am enrolled in a treatment program and that failing to do so is medically dangerous.

16. I agree that I am to fill all of my prescriptions at a pharmacy located within my state of residency.

COMP-02 Revised July 9, 2013

17. I agree to notify this office with the name of the prescribing provider(s) or facility and the pharmacy filling any stimulants or controlled substances which are prescribed in the event of an emergency.

18. I agree to not share, sell or exchange my medication with anyone else.

19. I understand that each prescription is for a specific number of pills designated to last a certain amount of time and will not be filled early.

20. I understand that this office may contact police or other governmental agencies as deemed necessary.

21. I understand that my provider(s) or designee may contact other pharmacies in the management of my condition

22. I understand that the prescribing provider(s) can stop treatment with if I am determined to be giving away, selling or misusing the medication, failing to keep scheduled appointments or attempting to obtain controlled medications after hours, early refills, from other providers, facilities or any other sources

23. I understand that I must adhere to the advice of the prescribing provider(s) regarding the operation of motor vehicles while using controlled medications

24. I understand that any alteration of controlled substances prescriptions will be reported to the police for prosecution and that I will be discharged from the practice.

I certify that:

1. I am not currently using illegal drugs or abusing prescription medication(s) and I am not undergoing treatment for substance dependence (addiction) or abuse.

2. I have read and entered into this Agreement while in full possession of my faculties and not under the influence of any substance that might impair my judgment.

3. I have never been involved in the sale, illegal possession, misuse/diversion or transport of controlled substance(s) (narcotics, sleeping pills, nerve pills, or painkillers) or illegal substances (marijuana, cocaine, heroin, etc…)

4. I understand there is no guarantee or assurance that has been made as to the results that may be obtained when utilizing these medications for my condition.

5. I have reviewed the side effects of the medication(s) that may be used in the treatment of my condition. I fully understand the explanations regarding the benefits and the risks of this medication(s) and I agree to the use of these medication(s) in the treatment of my condition.

6. I am not pregnant and that I will notify this office should I become or intend to become pregnant.

7. I understand the potential benefits and the possible side effects/risks involved in using these medications.

Acknowledgement

I have read the conditions and terms stated above and have had all of my questions regarding these conditions and terms explained to my satisfaction. I have met the conditions and agree to honor all of the terms of this agreement. I also understand that if I violate any of the terms of this agreement, it is cause for the provider(s) to refuse further prescriptions or treatment. I have been provided a copy of this contract. Patient Name __________________________________________________________ DOB __________________ Patient/Parent/Legal Guardian Signature _____________________________________ Date __________________ If Parent/Legal Guardian, Print Name ________________________________________ Initiating Provider’s Signature ______________________________________________ Date _________________ Initiating Provider’s Practice Site __________________________________________________________________

COMP-07 Revised July 9, 2013

PATIENT RIGHTS AND RESPONSIBILITIES

Patient Rights

All patients will have access to treatment regardless of race, creed, sex, nationality, or source of payment. All patients have the right to considerate, respectful care at all times and under all circumstances. All patients have the right of privacy in regard to their medical treatment and records of their treatment. All patients have the right to expect reasonable safety in clinical practices and clinical environment. All patients have the right to know the identity and professional status of individuals providing service to them, as well as their relationship to any other health care or educational institution. All patients have the right to complete and current information concerning their medical treatment. All patients who do not speak or understand the predominant language of the community will have access to an interpreter. All patients have the right to reasonably informed participation in and consent for decisions involving their health care. Patients also have the right to be informed of human experimentation or other research/educational projects affecting their care or treatment and the patient has the right to refuse to participate. All patients have the right to refuse treatment to the extent permitted by law. If such refusal prevents the provision of appropriate care, the relationship with the patient may be terminated upon reasonable notice. All patients have the right to request and receive an itemized and detailed explanation of their bill. All patients have the right to know the rules and regulations that apply to their conduct as patients. All patients have the right to file complaints regarding their treatment with the appropriate department head.

Patient Responsibilities The patient has the responsibility to be considerate and cooperative in dealing with health care staff and to respect the rights of fellow patients. The patient has the responsibility to ask any questions and to seek clarification as may be necessary to adequately understand his or her illness and/or treatment. The patient has the responsibility to obtain and carefully consider all information he or she may need or desire in order to give informed consent for a procedure and/or treatment. The patient has the responsibility to weigh the potential consequences of any refusal to comply with the instructions or recommendations of the health care provider. The patient has the responsibility to schedule appointments, and to arrive at the office in time for scheduled visits. The patient also has the responsibility to notify us if he or she must cancel or be late for a scheduled appointment. The patient also has the responsibility to express opinions, concerns or complaints in a constructive manner. The patient has the responsibility to insure that all information provided for inclusion in his or her record is complete and accurate.