Our Policy on Forms Completion

Turnure Medical Group, Inc.

If you have a form that needs to be completed by your physician please adhere to the following guidelines:

ADMINISTRATIVE FORMS: -School entrance, sports & DMV

Most administrative forms require a physical, so please allow adequate time for scheduling an appointment. Please bring the proper form with you to your appointment. In most cases your physician will be able to fill out the form during your appointment. Please have the patient section of your form completed ahead of time. Finally, be aware that some insurance companies do not cover physicals. In this case, we do require full payment at the time of your visit.

DISABILITY FORMS: Our fee for these forms range from $50.00-$300.00; the fee will be higher relative to the physician’s time involved to complete the form. Please allow one (1) week for these forms to be completed by your physician. You have the option of picking them up or we can mail them directly to you but payment must be received prior to you receiving these forms. Please note that we do not bill third parties for these forms. If you need assistance in properly getting reimbursed please ask for a receipt. Also note that your physician reserves the right to honor or dishonor your disability claim. It is best to discuss your situation with your physician prior to making a disability claim. In no event will a disability form be completed when you have not seen your physician for the reason for your disability. Our fee for medical records review or other miscellaneous letters is charged based on the time involved in compiling the letter. Therefore, the charge is up to your physician’s discretion. We hope this information is helpful in clarifying our policies. Thank you in advance for your cooperation. If you have any questions regarding these policies, please contact our Office Manager at (916) 624-3500. Thank you. 10/17

PATIENT’S PERSONAL HISTORY Date: _______________

Name____________________________________________ Birth Date___________________________________

Occupation________________________________________ Education___________________________________

Smoker: Never Former Current-daily Current-social

Marital Status____________________________ Religion_ __________________________________

Past Medical History:

Liver Disease

Lung Disease

Major injuries/illnesses_________________

Seizures

Stroke

Diabetes

Eye Problems Hearing Problems Heart Attack

Heart Burn

Heart Murmur Heart Problems High Blood Pressure

Headaches (Severe)

Kidney Disease

Thyroid Disease

Ulcers

Cancer Type:_______________________

___________________________________

Other: ________________________________________________________________

Allergies/Hay Fever Anemia

Anxiety Disorder

Arthritis/Joint Problems Back Problems Bleeding Problems Blood Transfusions Childhood Diseases

Clotting Problems Depression

Current Medications: including Vitamins and Herbals:

1. 6.

2. 7.

3. 8.

4. 9.

5. 10.

Allergies: (Are you allergic to…?):

Tetanus antitoxin yes no

Penicillin yes no

Sulfa yes no

Other Drugs yes no

PLEASE LIST

__________

Foods__________________________________________________

Eggs yes no

Cosmetics yes no

Other yes no

PLEASE LIST

__ ______________________________________________

__________

Past Surgeries:

Heart Prostate Skin Back

Thyroid Hemorrhoids Head Any Biopsies

Breast Appendix Abdomen Other

Uterus/ Ovary Gallbladder Cesarean

Hernia Tonsils Eyes

Family History: If Living If Deceased Age Health Age At Death Cause

Father

Mother

Brothers/Sisters

M F

Husband/Wife

Sons/Daughters

(Circle sex)

Do you know of any blood relative who has had: (check and give relationship)

Stroke Epilepsy Elevated Cholesterol

Heart Attack Diabetes Anemia

Arthritis Colitis Migraines

Hypertension Stomach ulcers Kidney disease

Suicide Asthma Thyroid disease

Lifestyle/ Social Issues:

Yes No Do you regularly smoke? Check: ____Cigarettes ____Pipe ____Cigar

For how many years?

Yes No Do you usually drink over 4 cups of coffee per day?

Yes No Have you ever been concerned about your alcohol use?

Yes No Has a friend, relative, or co-worker ever expressed concern regarding your

use of alcohol or other chemicals?

Yes No Have you ever tried to restrict your use of alcohol or other chemicals?

Yes No Have you ever used more alcohol than you planned to use?

Yes No Do you have difficulty falling asleep?

Yes No Do you awaken early in the morning without apparent cause?

Yes No Does your home have a smoke detector?

Yes No Do you frequently eat fried or fatty foods?

Yes No Do you drive without a seatbelt?

Yes No Do you engage in sex/intercourse without contraception?

2nd Measles shot?

Hepatitis B –series of 3 shots?

Immunization / Vaccines:

Last Tetanus?

Last TB shot test and result?

Last Flu shot? Had Chickenpox or its vaccine?

Screening Tests:

(Please indicate if you’ve had any of the following and the results and date of test done, if known):

EKG

Sigmoid/ Colonoscopy

Cholesterol

PSA (Prostate Specific Antigen)

General:

Please put an X if you frequently have this problem: Recent weight loss/gain. How much over Loss of interest in things you normally enjoy

Excessive Anxiety/Worry

Falls

Depressed/Sad

Phobias

Memory Loss

what period of time?

Fatigue

Weakness

Fever

Chills/Night Sweats

Insomnia - difficulty falling/asleep

Head / Eyes / Ears / Nose / Throat:

Frequent Headaches

Dizzy

Fainting/Blackout

Swollen Glands

Eye/Vision Problems

Hearing Problems

Ringing/Buzzing Ears

Nose Bleeds

Allergies/Hay Fever

Mouth Sores

Sore Tongue

Bleeding Gums

Dry Mouth

Hoarseness

Sore Throats

Swallowing Difficulty

Thirst

Frequent Sinus Infections

Heart / Lungs:

Chest pain. Tightness

Irregular Heartbeat

Sleep on more than one pillow

Cough

Wheeze

Swollen Legs/Feet

Chills/Night Sweats

Shortness of Breath with Normal Activities

Have Coughed Up Blood

Gastrointestinal:

Nausea

Vomiting

Appetite Change

Loss of Eating Control

Diarrhea

Constipation

Bloody/Black Stools

Abdominal Pain

Heartburn

Yellow Skin/Jaundiced

Urinary:

Painful Urination

Frequent Urination

Trouble Holding Urine

Difficulty Starting Urination

Bloody/Cloudy Urine

Waking Up at Night to Urinate

Skin:

Rash

Hives

Hair Loss

Change Skin Texture - Dry or Moist

Itching

Easy Bruising

Easy Sun Burning

New/Changing Mole

Musculoskeletal / Neurologic / Vascular:

Joint Pain

Joint Swelling/Redness

Morning Stiffness Longer than 1 hour

Muscle Pain

Muscle/Leg Cramps

Weakness of Arm or Leg

Tremor

Varicose Veins

For All Men:

What form of contraception are you/ your partner using?

Lumps or swelling of testicles?

Problems with impotence?

Discharge from the penis?

For men over 40, date of your last rectal exam?

For All Women:

Number of times pregnant?

Total term births?

Total preterm births?

Total miscarriages?

Total therapeutic abortions?

Complications of pregnancy?

Vaginal discharge or irritation? Pelvic pain?

Discomfort with intercourse?

Breast discomfort, lumps, or discharge?

Have you ever had an abnormal Pap smear or been treated with colposcopy?

When was your last pap smear?

Do you do regular self breast exams?

Do you take a calcium supplement? If so, how much?

For Menstruating Women:

Your menstrual periods come every days and last days.

Date of last menstrual period Was it normal?

Are your periods regular? Do you have bleeding between periods?

Any recent change in your menstrual cycle?

How heavy are your menses?

What method of contraception are you using?

What methods of contraception have you used before?

For Menopausal Women:

How long ago was your last period?

Any vaginal bleeding since menopause?

Date of last mammogram?

Rev. 3/13

Turnure Medical Group, Inc. Authorization for Release of Medical Records

To: Previous Physician/clinic Phone Number/Fax Street Address City State Zip NOTICE: Physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, state or federal confidential law may no longer protect it. DISCLOSURE: I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. YOUR RIGHTS: This authorization to release health information is voluntary. This authorization shall become effective immediately and shall remain in effect one-year from the date of signature unless a different date is specified here __________________. Treatment, payment, enrollment of eligibility from benefits may not be conditioned on signing this authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity’s obligation to pay a claim, or (4) to create health information to provide to a third party. This authorization may be revoked at any time. The revocation must be in writing, signed by you or your patient representative, and delivered to Turnure Medical Group, Inc. The revocation will take effect the date we receive it. You are entitled to receive a copy of the authorization if you request it.

By signing below I hereby authorize the release of my medical records to the following physicians:

Turnure Medical Group, Inc.

6805 Five Star Blvd., Suite 100 Rocklin, California 95677

Telephone: (916) 624-3500 Facsimile: (916) 624-3351

Raymond E. Turnure III, M.D. Ursula Hempstead, M.D. Thomas Stafford, M.D. Vance VanTassell, M.D. Joshua Laird-Wilson NP-BC Pang Her, NP-BC

Specify records: Medical Information _________

Psychiatric Information

_______________________ _________

Signature Date

Drug/Alcohol Information

_______________________ _________

Signature Date

Results of an HIV Blood Test

________________________ _________

Signature Date

Other Health Information (specify below)

Specify the records to be disclosed: Print Name Birthdate Signature (Patient/Parent/Guardian) Date If signed by other than patient, indicate relationship:

Release of Medical Information to Family Members

Turnure Medical Group, Inc.

• Raymond Turnure, MD

• Ursula Hempstead, MD

• Thomas Stafford, MD

• Vance VanTassell, M.D

• Pang Her, NP-BC

• Joshua Laird-Wilson, NP-BC

I, authorize Turnure Medical Group to discuss and release all medical information to family members named below. This includes medical records, x-rays, history, findings and prognosis pertaining to the medical condition, services rendered, or treatment given to me. This authorization complies with the Confidentiality of Medical Information Act, Section 56 ET SEQ of the California Civil Code. __________________________________________________________________ Name Relationship ___________________________________________________________________ Name Relationship ___________________________________________________________________ Name Relationship

___________________________________________________________________Name Relationship ________________________________________ ____________________ Patient Name (Please Print) Date of Birth ___________________________________________________________________Patient, Parent/Guardian or Power of Attorney Signature Date

PATIENT DEMOGRAPHIC SHEET

Turnure Medical Group, Inc.

Patient Name: _____________________________________________________ Sex: _______

Last First Middle

Street Address: __________________________________Marital Status__________________

City: _______________________________ State: _______________ Zip: ________________

Date of Birth: _______/_______/_______ Social Security: _________-__________-_________

Home Phone: (_______) _______-_________ Work Phone: (_______)_________-__________

Cell Phone: (______)_ _______-_________Email:____________________________________

Occupation: ________________________Employer: _________________________________

Who may we thank for referring you? ____________________________________________

IN CASE OF AN EMERGENCY WHO SHOULD WE CONTACT? (OUTSIDE OF YOUR HOME):

Name:_____________________________________Home: (_______)_______-____________

Relationship:__________________________________Cell: (_______)_______-____________

If you have insurance you would like us to bill please present us with your ID card.

Subscriber Name: _______________________________Date of Birth: ______/______/______

Social Security #:________-________-________Relationship to Patient: ___________________

Sex: _____________Street Address: _______________________________________________

City: ___________________________________State: ____________ Zip: _________________

Home Phone: (_________) ________-________ Work Phone: (________) _________-________

Cell: (________) __________-__________ Email: _____________________________________

Occupation: ____________________________Employer: _______________________________

If responsible party different from subscriber please provide us with that information.

6/15

Patient Demographic Questionnaire Turnure Medical Group

Name: ______________________________ Date of Birth: _____________________ (Patient Name - Please print)

We are asking for your race and ethnicity because some people of different backgrounds have a greater risk of developing certain diseases such as high blood pressure, diabetes and heart disease. It is also important for us to know your preferred spoken language so that we may communicate clearly with you. This information will be updated in your medical record and will be kept confidential. Thank you for providing us with this information as it will assist us in continuing to provide you with the best possible service for your healthcare. We appreciate your participation. Thank you!

Race-check the box which best describes you.Native HawaiianGuamanian/ChamorroSamoanOther Pacific Islander Other Race

White/CaucasianBlack/African AmericanAmerican Indian/Alaska Native Asian IndianChinese

FilipinoJapaneseKoreanVietnameseOther Asian

I prefer not to answer

Ethnicity: Non-Hispanic/Latino Hispanic/Latino

I prefer not to answer

Please indicate your preferred spoken language.We are required by law (CA Health & Safety Code AB800, Section 123147) to request thisinformation.

English Spanish Other:_______________________

I prefer not to answer

Communication Preference: Home Phone Cell Phone US Mail

Smoking Status: Quit Smoking Current Occasional Smoker Never SmokedCurrent Daily Smoker

Marital Status: Married Never Married Legally Separated Divorced

Widowed Domestic Partner Annulled

Preferred Imaging Facility: _______________________________________________

Preferred Hospital: _______________________________________________

Preferred Pharmacy/Location:

Preferred Lab:

_________________________________________________ ____________________________ Signature (Patient, Parent/Guardian or Power of Attorney) Date

Rev. 4/15

_______________________________________________

_______________________________________________

TURNURE MEDICAL GROUP OFFICE POLICIES

It is our philosophy at Turnure Medical Group that our relationship with you is built upon mutual trust and open communication. We value you as a patient; therefore, it is in your best interest that we disclose this information to you.

Please note that there are several providers in this office. Each provider runs on their own separate schedule. Therefore, other patients that arrive after you may be called back before you. Thank you for your patience.

INSURANCE & PAYMENT POLICY FOR SERVICES

Unless prior arrangements have been made we request full payment at a time of service. If we are contracted with your insurance, as a courtesy we will submit your charges for reimbursement. Your copayment will be collected and if you have a deductible please be prepared to leave a credit card on file or make a “good faith” estimated deposit on your account until your deductible has been satisfied. After billing your insurance you will be responsible for any additional co-insurance or services that were not covered. We recommend that you KNOW YOUR PLAN and what you are covered for as most plans do not cover everything at 100%. You will also be responsible for any charges that your insurance company does not pay in a timely manner or if your insurance company were to become insolvent. We cannot, as a third party, become involved in prolonged insurance negotiations as this is a contract between you and your insurance company.

If your check is dishonored by your bank, your account will be assessed a $25 non-sufficient funds fee. Any accounts past due over 30 days will be assessed a late fee of $15 per month.

At times it may be necessary for us to file a complaint against your insurance company or Labor Union. My signature below indicates that I have given Turnure Medical Group authorization to file a complaint with the Department of Insurance/Managed Care or the Labor Board on my behalf.

HMO PLANS

We are not contracted with any HMO plans. Some HMO plans do allow you to be seen in Urgent Care with the

proper authorization. IT IS YOUR RESPONSIBILITY TO OBTAIN THE PRIOR AUTHORIZATION prior to your visit. If

you are seen without Prior Authorization you will be responsible for the cost of your visit. There are no exceptions

as Prior Authorizations are NOT allowed to be back dated.

AUTHORIZATION RELEASE

I authorize Turnure Medical Group to release any medical information including diagnosis, x-rays, test results,

reports and records pertaining to any treatment or examination rendered to me. I understand that this medical

information may be used for diagnostic, insurance, legal and research at times when my physician deems it

necessary in order to ensure the best medical care on my behalf. I further understand that any person(s) that

receives these medical records will not release any medical information obtained by this authorization to any

other person or organization without further authorization signed by me for release of information. This office

protects patient’s information in accordance with Health Insurance Portability & Accountability Act (HIPAA). My

signature below indicates my authorization and acknowledges that I have received information on our Office

Privacy Practices.

Print Name:____________________________ Signature:______________________________

Signed: _______________________________ Date: __________________________________ (Patient, Parent/Guardian or Power of Attorney)

8/18

Turnure Medical Group

Pre-Authorized Credit Card Agreement I hereby authorize Turnure Medical Group to charge the credit card listed below for any amount owed by me (or my family) after my insurance has been billed.

This amount may be due to deductibles, co-insurance, unpaid co-pays or any amount that may not be covered by your insurance company. A receipt will be emailed once the card is charged.

Cardholder’s Full Name:____________________________________________

Billing Address:___________________________________________________

City: _____________________________________ Zip: _________________

Card Number:____________________________________________________

Exp. Date:_______________________________________________________ Please circle one: Visa Mastercard Discover American Express HSA (credit card preferred; no debit cards)

Patient’s Name: __________________________________________________ (Please Print)

Date of Birth: __________________________________________________

Please list all family members that you would like to add to your credit card:

Name: Date of Birth: ______________________________________ _______________________ ______________________________________ _______________________ ______________________________________ _______________________ Phone Number: __________________________________________________

Insurance Plan Type: Co-Pay Plan Deductible Plan Signature: _______________________________________________________ Date:___________________________________________________________

Please provide us your email address and we can email you the receipt

Email:__________________________________________________________

Most visits range between $75-$200. If your bill is greater than this amount, please check here if you would like to be notified before we charge your credit card. Please initial _______

Notice of Privacy Practices Turnure Medical Group, Inc.

This notice describes how medical information about you may be used and disclosed by Turnure Medical Group and how you can get access to this information. Please read carefully.

What is This Notice and Why is it Important? Each time you visit our office a record of your visit is made. Typically this record contains a description of your symptoms, medical history, exam and test results, diagnoses, treatment, and a plan for future care. This information is referred to as your medical record. This information serves the following:

A basis for planning your care and treatment

Serves as a means of communication among healthcare professionals who contribute to your care

Legal document of the care you receive

Means by which you or your insurance company can verify the services you received were appropriately billed

A tool with which we can assess and work to improve the care we provide

Your Health Information Rights You have the following rights related to your medical and billing records kept:

Obtain a copy of this notice. You will receive a copy of this notice at your first visit.

Thereafter you may request a copy of this notice or any revisions by asking our staff or calling us at (916) 624-3500.

Authorization to use your health information. Before we use or disclose your

health information other than as described below, we will obtain your written authorization, which you may revoke at any time to stop future disclosure.

Access to your health information. You may request a copy of your health

information that we keep in your medical or billing record. Your request must be submitted in writing. We may charge a fee for the costs involved in providing you access and for your copies.

Amend your health information. If you believe the information we have about

you is incorrect or incomplete, you may request that we correct the information. Your request must be in writing.

Request confidential communications. You may request that when we

communicate with you about your health information, we do so in a specific way (ie. at a certain mailing address, email or phone number). We will make every reasonable effort to comply with your request.

Limit our use of your health information. You may request that we restrict the

use or disclosure of your health information for treatment, payment, healthcare operations, or any other purpose except when specifically authorized by you, when we are required by law or in an emergency situation in order to treat you. We will consider your request and respond, but we are not legally required to agree if we believe your request would interfere with our ability to treat you or collect payment for our services.

Accounting disclosures. You may request a list of disclosures of your health

information that we have made for reasons other than treatment or payment of healthcare operations.

Other Responsibilities We are required by law to protect the privacy of your healthcare information, establish policies and procedures that govern the behavior of our staff and business associates and provide this notice about our Privacy Practices and abide by the terms of this notice. We reserve the right to change our policies and procedures for protecting health information. When we make a significant change in how we use or disclose your health information, we will also change this notice. This new notice will be available as a “Waiting Room Copy” or at the front desk if requested. Except for purposes related to your treatment, to collect payment for our services, to perform necessary business functions, or when otherwise permitted or required by law, we will not use or disclose your health information without your authorization. You have the right to revoke your authorization at any time. We are unable to take back any disclosure we have already made with your permission.

Special Situations Military and Veterans. If you are a member of the armed forces, we may disclose

your health information as required by military command authorities. We may also disclose health information about foreign military personnel to the appropriate foreign military authority.

National Security and Intelligence Activities. We may disclose your health

information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Service for the President and Others. We may disclose your health

information to authorized officials so they may provide protection to the President and other governmental leaders, or conduct special investigations.

Regulatory Oversight. We may disclose your health information to appropriate

health oversight agencies, public health authorities or attorneys, when required by law. Your health information may also be disclosed if a workforce member or business associate believes in good faith that Turnure Medical Group has engaged in unlawful conduct or has otherwise violated professional or clinical standards and is potentially endangering one or more patients, workers or the public.

For More Information or to Report a Problem If you believe we have not properly protected your privacy, have violated your privacy rights or you disagree with a decision we have made about your rights, you may contact Dr. Turnure directly at (916) 624-3500. He can also be contacted with any questions you have or if you need any additional information. You may also send a written complaint to the U.S. Department of Health and Human Services. Turnure Medical Group will ensure that the care you receive at our facility will in no way be impacted if you file a complaint.