UFHealth Pediatrics titlepage

UFHealth Pediatrics

School Based Telehealth

Program

Enrollment Packet

Parents- Please turn this completed packet into your school nurse’s office.

School nursing staff - Please fax this completed packet to 352-334-4041 ATTN: Lisa Hester

Participating Providers List

UFHealth can provide school-based telehealth visits to children who attend the following clinics:

• Uninsured children or children who do not have primary medical provider • UF Health Pediatrics at CMS • UF Health Pediatrics at Magnolia Parke • UF Health Pediatrics at Tower Square • UF Health Pediatrics at Tioga • UF Health Family Medicine at Eastside Clinic • UF Health Family Medicine at Main Street

UF Health Pediatrics/SBAC School Based Telemedicine Medical Intake Form

Today’s Date:______________________

Student Information: Student First and Last Name: ________________________________________________

Student Date of Birth: _____________________ Gender Identity: __________________

Student Home Address:____________________________________________________

Parent/Guardian(s) Information: (1) Full Name:______________________________

a. Contact Phone:____________________ Contact Email__________________

(2) Full Name: ______________________________

a. Contact Phone:____________________ Contact Email__________________

Student’s Insurance Information: Name of Insurance: ________________________________________________

Policy Number: ____________________________________________________

Primary person Insured: _____________________________________________

Student’s Primary Care Physician Information: Name of Primary Doctor/Medical Provider: ____________________________

Office Location (please circle one):

UF Health Pediatrics at CMS

UF Health Pediatrics at Tower Square

UF Health Pediatrics at Magnolia Parke

UF Health Pediatrics at Tioga

UF Health Family Medicine Main Street

UF Health Family Medicine East Side

Other: ______________________________________________________

Office Phone Number: _______________________________________________

Student’s Health Information: Please select any of the following medical conditions/surgeries your child has or has

had in the past:

• Allergies

• Asthma/Wheezing

• Frequent ear infections

• Surgery for ear tubes

• Tonsil removal

• Constipation

• Celiac disease

• Ulcerative Colitis

• Inflammatory Bowel Disease

• Diabetes

• Thyroid Disease

• Migraines

• ADHD

• Depression

• Anxiety

• Seizures

• Sickle Cell Anemia

• Cystic Fibrosis

• Heart condition. Please list:

________________________

• Food Allergy/ Please list:

________________________

• Cancer. Please list:

________________________

• Other. Please list:

________________________

________________________

_______________________

Does your student take any medications? Check one – Yes No

If yes, please list the names and dosages of their medications below:

Medication Name: Dose: Timing:

Has your student every had an allergic reaction to a medication or food? Circle one – Yes No Unsure

If yes, please list the name of the medication and/or food and the reaction below:

Medication/ Food Name Reaction

By signature below, I acknowledge that I have read and understand that the foregoing is applicable to the minor child identified above and that all information provided is accurate to the best of my knowledge. Parent/Guardian __________________________________________ Date ___________ Insured (if other than above for assignment of benefits) ___________________________ Date ______ Witness _________________________________________________ Date ______________

Consent and Authorization / Notice of Limited Liability (page 1 of 3)

Patient Name:

Date:

Medical Record Number:

If printed electronically, all pages must be stapled.Revised 6/29/20

PS141198

*For purposes of this Consent and Authorization, UF Health describes a collaboration of the University of Florida Board of Trustees for the benefit of the University of Florida College of Medicine, Shands Jacksonville

Medical Center, Inc., Shands Teaching Hospital and Clinics, Inc., and Shands Recovery, LLC. Collectively, these entities are referred to as UF Health in this form.

Consent and Authorization for Routine Treatment – I consent to and authorize UF Health*, my physicians and health care providers (collectively “my providers”) to provide or order the routine medical care, diagnostic and laboratory procedures, which my providers believe to be necessary. I understand UF Health is affiliated with a teaching institution, and that residents, interns, students, and other individuals may observe or participate in my care, treatment, and services (“Care”). I consent to UF Health taking photographs and/or video/audio recordings of me in the course of and related to my Care, and to their use of such photographs or videos and my medical data for educational purposes within UF Health. I authorize UF Health to retain, preserve, use for educational purposes, or to otherwise dispose of, any specimens, tissues, medical devices, or implants removed from my body during my Care. Telemedicine: I understand and agree that my providers may utilize telemedicine (the electronic communication of medical information) including, but not limited to, videoconferencing, electronic transmission of imaging, and remote monitoring of vital signs as part of my Care. Except in emergency circumstances, my providers will explain the risks and benefits of telemedicine prior to the telemedicine encounter. I understand that I have the right to seek Care elsewhere in lieu of a telemedicine encounter.Pelvic Examination Consent: I understand that as a part of my medical care and treatment, a pelvic examination may be performed by my health care practitioner(s). In addition, I understand that a pelvic examination may be performed by a medical student, or any other student receiving training as a health care practitioner.Valuables Release – I understand and acknowledge that UF Health has no responsibility for the loss of any valuables or personal belongings (“property”) unless those items are deposited with UF Health Security, and I release UF Health from all liability for loss of any property which I do not deposit with UF Health Security. All items deposited with UF Health Security that remain unclaimed for ninety (90) days will be considered abandoned and may be disposed of by UF Health.Safety and Security – In order to protect the health and safety of patients, visitors and staff, I understand UF Health does not permit contraband on its premises (including guns, knives, other weapons, illicit drugs, or alcohol). I consent to a search of my person and belongings to identify and remove contraband should UF Health reasonably suspect the presence or use of contraband on its premises. If my providers reasonably suspect the use of contraband substances, I consent to an alcohol and/or drug test as necessary to provide me appropriate patient Care. I understand and acknowledge that UF Health has zero tolerance for harassing, aggressive or violent behavior by its visitors, staff, and patients. I agree that neither I nor my visitors will photograph, film, or record any provider without that provider’s express consent.Disclosure of Patient Information – I authorize UF Health and my providers to release my health information (including information relating to mental health/psychiatric care, alcohol and/or substance abuse, genetic testing, and HIV tests) and any other information for treatment purposes and/or to obtain payment for charges incurred by me or on my behalf to: my providers or any affiliated provider; my referring or treating providers; any third party engaged in the collection or dissemination of my medication information; the guarantor on my accounts; any third party payors (defined as including, but not limited to, Medicare, Medicaid, Tri-care or governmental programs; health, accident, automobile or other insurance; workers’ compensation payors, agents or administrators; HMOs; self-insured employers; and any sponsors who may contribute payment for medical services) or their agents; regional or national health information networks; and other providers of medical services and products related to or connected with this admission or course of Care.I authorize UF Health to disclose my patient information to: business associates, public health and oversight agencies, regulatory entities, other health care providers or organizations who have provided me with Care to facilitate health care operations of any of these parties; residents, interns, students, and others in furtherance of educational purposes; disaster relief agencies as necessary to assist in their endeavors; law enforcement to correctly identify me or to report a crime; affiliated charitable foundations in connection with fundraising programs; and UF Health to send health promoting or informational materials to me. If my admission or treatment is due to a motor vehicle accident, I authorize UF Health or my providers to obtain a copy of my “crash report” required by Florida Statutes, in order to facilitate third party payment.I understand that my patient information is protected by the right to privacy guaranteed by Article 1, Section 23 of the Florida Constitution. I do not authorize the release of my patient information, including the release of information with my name or identifying information redacted, if requested by other patients or their representatives.Medicare Request for Payment/Assignment of Benefits – I request payment of authorized Medicare benefits due to me or on my behalf for any services furnished to me by UF Health and my providers. I hereby assign to UF Health and my providers payment from Medicare, Medicaid and all third party payors with whom I have coverage or from whom benefits are or may become payable to me, for the charges I receive for, related to, or connected with Care (past, present, or future) I receive from UF Health and my providers. I agree to be personally responsible for payment for all Care that is not covered by my third party payors, including, but not limited to, non-covered or out-of-network services, deductibles, co-insurance, and/or co-payments.Guarantor Agreement – I agree to the following: 1) I am responsible for UF Health’s and providers’ charges for this Care and past and future Care if related to the same accident or illness; 2) the charges are due and payable at the time of discharge or discontinuation of Care; 3) I agree to pay the charges in effect at the time Care is provided; 4) unless otherwise precluded by contract or law, if UF Health or providers bill third party payors, they do so as a courtesy, and UF Health and providers may demand payment in full of any balance due at any time; 5) if I have not paid a final bill within one hundred and twenty days (120) days, I may be declared in default, and the overdue account may be referred to a collection agency. I consent to UF Health or any third party contacting me by telephone, including my cellular phone, for purposes of collecting any amounts owed by me.

(continued on next page)

*AC0001*AC0001

Patient Name:

Date:

Medical Record Number:

If printed electronically, all pages must be stapled.

Revised 6/29/20

PS141198

NOTICE OF LIMITED LIABILITYPURSUANT TO SECTION 1012.965, FLORIDA STATUTES

I, ON BEHALF OF MYSELF, MY CHILD, AND/OR MY WARD, HEREBY ACKNOWLEDGE THAT:THE MEDICAL CARE AND TREATMENT I, MY CHILD AND/OR MY WARD RECEIVE AT SHANDS TEACHING HOSPITAL AND CLINICS, INC., SHANDS JACKSONVILLE MEDICAL CENTER, INC., OR SHANDS RECOVERY, LLC, WILL BE PROVIDED BY EMPLOYEES AND/OR AGENTS OF THE UNIVERSITY OF FLORIDA BOARD OF TRUSTEES (UFBOT);THE UFBOT EMPLOYEES AND/OR AGENTS PROVIDING THIS MEDICAL CARE AND TREATMENT INCLUDE BUT ARE NOT LIMITED TO: PHYSICIANS; PHYSICIAN ASSISTANTS; HEALTHCARE RESIDENTS, FELLOWS, AND STUDENTS IN TRAINING; ADVANCED REGISTERED NURSE PRACTITIONERS; NURSES; PERFUSIONISTS; AND TECHNICIANS, WHO WILL AT ALL TIMES BE UNDER THE EXCLUSIVE SUPERVISION AND CONTROL OF THE UFBOT; ANDTHE LIABILITY FOR THE NEGLIGENT ACTS AND OMISSION OF THESE UFBOT EMPLOYEES AND/OR AGENTS IS LIMITED BY LAW TO $200,000 PER CLAIM OR JUDGMENT BY ANY ONE PERSON AND TO $300,000 FOR ALL CLAIMS OR JUDGMENTS ARISING OUT OF THE SAME INCIDENT OR OCCURRENCE (SEE SECTION 768.28(5), FLORIDA STATUTES).I FURTHER ACKNOWLEDGE, ON BEHALF OF MYSELF, MY CHILD AND/OR MY WARD, THAT THE UFBOT EMPLOYEES AND AGENTS PROVIDING MEDICAL CARE AND TREATMENT AT A SHANDS TEACHING HOSPITAL AND CLINICS, INC., SHANDS JACKSONVILLE MEDICAL CENTER, INC., OR SHANDS RECOVERY, LLC. (collectively “SHANDS”) FACILITY ARE NEITHER EMPLOYEES NOR AGENTS OF SHANDS.

Printed Patient Name

Patient/Parent/Guardian Date

(continued)Lien on Third Party Liability Proceeds – If my Care is due to an accident or injury, UF Health shall have a lien upon the proceeds of any cause of action, suit, or settlement I receive related to such accident or injury, in order to recover payment for all charges for Care I receive related to such accident or injury (past, present, or future), effective as of the date Care was first provided.University of Florida and Other Independent Providers – I acknowledge that I will receive Care from Independent Providers (including, but not limited to, radiologists, anesthesiologists, pathologists, emergency physicians, surgeons, obstetricians, and perfusionists) who are NOT employees or agents of EITHER the University of Florida Board of Trustees OR any of the following (collectively referred to as the “Shands Entities”): Shands Jacksonville Medical Center, Inc.; Shands Teaching Hospital and Clinics, Inc.; or Shands Recovery, LLC. I further acknowledge that I will receive care from health Care providers who are employees and/or agents of the University of Florida Board of Trustees (“UF Providers”), but are not the employees and/or agents of any of the Shands Entities. To the extent that the law imposes any duty upon any UF Health hospital to provide certain services, I HEREBY: consent to the delegation of that duty to UF Providers and/or Independent Providers participating in my Care; discharge UF Health from any duties the hospital may have with regard such services; and give up my right to hold a UF Health hospital liable for any injury suffered as a result of a negligent act or omission based on any UF Provider or Independent Provider.Risk Management and Dispute Resolution – I agree that my patient information (including, but not limited to, my medical records, billing information, and information I disclose to a health care provider in the course of my Care) may at any time be used by and disclosed to employees, officers, agents, and legal representatives of UF Health, for purposes of risk management, and formal and informal dispute resolution processes (including, but not limited to, litigation and mediation) involving one or both entities.Agreement to Mediate – In accepting Care at a UF Health facility, I agree that before I file any lawsuit against UF Health or any of its facilities, employees or agents arising out of the Care provided to me by providers, I will first attempt to resolve my claim through confidential mediation. Mediation is a process through which a neutral third person who has been certified to be a mediator tries to help settle claims. UF Health will pay the cost of the mediator. I further agree that any mediation must take place in the State of Florida and in the county where my Care was rendered, unless all parties agree otherwise. This agreement is binding on me and any entity or individual making a claim on my behalf. This agreement does not waive my right to file a lawsuit if the mediation process fails to resolve my claim. I understand that lawsuits must be filed within a certain time period and that the time for me to file a lawsuit is not extended as a result of my participation in mediation.By signature below, I acknowledge that I have read, understand, and agree to the foregoing as applicable to me and/or my minor child(ren), if provided Care by or on behalf of UF Health, or if born during this admission or Care by UF Health. A signed copy shall be as valid as the original.


PATIENT/GUARDIAN DATE INSURED (If other than the above for assignment of benefits, e.g., step-parent) DATE

DATE DATE

DATEDATE

WITNESS (Print Name)

WITNESS (Signature)GUARANTOR (Spouse, Partner, etc.)

AUTHORIZED REPRESENTATIVE (Patient unable to sign)


Revised 6/29/20

PS141198

Patient Rights and ResponsibilitiesYou have the right to: • Respectful care that is free from discrimination on the basis of race, color, national origin, religion, age, sex, physical, mental or other disability, medical condition, sexual orientation, gender identity, gender expression, pregnancy, ancestry, marital status, citizenship, status as a veteran, ownership of a firearm, or other non-medically relevant factors. • Expect certain rights to privacy and confidentiality without regard to economic status. • Receive financial counseling so you may meet financial obligations and know what patient services are available to you. • If you are a Medicare patient, upon request and in advance of treatment you have a right to know whether the Medicare assignment rate is accepted and you have the right to receive a “Notice of Beneficiary Discharge Rights, “Notice of Non-coverage Rights” and “Notice of the Beneficiary Right to Appeal Premature Discharge.” • Be called by your preferred names and pronoun. • Know the name, function, and qualifications of the physician who has primary responsibility for coordinating your care, as well as the names and professional relationships of other providers, nurses and staff who will be involved in your care. • Be provided sign language or medical interpreter services if you have a need at no charge to you. • Have reasonable accommodations made for your religious or spiritual preferences. • Upon request have your primary care provider notified of admission to the hospital. • Have visitors. • To ensure the safety of all of our patients your visitors under 14 years of age should be with an adult (who is not the patient) during the visit. • Your visitors should be free from colds, flu, or any illness that might be spreadable. • Reasonable restrictions are placed upon visitation, including restrictions upon the hours of visitation and number of visitors. • Discrimination in visitation access based on sexual orientation, gender identity or gender expression is prohibited. • Have someone remain with you in patient-accessible areas for emotional support during your hospital stay (unless your visitor(s) compromises other patients’ rights to safety and health). • Receive a careful evaluation, followed by polite and prompt treatment, reasonable response to a question or request, and if it is safe for you to participate, be given the choice to watch certain procedures. • Have your pain assessed and reduced as much as safely possible with pain management. • If you suffer from severe chronic intractable pain, the doctor may choose alternatives to opiate medication, and can provide information about physicians who specialize in the treatment of severe chronic pain. • Receive information and instructions in ways that you understand. Your doctor will inform you about your diagnosis, planned course of treatment, any alternatives, the risks and benefits of any treatments, the prognosis, and the expected and unexpected outcomes of any treatment, unless it is medically inadvisable or impossible to give this information to you. You may refuse treatment which shall be documented by the medical provider and be informed of the medical results of this decision. • Please talk openly with your doctor regarding: – Your illness – Why treatments and tests are done, who does them and who will share the results of those treatment or tests with you – Your wish for a second opinion from another doctor – Your wish to change doctors and/or hospitals – Ethical issues about your care • Receive treatment for any medical condition that will deteriorate from failure to provide treatment. • Know if medical treatment is for purposes of experimental research and to give your consent or refusal to participate in such research. • Receive an explanation of all papers you are asked to sign and upon request receive an itemized bill or statement of charges. • Express complaints regarding any violation of your rights • Report unexpected changes in your condition to the responsible caregiver. • If you feel your concerns about your clinical care are not being addressed you have the right to call a Condition H.

You are responsible to/we ask that you: • Provide your health care team accurate and complete information about your health. • Share information about your health, such as a complete health history, symptoms, treatments, medicines, vitamins, supplements taken and any other information that could bear on your health. • Be honest about what you tell us. • Tell us about your health risks, such as allergies, or other risks that might impact your care. • Give us copies of any legal documents that affect your healthcare, including any advance care plans/advance directives or health care surrogate documents. • Meet the financial responsibilities associated with your care. • Follow the care recommended by doctors, nurses and other care team members and remember you are responsible for your actions if you do not follow instructions or refuse treatment. • If you leave the hospital against the advice of your doctor, the hospital and doctors will not be responsible for any medical consequences that may occur. • Respect the rights of other patients, families and hospital personnel. • Keep a quiet restful environment because rest is an important part of healing. • Not use inappropriate language such as cursing or swearing. • Respect hospital property. • Follow hospital rules and regulations that apply to patient conduct. Such as: – Not smoking on hospital grounds. • Refrain from behavior that is threatening to staff such as putting another person in fear of bodily injury: – Please do not use words, actions, or behaviors that are threatening to oneself or others and that a reasonable person would find threatening, violent, and/or potentially violent. – This includes words, actions, or behaviors that reflects a serious intention to instill fear in another person or the intent to cause physical or mental harm that could lead to psychological or physical harm of another person.* It is the policy of UF Health to honor all appropriately completed Advance Directives.** Agency for Health Care Administration / 2727 Mahan Drive / Tallahassee, FL 32308 / (888) 419-3456 or Joint Commission on Accreditation of Healthcare Organizations / Office of Quality Monitoring / One Renaissance Boulevard / Oakbrook Terrace, IL 60181 / 800.994.6610

JOINT NOTICE OF PRIVACY PRACTICES AND NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT

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Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. If you have any questions about this Notice, please contact either the Privacy Office for UF Health Shands or the Privacy Office for the University of Florida at the contact information listed below:

UF Health Shands Privacy Office 1-866-682-2372 University of Florida Privacy Office 1-866-876-4472

OUR LEGAL DUTY TO PROTECT HEALTH INFORMATION ABOUT YOU We understand your health information is personal and we are committed to protecting it. We create a record of the care and services you receive at UF Health Shands or the University of Florida Health Science Center (UFHSC) to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by UF Health Shands and/or the UFHSC, whether made by hospital personnel, University of Florida faculty, staff, students, or your personal doctor. This Notice describes how we may use and disclose your health information, and provides examples where necessary. This Notice also describes your rights regarding your health information. We are required by law to maintain the privacy of health information, to provide individuals with notice of our legal duties and privacy practices with respect to health information, and to abide by the terms of the notice currently in effect.

CHANGES TO THIS NOTICE We reserve the right to change our privacy practices and this notice at any time. We reserve the right to make the revised notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at all our facilities.

NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT UF Health Shands, which for the purposes of this notice includes Shands Teaching Hospital and Clinics, Inc. and Shands Jacksonville Medical Center, Inc., and the UFHSC, together with the UFHSC clinics* and other affiliated health care providers have agreed as permitted by law, to share your health information among themselves for purposes of treatment, payment or health care operations. This arrangement enables us to better address your health care needs in the integrated setting found within UF Health Shands and the University of Florida health care providers. The organizations participating in the Joint Notice are participating only for the purposes of providing this Joint Notice and sharing medical information as permitted by applicable law. These organizations are not in any way providing health care services mutually or on each other’s behalf. UF Health Shands and the University of Florida are separate health care providers and each is individually responsible for its own activities, including compliance with privacy laws, and all heath care services it provides.

CONSISTENT WITH STATE AND FEDERAL LAW, WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN PERMISSION IN THE FOLLOWING CIRCUMSTANCES: We may use and disclose your health information to provide medical treatment to you and to coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example: we may use and disclose your health information when you need lab work or an x-ray. Also, we may use and disclose your health information when referring you to another health care provider or to recommend treatment alternatives to you. We may use and disclose your health information to bill and receive payment for services rendered. For example: A bill may be sent to you or your insurance company. The items on, or accompanying, the


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bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used so that your health plan will pay the medical bill. We may also tell your health plan about a treatment you are expected to receive in order to obtain prior approval or to determine if your health plan will pay for that treatment. We may use and disclose your health information for health care operations. We will use your health information for regular operations of the hospital and clinics to provide patients with quality care. For example: Members of the medical staff, the risk management team or the quality improvement team, including Patient Safety Organizations (PSOs), may use information in your health record to assess the care you receive and the outcomes of your treatment. We may also disclose information to doctors, nurses, technicians, medical students and other UFHSC personnel for review and teaching purposes. We may also use and disclose your health information:

x When necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

x To organizations that facilitate donation and transplantation of tissues and/or organs. x To authorized officials when required by federal, state, or local law. x In response to a subpoena, court, or other administrative order. x As required by law, for public health activities. For example: preventing or controlling disease,

reporting births and deaths, and reporting abuse and neglect. x For authorized Worker’s Compensation activities. x To health oversight agencies. For example: agencies that enforce compliance with licensure or

accreditation requirements. x To coroners, medical examiners, or funeral directors to carry out their duties. x As required by military command authorities, if you are a member of the armed forces. x To our business associates to carry out treatment, payment, or health care operations on our

behalf. For example: we may disclose health information about you to a company who bills insurance companies for our services.

x For research or to collect information in databases to be used later for research. All research projects are reviewed and approved by an independent review board to protect the privacy of your health information.

x To a correctional institution having lawful custody of you as necessary for your health and the safety of others.

We may also use and disclose your information for fundraising activities to raise money for UF Health Shands or UFHSC and their operations. If you do not want to be contacted for fundraising efforts, you must notify either the UF Health Shands Privacy Office or the University of Florida Privacy Office.

SPECIAL CIRCUMSTANCES Alcohol, Drug Abuse, Psychotherapy Notes, and Psychiatric Treatment Information may have special privacy protections. We will not disclose any health information identifying an individual as a patient or provide information relating to the patient’s substance abuse or psychiatric treatment unless:

1. You or your personal representative consents in writing; 2. A court order requires disclosure; 3. Medical personnel need information to treat you in a medical emergency; 4. Qualified personnel use the information for research or operations activities; 5. It is necessary to report a crime or a threat to commit a crime; or 6. To report abuse or neglect as required by law.


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YOU MAY REFUSE TO PERMIT CERTAIN USES AND DISCLOSURES OF YOUR HEALTH INFORMATION Unless you object, we may use or disclose your health information in the following circumstances:

x Hospital Directories. We may share your name, room number, and condition in our patient listing with clergy and with people who ask for you by name. We also may share your religious affiliation with clergy.

x Individuals Involved in Your Care or Payment for Your Care. We may use or disclose information to a family member, legal representative, or other persons involved with or responsible for your care or the payment of your care.

x Emergency Circumstances and Disaster Relief. We may disclose information about you to an agency assisting in a disaster relief effort so that your family can be notified of your location and general condition. Even if you object, we may still share the health information about you, if necessary for emergency circumstances.

USES AND DISCLOSURES OF HEALTH INFORMATION THAT REQUIRE YOUR WRITTEN PERMISSION Other uses and disclosures of health information not covered by this notice or applicable law will be made only with your written permission. If you provide permission to use or disclose health information, you may revoke that permission at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your revocation. We are unable to take back any disclosures already made with your permission. We will not use or disclose your protected health information for marketing purposes, nor will we sell your protected health information without your written permission.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION You have the following rights regarding health information we maintain about you:

x Right to See and Obtain Copies of your Health Information You have the right to see and obtain copies of health information used to make decisions about

your care. Usually, this includes medical and billing records, and excludes psychotherapy notes. To view and copy your health information, you must submit your written request on the

appropriate form to Health Information Management or the Clinic Manager. We may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to see and obtain copies of your health information in certain very limited circumstances. You have the right to appeal the denial.

x Right to Amend If you think that your health and billing information is incorrect or incomplete, you may ask us to correct it. We may deny your request if:

1) The information was not created by us; 2) The information is not part of the records used to make decisions about your care; 3) We believe the information is correct and complete; or 4) You do not have the right to review parts of the medical record under certain circumstances.

We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, as needed, including persons you name who have received information about you and who need the amendment. Your request must be in writing and include an explanation of your reason(s) for the amendment. The request must be submitted on the proper


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form to the Health Information Management or Clinic Manager where you received treatment. x Right to an Accounting of Disclosures

You have the right to request an Accounting of Disclosures. This Accounting of Disclosures report does not include disclosures made for your treatment, payment, or health care operations. It also does not include disclosures made to or requested by you, or that you authorized. You must submit your request for a report in writing to the Health Information Management or the Clinic Manager where you received care. Your request must state a time period, which is limited to the previous six years from the date of the request. The first request for an accounting of disclosures will be provided free of charge. We may charge you for additional report requests made within a 12 month period.

x Right to Request Restrictions You have the right to request a restriction or limitation on the health information we use or

disclose about you for treatment, payment or health care operations. If we agree with your request, we will comply unless the information is needed to provide emergency treatment, is required by law, or otherwise required to be disclosed as listed in this notice. You must make your request for restrictions in writing to either the UF Health Shands Privacy Office or the UF Privacy Office. Your request must include what information you want to limit and how you want the limits to apply. You have the right to restrict disclosures of health information made to a health plan when the items or services were paid in full prior to being rendered. Certain limitations apply.

x Right to Choose How We Communicate With You You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example: you can ask that we only contact you at work or by mail. You must make your request for alternate communications in writing to the Admissions supervisor at UF Health Shands, or to the UF Clinic Managers or supervisors. We will not ask you the reason for your request and will accommodate reasonable requests.

x Right to a Paper Copy of This Notice You have the right to receive a copy of this notice from UF Health Shands or any UF clinic. You may obtain an electronic copy of this notice from our websites at: https://ufhealth.org/patient-care or www.privacy.health.ufl.edu.

x Right to Breach Notification You have the right to and will receive notification in the event of a breach of your unsecured

protected health information, unless such notification is exempted by law.

COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with us. You will not be penalized or denied services for filing a complaint. To file a privacy complaint with UF Health Shands, please contact the Privacy Office, at, P.O. Box 103175, Gainesville, FL 32610-3175, or call 1-866- 682-2372. To file a privacy complaint with the UFHSC or UF Clinics, please contact the UF Privacy Office at P.O. Box 113210, Gainesville, FL 32611 or call 1-866-876-4472. All complaints must be submitted in writing on the appropriate form that is available on our website: www.privacy.health.ufl.edu. To file a complaint with the Secretary of the Department of Health and Human Services, visit the Office for Civil Rights website at www.hhs.gov/ocr. *The University of Florida clinics and physicians’ offices; the Florida Clinical Practice Association; the University of Florida Jacksonville Physicians, Inc., the University of Florida Jacksonville Healthcare, Inc.; the University of Florida Colleges of Medicine, Nursing, Health Professions, Dentistry and Pharmacy; the University Proton Therapy Institute; and other affiliated health care providers, including all employees, volunteers, staff and other University of Florida health services staff.

Revised 5/29/18Reviewed 10/26/18

PS137484

Acknowledgement of Receipt of Notice of Privacy Practices

I have been provided a copy of the UF Health* Notice of Privacy Practices. I understand that I may ask questions about this Notice at any time.

* For purposes of this agreement, UF Health describes a collaboration of the University of Florida Board of trustees for the benefit of the University of Florida College of Medicine, Shands Jacksonville Medical Center, Inc., Shands Teaching Hospital and Clinics, Inc., and Shands Recovery, LLC. Collectively, these entities are referred to as UF Health in this form.

Patient Name: Patient Identification #:

Acknowledgement of Receipt of Notice of Privacy Practices CP03.022

Patient’s Printed Name:

Patient’s Signature: Date: Time:

If not signed by the patient, please indicate relationship:

Legal Representative’s Printed Name:

Legal Representative’s Signature: Date: Time:

Relationship:

For Office Use Only:

□ Signed form received by:

□ Acknowledgement refused:

Efforts to obtain:

Reason for refusal:

Form # 340 /UF Health Physicians/Updated 7/6/2016 DXM

Patients of UF Health Physicians:

COLLECTION AND USE OF YOUR SOCIAL SECURITY NUMBER

Your Social Security Number has been collected because it is necessaryfor the performance of the practices' legal responsibilities, such asbilling your health insurance company. UF Health Physicians, whereyou are being seen as a patient, is authorized by law to collect yoursocial security number for this purpose.

If you have questions about the collection and use of your SocialSecurity Number, please visit: http://privacy.ufl.edu/SSNPrivacy.html

PATIENT NAME: VISIT DATE:MRN:

SSN Privacy Notice


12/10/18

PS16077

Notice to Patients Regarding Professional Licensure (page 1 of 1)

Notice to Patients Regarding Professional Licensure

Patient Name: MRN Visit Date:

I was advised at the time I scheduled this appointment that I had a choice of seeing either a Physician or Physician Assistant - Certified (PA-C) or Advanced Practice Registered Nurse (APRN) who works under the supervision of the physician.

I have agreed to see a PA or APRN and this is acceptable to me.

Patient/Guardian Signature Date Time

Patient/Guardian Print Name

PATIENT NAME: VISIT DATE:MRN:

UFP FINANCIAL POLICIES

Form #303/University of Florida Physicians/Updated 2/28/06 DXM

1. Payment is expected at time of service. This includes co-pays, co-insurances and deductibles.

2. At check out, our staff will ask you for payment for any past due balances as well as your portion ofthe payment for today's service. Failure to meet your financial obligations could result in beingdischarged from the practice.

3. If you are unable to keep your appointment, it is important to notify us prior to your appointment.This will allow us to free your appointment time for other patients. You may be charged a $25 noshow fee if you fail to notify us.

4. Adult patients who do not show up for a scheduled appointment 3 times within a 12 month periodand fail to notify us prior to the appointment, will be discharged as a patient. Patients under the ageof 18 may be discharged for the same.

5. If you are scheduled for an elective non-covered procedure, an estimate of your portion of thepayment will be given to you. Payment will be expected at least 10 days prior to this procedure. Ifyou have any outstanding balance, we will also expect payment 10 days prior to the procedure.Failure to make the required payments will result in the service being rescheduled. When youreceive your estimate, you will also receive a payment voucher to send back with your payment.Please remember to include the voucher along with your payment.

6. Some insurances require that your labs be performed in a different location other than your doctor'soffice. If you choose to have the test performed at your physician's office, you will be expected topay the fee for this service. Your insurance cannot be billed in those instances.

7. Similarly, if your insurance does not authorize a procedure or test and you choose to have theprocedure or test done anyway, you will need to pay for the service up front. Your insurance cannotbe billed in those instances.

8. We can no longer extend professional courtesy discounts to you.

If you have any questions, please call our Patient Relations department at (352) 265-7906 or1-888-766-8154, Monday thru Friday, 8:30 AM to 4:30 PM.

RE-UFP 8.30

Proxy Request for Access to MyUFHealth

Patient is: □ A Child under 12 years of age (Full Access) □ An Adolescent, aged 12 to 17 years (Limited Access) □ Mentally Incapacitated-any age (Full Access) □ Adult 18+ years Capacitated (Full Access)**

Proxy’s Relationship to Patient: □ Parent □ Legal Guardian* □ Spouse/Adult Child □ Other*

*Legal documents may be required, such as birth certificate, guardianship papers and/or power of attorney.

Patient Full Name

Street Address City

City

State

State

Zip

Zip

Home Phone

Proxy Full Name

Proxy Street Address

Date of Birth

Proxy Date of Birth

Health Record Number

Proxy E-mail

Proxy Phone Number

By signing below, I acknowledge that I have read and agree to the Terms and Conditions.

*Limited Access for Adolescent Patients. Under State and Federal law, there are certain types of medical information that the parent/guardian of a minor patient may not view without consent of the minor patient. Parents or guardians of minors aged 12 to 17 (inclusive), although acting as proxy, will not be given full access to the patient’s record but will be able to view the patient’s immunization records and allergy information, and will also be able to request appointments for the patient.**For purposes of this agreement, UF Health includes the University of Florida Board of Trustees for the benefit of the University Of Florida College Of Medicine, Shands Jacksonville Medical Center Inc., and Shands Teaching Hospitals & Clinics, Inc.

Proxy Request for Access to MyUFHealth

*RI0001*RI0001


Terms and Conditions: • I agree that I may use the MyUFHealth account of the patient named above only to access medical information and services on behalf of the patient. • I understand that MyUFHealth contains select health information from the patient’s medical record and does not reflect the complete contents of the patient’s official UF Health medical record. • I understand that communications and/or documents submitted via MyUFHealth may be tracked by computer audit and that any entries I make may become part of the patient’s medical record. • I certify that I am a legally authorized representative of the above-named patient, with legal authority to make health care decisions on behalf of the patient, and all information I have provided above is correct. **This does not apply for proxy access to an adult who is not incapacitated. • I am aware that UF Health reserves the right to terminate proxy access at any time. • This agreement will remain in effect until the earlier of: 1) when I choose to revoke it in writing; or 2) access is ended by UF Health. Any revocation must be in writing, signed on the patient’s behalf, and sent to UF Health.

Patient Information (This person’s health record will be accessible)

Proxy Information (This person will receive access to the above MyUFHealth account - please print)

Revised 12/18/19PS138060

Proxy Signature Date

**For Adult to Adult Capacitated Proxy only • I understand that my designated proxy will have access to my health record which may contain information related to HIV/AIDS, sexual health (including STDs), pregnancy, mental health, and drug and alcohol use. • I understand that I may revoke this access at any time. • I understand that health information accessed by my proxy may no longer be protected by state or federal privacy laws, and could be redisclosed by my proxy. • I understand that I may refuse to sign this authorization and doing so will not affect my treatment, payment, enrollment or eligibility for benefits or the quality of care that I will receive. Patient Signature Date

UFHealth Pediatrics titlepage

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