Common use of Assignment of Benefits Clause in Contracts

Assignment of Benefits. I hereby authorize and assign all payments and/or insurance benefits for medical services rendered to me directly to Women’s Health Associates of Southern Nevada. I hereby authorize Women’s Health Associates of Southern Nevada to release medical information necessary to obtain payment for services rendered by providers of Women’s Health Associates of Southern Nevada. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND FULLY UNDERSTAND IN ITS ENTIRETY, THE INFORMATION IN THIS FINANCIAL POLICY AGREEMENT. I UNDERSTAND THAT BY SIGNING THIS FINANCIAL POLICY AGREEMENT, I AM AGREEING TO THE TERMS AND CONDITIONS PROVIDED WITHIN THIS AGREEMENT. / / Patient Name Date of Birth / / Patient/Health Care Agent/Guardian/Relative Signature Date Name: DOB: / / PCP: DATE: / / _ Anxiety/Depression □ Yes □ No Last pap smear: □ Normal □ Abnormal Anemia □ Yes □ No Last mammo: □ Normal □ Abnormal Asthma/Lung condition □ Yes □ No Last colonoscopy: □ Normal □ Abnormal Arthritis □ Yes □ No Last DEXA (bone) scan: □ Normal □ Abnormal Bleeding disorder □ Yes □ No Previous treatment for abnormal pap smears? Bowel problems □ Yes □ No □ Colpo □ Cryo □ LEEP □ Conization □ N/A Cancer: Last menstrual period: Diabetes □ Yes □ No Age of first period: Elevated cholesterol □ Yes □ No Periods occur every days and last days Endometriosis/PCOS □ Yes □ No □ Heavy □ Clots □ Pain □ Cramping □ Irregular bleeding Heart disease □ Yes □ No Average # of pads/tampons used per day: High blood pressure □ Yes □ No Menopausal: □ Yes □ No Age began: Headaches □ Yes □ No Hysterectomy: □ Yes □ No When? Kidney disease/stones □ Yes □ No Complaints of: □ Breast pain □ Infertility □ Fibroids □ Ovarian cysts Liver disease/Hepatitis □ Yes □ No □ Pain w/ intercourse □ Vaginal infections □ Leaking of urine Stroke □ Yes □ No Have you ever been diagnosed with any of the following: Thyroid disorder □ Yes □ No Gonorrhea □ Yes □ No Other: Chlamydia □ Yes □ No SOCIAL HISTORY Herpes (Genital) □ Yes □ No Married/Single/Divorced/Widowed/Separated HPV/Genital warts □ Yes □ No Smoke: □ Yes □ No Packs per day: Hepatitis B or C □ Yes □ No Alcohol: □ Yes □ No How much? HIV □ Yes □ No Street drugs: Syphilis □ Yes □ No Marijuana: □ Medical □ Recreational Number of sexual partners (in lifetime): Sexual preference: Current birth control method: Number of Miscarriages: Abortions: Ectopic: Live Births: Ablation Date: Breast surgery Date: D&C Date: Hysterectomy Date: Laparoscopy Date: Ovaries removed Date: Tubal ligation Date: □ Appendectomy □ Back surgery □ Bowel □ Fibroid removal □ Gallbladder □ Tonsillectomy Other: Breast Cancer □ Yes □ No Family Member: Ovarian Cancer □ Yes □ No Family Member: Colon Cancer □ Yes □ No Family Member: Other: List all medications taken daily Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: ePrescribing is defined as a physician’s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBMs are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan. The Medicare Modernization Act (MMA) 2003 listed standards that have to be included in an ePrescribe program. These include: • Formulary and benefit transactions-- Gives the prescriber information about which drugs are covered by the drug benefit plan. • Medication history transactions--Provides the physician with information about medications the patient is already taking prescribed by any provider, to minimize the number of adverse drug events. By signing this consent form you are agreeing that Women’s Health Associates of Southern Nevada can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes. Patient Name (printed): Date of Birth: / / Signature of Patient (or representative): Date: / / Relationship (If other than patient): Consent Denied: Date: / / We provide an online Patient Portal to make managing your health care simple and convenient. Our secure portal is a helpful resource to: • Request appointment times • Pay statement balances and bills • Request prescription refills • Access patient forms before your appointment • Ask non-emergency medical questions • Request test results We still welcome your phone calls, but we offer this service to you as a convenient way to communicate with your care center. The Patient Portal may also be used to contact you. Please fill out the information below and we will send an invitation to the email you provide. Once you receive the email, click the hyperlink and follow the prompts to set up your account. Be sure to mark us as a safe sender so the emails aren’t filtered into your junk folder. If you created a Portal account before January 1, 2018, you need to create a new account with our improved system. Please note your first and last name must reflect exactly how they are listed in our system to activate your account. Should you have any login issues in the future, you can request your username and reset your password through the website. Preferred Email: Patient name: (Please print clearly) Patient DOB: / / The communication of health care information plays an essential role in ensuring that individuals receive prompt and effective health care. Due to the nature of these communications and the various environments in which individuals receive health care, the potential exists for an individual’s health information to be disclosed incidentally. The HIPAA Privacy Rule permits certain incidental uses or disclosures of protected health information to occur when the provider has in place reasonable safeguards and minimum necessary policies and procedures to protect an individual’s privacy. Women’s Health Associates of Southern Nevada understands there may be times when a patient will need to discuss their protected health information over the phone. As a reasonable safeguard you are personally required to select a password for your protected health information. You will be required to provide the password prior to discussing any of your protected health information with our staff over the phone. Should you require a family member or friend to contact our office to discuss any of your protected health information, they will need this password. It is very important that you maintain the integrity of your password. In the event you become concerned that you may have shared your password inadvertently, please contact our office immediately to begin the process of changing your password. My personally selected password to discuss any protected health information over the phone is: (Password must be less than 20 characters) I understand that I can only change my password in person. I further understand that it is my responsibility to maintain the integrity of my personally selected password. I authorize the disclosure of my protected health information in the above manner. Patient Name / / Patient/Health Care Agent/Guardian/Relative Signature Date Women’s Health Associates of Southern Nevada Las Vegas, NV

Assignment of Benefits. I hereby authorize and assign all payments and/or insurance benefits for medical services rendered to me directly to Women’s Health Associates of Southern Nevada. I hereby authorize Women’s Health Associates of Southern Nevada to release medical information necessary to obtain payment for services rendered by providers of Women’s Health Associates of Southern Nevada. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND FULLY UNDERSTAND IN ITS ENTIRETY, THE INFORMATION IN THIS FINANCIAL POLICY AGREEMENT. I UNDERSTAND THAT BY SIGNING THIS FINANCIAL POLICY AGREEMENT, I AM AGREEING TO THE TERMS AND CONDITIONS PROVIDED WITHIN THIS AGREEMENT. / / Patient Name Date of Birth / / Patient/Health Care Agent/Guardian/Relative Signature Date Name: DOB: _/ / PCP: DATE: / _/ _ Anxiety/Depression □ Yes □ No Last pap smear: □ Normal □ Abnormal Anemia □ Yes □ No Last mammo: □ Normal □ Abnormal Asthma/Lung condition □ Yes □ No Last colonoscopy: □ Normal □ Abnormal Arthritis □ Yes □ No Last DEXA (bone) scan: □ Normal □ Abnormal Normal □ Abnormal □ Normal □ Abnormal Normal □ Abnormal Bleeding disorder □ Yes □ No Previous treatment for abnormal pap smears? Bowel problems □ Yes □ No □ Colpo □ Cryo □ LEEP □ Conization □ N/A Cancer: Last menstrual period: Diabetes □ Yes □ No Age of first period: Elevated cholesterol □ Yes □ No Periods occur every days and last days Endometriosis/PCOS □ Yes □ No □ Heavy □ Clots □ Pain □ Cramping □ Irregular bleeding Heart disease □ Yes □ No Average # of pads/tampons used per day: High blood pressure □ Yes □ No Menopausal: □ Yes □ No Age began: Headaches □ Yes □ No Hysterectomy: □ Yes □ No When? Kidney disease/stones □ Yes □ No Complaints of: □ Breast pain □ Infertility □ Fibroids □ Ovarian cysts Liver disease/Hepatitis □ Yes □ No □ Pain w/ intercourse □ Vaginal infections □ Leaking of urine Stroke □ Yes □ No Have you ever been diagnosed with any of the following: Thyroid disorder □ Yes □ No Gonorrhea □ Yes □ No Other: Chlamydia □ Yes □ No SOCIAL HISTORY Herpes (Genital) □ Yes □ No Married/Single/Divorced/Widowed/Separated HPV/Genital warts □ Yes □ No Smoke: □ Yes □ No Packs per day: Hepatitis B or C □ Yes □ No Alcohol: □ Yes □ No How much? HIV □ Yes □ No Street drugs: Syphilis □ Yes □ No Marijuana: □ Medical □ Recreational Number of sexual partners (in lifetime): Sexual preference: Current birth control method: Number of Miscarriages: Abortions: Ectopic: Live Births: Ablation Date: Breast surgery Date: D&C Date: Hysterectomy Date: Laparoscopy Date: Ovaries removed Date: Tubal ligation Date: □ Appendectomy □ Back surgery □ Bowel □ Fibroid removal □ Gallbladder □ Tonsillectomy Other: Breast Cancer □ Yes □ No Family Member: Ovarian Cancer □ Yes □ No Family Member: Colon Cancer □ Yes □ No Family Member: Other: List all medications taken daily Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: ePrescribing is defined as a physician’s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBMs are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan. The Medicare Modernization Act (MMA) 2003 listed standards that have to be included in an ePrescribe program. These include: • Formulary and benefit transactions-- Gives the prescriber information about which drugs are covered by the drug benefit plan. • Medication history transactions--Provides the physician with information about medications the patient is already taking prescribed by any provider, to minimize the number of adverse drug events. By signing this consent form you are agreeing that Women’s Health Associates of Southern Nevada can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes. Patient Name (printed): Date of Birth: / / Signature of Patient (or representative): _ Date: / / Relationship (If other than patient): Consent Denied: Date: / / We provide an online Patient Portal patient portal to make managing your health care simple and convenient. Our secure portal is a helpful resource to: • Request appointment times Access your health record • Book appointments online • Pay statement outstanding balances and bills • View test results • Request prescription refills • Access patient forms before your appointment • Ask non-emergency medical questions • Request test results We still welcome your phone calls, but we offer this service to you as a convenient way to communicate with your care centerCare Center digitally. The Patient Portal patient portal may also be used to contact you. Our patient portal is powered by Healow, a trusted service specializing in health and online wellness. Please fill out the information below and we will send an invitation to the email you provide. Once you receive the email, click the hyperlink and follow the prompts to set up your account. Be sure to mark us as a safe sender so the emails aren’t are not filtered into your junk folder. If you created a Portal account before January 1, 2018, you need to create a new account with our improved system. Please note your first and last name must reflect exactly how they are listed in our system to activate your account. Should you have any login issues in the future, you can request your username and reset your password through the website. Preferred Email: Patient name: (Please print clearly) Patient name: Patient DOB: / / Our patient portal is also available through the free Healow app, available on iOS and Android. Visit ▇▇▇▇▇.▇▇▇/▇▇▇▇▇▇▇-▇▇▇▇▇▇ to learn more. The communication of health care information plays an essential role in ensuring that individuals receive prompt and effective health care. Due to the nature of these communications and the various environments in which individuals receive health care, the potential exists for an individual’s health information to be disclosed incidentally. The HIPAA Privacy Rule permits certain incidental uses or disclosures of protected health information to occur when the provider has in place reasonable safeguards and minimum necessary policies and procedures to protect an individual’s privacy. Women’s Health Associates of Southern Nevada understands there may be times when a patient will need to discuss their protected health information over the phone. As a reasonable safeguard you are personally required to select a password for your protected health information. You will be required to provide the password prior to discussing any of your protected health information with our staff over the phone. Should you require a family member or friend to contact our office to discuss any of your protected health information, they will need this password. It is very important that you maintain the integrity of your password. In the event you become concerned that you may have shared your password inadvertently, please contact our office immediately to begin the process of changing your password. My personally selected password to discuss any protected health information over the phone is: (Password must be less than 20 characters) I understand that I can only change my password in person. I further understand that it is my responsibility to maintain the integrity of my personally selected password. I authorize the disclosure of my protected health information in the above manner. Patient Name / / Patient/Health Care Agent/Guardian/Relative Signature Date Women’s Health Associates of Southern Nevada Las Vegas, NVTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Assignment of Benefits. I hereby authorize and assign all payments and/or insurance benefits for medical services rendered to me directly to Women’s Health Associates of Southern Nevada. I hereby authorize Women’s Health Associates of Southern Nevada to release medical information necessary to obtain payment for services rendered by providers of Women’s Health Associates of Southern Nevada. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND FULLY UNDERSTAND IN ITS ENTIRETY, THE INFORMATION IN THIS FINANCIAL POLICY AGREEMENT. I UNDERSTAND THAT BY SIGNING THIS FINANCIAL POLICY AGREEMENT, I AM AGREEING TO THE TERMS AND CONDITIONS PROVIDED WITHIN THIS AGREEMENT. / / Patient Name Date of Birth / / Patient/Health Care Agent/Guardian/Relative Signature Date Name: DOB: _/ / PCP: DATE: / _/ _ Anxiety/Depression □ Yes □ No Last pap smear: □ Normal □ Abnormal Anemia □ Yes □ No Last mammo: □ Normal □ Abnormal Asthma/Lung condition □ Yes □ No Last colonoscopy: □ Normal □ Abnormal Arthritis □ Yes □ No Last DEXA (bone) scan: □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal □ Normal □ Abnormal Bleeding disorder □ Yes □ No Previous treatment for abnormal pap smears? Bowel problems □ Yes □ No □ Colpo □ Cryo □ LEEP □ Conization □ N/A Cancer: Last menstrual period: Diabetes □ Yes □ No Age of first period: Elevated cholesterol □ Yes □ No Periods occur every days and last days Endometriosis/PCOS □ Yes □ No □ Heavy □ Clots □ Pain □ Cramping □ Irregular bleeding Heart disease □ Yes □ No Average # of pads/tampons used per day: High blood pressure □ Yes □ No Menopausal: □ Yes □ No Age began: Headaches □ Yes □ No Hysterectomy: □ Yes □ No When? Kidney disease/stones □ Yes □ No Complaints of: □ Breast pain □ Infertility □ Fibroids □ Ovarian cysts Liver disease/Hepatitis □ Yes □ No □ Pain w/ intercourse □ Vaginal infections □ Leaking of urine Stroke □ Yes □ No Have you ever been diagnosed with any of the following: Thyroid disorder □ Yes □ No Gonorrhea □ Yes □ No Other: Chlamydia □ Yes □ No SOCIAL HISTORY Herpes (Genital) □ Yes □ No Married/Single/Divorced/Widowed/Separated HPV/Genital warts □ Yes □ No Smoke: □ Yes □ No Packs per day: Hepatitis B or C □ Yes □ No Alcohol: □ Yes □ No How much? Street drugs: Hepatitis B or C □ Yes □ No HIV □ Yes □ No Street drugs: Syphilis □ Yes □ No Marijuana: □ Medical □ Recreational Number of sexual partners (in lifetime): Sexual preference: Current birth control method: Number of Miscarriages: Abortions: Ectopic: Live Births: Ablation Date: Breast surgery Date: D&C Date: Hysterectomy Date: Laparoscopy Date: Ovaries removed Date: Tubal ligation Date: □ Appendectomy □ Back surgery □ Bowel □ Fibroid removal □ Gallbladder □ Tonsillectomy Other: Breast Cancer □ Yes □ No Family Member: Ovarian Cancer □ Yes □ No Family Member: Colon Cancer □ Yes □ No Family Member: Other: List all medications taken daily Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: ePrescribing is defined as a physicianprovider’s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBMs are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan. The Medicare Modernization Act (MMA) 2003 listed standards that have to be included in an ePrescribe program. These include: • Formulary and benefit transactions-- Gives the prescriber information about which drugs are covered by the drug benefit plan. • Medication history transactions--Provides the physician provider with information about medications the patient is already taking prescribed by any provider, to minimize the number of adverse drug events. By signing this consent form form, you are agreeing agree that Women’s Health Associates of Southern Nevada can request and use your prescription medication history from other healthcare providers and/or third third- party pharmacy benefit payors for treatment purposes. Patient Name (printed): Date of Birth: / / Signature of Patient (or representative): Date: / / Relationship (If other than patient): Consent Denied: Date: / / We provide an online Patient Portal to make managing your health care simple and convenient. Our secure portal is a helpful resource to: • Request appointment times • Pay statement balances and bills • Request prescription refills • Access patient forms before your appointment • Ask non-emergency medical questions • Request test results We still welcome your phone calls, but we offer this service to you as a convenient way to communicate with your care center. The Patient Portal may also be used to contact you. Please fill out the information below and we will send an invitation to the email you provide. Once you receive the email, click the hyperlink and follow the prompts to set up your account. Be sure to mark us as a safe sender so the emails aren’t filtered into your junk folder. If you created a Portal account before January 1, 2018, you need to create a new account with our improved system. Please note your first and last name must reflect exactly how they are listed in our system to activate your account. Should you have any login issues in the future, you can request your username and reset your password through the website. Preferred Email: Patient name: (Please print clearly) Patient DOBDate of Birth: / / The communication of health care information plays an essential role in ensuring that individuals receive prompt and effective health care. Due to the nature of these communications and the various environments in which individuals receive health care, the potential exists for an individual’s health information to be disclosed incidentally. The HIPAA Privacy Rule permits certain incidental uses or disclosures of protected health information to occur when the provider has in place reasonable safeguards and minimum necessary policies and procedures to protect an individual’s privacy. Women’s Health Associates of Southern Nevada understands there may be times when a patient will need to discuss their protected health information over the phone. As a reasonable safeguard you are personally required to select a password for your protected health information. You will be required to provide the password prior to discussing any of your protected health information with our staff over the phone. Should you require a family member or friend to contact our office to discuss any of your protected health information, they will need this password. It is very important that you maintain the integrity of your password. In the event you become concerned that you may have shared your password inadvertently, please contact our office immediately to begin the process of changing your password. My personally selected password to discuss any protected health information over the phone is: (Password must be less than 20 characters) I understand that I can only change my password in personperson or through a secure link sent to my phone. I further understand that it is my responsibility to maintain the integrity of my personally selected password. I authorize the disclosure of my protected health information in the above manner. Patient Name / / Patient/Health Care Agent/Guardian/Relative Signature Date Women’s Health Associates of Southern Nevada Las Vegas, NVDate

Assignment of Benefits. I hereby authorize and assign all payments and/or insurance benefits for medical services rendered to me directly to Women’s Health Associates of Southern Nevada. I hereby authorize Women’s Health Associates of Southern Nevada to release medical information necessary to obtain payment for services rendered by providers of Women’s Health Associates of Southern Nevada. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND FULLY UNDERSTAND IN ITS ENTIRETY, THE INFORMATION IN THIS FINANCIAL POLICY AGREEMENT. I UNDERSTAND THAT BY SIGNING THIS FINANCIAL POLICY AGREEMENT, I AM AGREEING TO THE TERMS AND CONDITIONS PROVIDED WITHIN THIS AGREEMENT. / / Patient Name Date of Birth / / Patient/Health Care Agent/Guardian/Relative Signature Date Name: DOB: / / PCP: DATE: / / _ Anxiety/Depression □  Yes □  No Last pap smear: □  Normal □  Abnormal Anemia □  Yes □  No Last mammo: □  Normal □  Abnormal Asthma/Lung condition □  Yes □  No Last colonoscopy: □  Normal □  Abnormal Arthritis □  Yes □  No Last DEXA (bone) scan: □  Normal □  Abnormal Bleeding disorder □  Yes □  No Previous treatment for abnormal pap smears? Bowel problems □  Yes □  No □  Colpo □  Cryo □  LEEP □  Conization □  N/A Cancer: Last menstrual period: Diabetes □  Yes □  No Age of first period: Elevated cholesterol □  Yes □  No Periods occur every days and last days Endometriosis/PCOS □  Yes □  No □  Heavy □  Clots □  Pain □  Cramping □  Irregular bleeding Heart disease □  Yes □  No Average # of pads/tampons used per day: High blood pressure □  Yes □  No Menopausal: □  Yes □  No Age began: Headaches □  Yes □  No Hysterectomy: □  Yes □  No When? Kidney disease/stones □  Yes □  No Complaints of: □  Breast pain □  Infertility □  Fibroids □  Ovarian cysts Liver disease/Hepatitis □  Yes □  No □  Pain w/ intercourse □  Vaginal infections □  Leaking of urine Stroke □  Yes □  No Have you ever been diagnosed with any of the following: Thyroid disorder □  Yes □  No Gonorrhea □  Yes □  No Other: Chlamydia □  Yes □  No SOCIAL HISTORY Herpes (Genital) □  Yes □  No Married/Single/Divorced/Widowed/Separated HPV/Genital warts □  Yes □  No Smoke: □  Yes □  No Packs per day: Hepatitis B or C □  Yes □  No Alcohol: □  Yes □  No How much? HIV □  Yes □  No Street drugs: Syphilis □  Yes □  No Marijuana: □  Medical □  Recreational Number of sexual partners (in lifetime): Sexual preference: Current birth control method: Number of Miscarriages: Abortions: Ectopic: Live Births: Ablation Date: Breast surgery Date: D&C Date: Hysterectomy Date: Laparoscopy Date: Ovaries removed Date: Tubal ligation Date: □  Appendectomy □  Back surgery □  Bowel □  Fibroid removal □  Gallbladder □  Tonsillectomy Other: Breast Cancer □ Yes □ No Family Member: Ovarian Cancer □ Yes □ No Family Member: Colon Cancer □ Yes □ No Family Member: Other: List all medications taken daily Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: ePrescribing is defined as a physician’s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBMs are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan. The Medicare Modernization Act (MMA) 2003 listed standards that have to be included in an ePrescribe program. These include: • Formulary and benefit transactions-- Gives the prescriber information about which drugs are covered by the drug benefit plan. • Medication history transactions--Provides the physician with information about medications the patient is already taking prescribed by any provider, to minimize the number of adverse drug events. By signing this consent form you are agreeing that Women’s Health Associates of Southern Nevada can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes. Patient Name (printed): Date of Birth: / / Signature of Patient (or representative): Date: / / Relationship (If other than patient): Consent Denied: Date: / / We provide an online Patient Portal to make managing your health care simple and convenient. Our secure portal is a helpful resource to: • Request appointment times • Pay statement balances and bills • Request prescription refills • Access patient forms before your appointment • Ask non-emergency medical questions • Request test results We still welcome your phone calls, but we offer this service to you as a convenient way to communicate with your care center. The Patient Portal may also be used to contact you. Please fill out the information below and we will send an invitation to the email you provide. Once you receive the email, click the hyperlink and follow the prompts to set up your account. Be sure to mark us as a safe sender so the emails aren’t filtered into your junk folder. If you created a Portal account before January 1, 2018, you need to create a new account with our improved system. Please note your first and last name must reflect exactly how they are listed in our system to activate your account. Should you have any login issues in the future, you can request your username and reset your password through the website. Preferred Email: Patient name: (Please print clearly) Patient DOB: / / The communication of health care information plays an essential role in ensuring that individuals receive prompt and effective health care. Due to the nature of these communications and the various environments in which individuals receive health care, the potential exists for an individual’s health information to be disclosed incidentally. The HIPAA Privacy Rule permits certain incidental uses or disclosures of protected health information to occur when the provider has in place reasonable safeguards and minimum necessary policies and procedures to protect an individual’s privacy. Women’s Health Associates of Southern Nevada understands there may be times when a patient will need to discuss their protected health information over the phone. As a reasonable safeguard you are personally required to select a password for your protected health information. You will be required to provide the password prior to discussing any of your protected health information with our staff over the phone. Should you require a family member or friend to contact our office to discuss any of your protected health information, they will need this password. It is very important that you maintain the integrity of your password. In the event you become concerned that you may have shared your password inadvertently, please contact our office immediately to begin the process of changing your password. My personally selected password to discuss any protected health information over the phone is: (Password must be less than 20 characters) I understand that I can only change my password in person. I further understand that it is my responsibility to maintain the integrity of my personally selected password. I authorize the disclosure of my protected health information in the above manner. Patient Name / / Patient/Health Care Agent/Guardian/Relative Signature Date Women’s Health Associates of Southern Nevada Las Vegas, NV:

Assignment of Benefits. I hereby authorize and assign all payments and/or insurance benefits for medical services rendered to me directly to Women’s Health Associates of Southern Nevada. I hereby authorize Women’s Health Associates of Southern Nevada to release medical information necessary to obtain payment for services rendered by providers of Women’s Health Associates of Southern Nevada. BY SIGNING THIS AGREEMENT, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ AND FULLY UNDERSTAND IN ITS ENTIRETY, THE INFORMATION IN THIS FINANCIAL POLICY AGREEMENT. I UNDERSTAND THAT BY SIGNING THIS FINANCIAL POLICY AGREEMENT, I AM AGREEING TO THE TERMS AND CONDITIONS PROVIDED WITHIN THIS AGREEMENT. / / Patient Name Date of Birth / / Patient/Health Care Agent/Guardian/Relative Signature Date Name: DOB: / / PCP: DATE: / / _ Anxiety/Depression □ Yes □ No Last pap smear: □ Normal □ Abnormal Anemia □ Yes □ No Last mammo: □ Normal □ Abnormal Asthma/Lung condition □ Yes □ No Last colonoscopy: □ Normal □ Abnormal Arthritis □ Yes □ No Last DEXA (bone) scan: □ Normal □ Abnormal Bleeding disorder □ Yes □ No Previous treatment for abnormal pap smears? Bowel problems □ Yes □ No □ Colpo □ Cryo □ LEEP □ Conization □ N/A Cancer: Last menstrual period: Diabetes □ Yes □ No Age of first period: Elevated cholesterol □ Yes □ No Periods occur every days and last days Endometriosis/PCOS □ Yes □ No □ Heavy □ Clots □ Pain □ Cramping □ Irregular bleeding Heart disease □ Yes □ No Average # of pads/tampons used per day: High blood pressure □ Yes □ No Menopausal: □ Yes □ No Age began: Headaches □ Yes □ No Hysterectomy: □ Yes □ No When? Kidney disease/stones □ Yes □ No Complaints of: □ Breast pain □ Infertility □ Fibroids □ Ovarian cysts Liver disease/Hepatitis □ Yes □ No □ Pain w/ intercourse □ Vaginal infections □ Leaking of urine Stroke □ Yes □ No Have you ever been diagnosed with any of the following: Thyroid disorder □ Yes □ No Gonorrhea □ Yes □ No Other: Chlamydia □ Yes □ No SOCIAL HISTORY Herpes (Genital) □ Yes □ No Married/Single/Divorced/Widowed/Separated HPV/Genital warts □ Yes □ No Smoke: □ Yes □ No Packs per day: Hepatitis B or C □ Yes □ No Alcohol: □ Yes □ No How much? HIV □ Yes □ No Street drugs: Syphilis □ Yes □ No Marijuana: □ Medical □ Recreational Number of sexual partners (in lifetime): Sexual preference: Current birth control method: Number of Miscarriages: Abortions: Ectopic: Live Births: Ablation Date: Breast surgery Date: D&C Date: Hysterectomy Date: Laparoscopy Date: Ovaries removed Date: Tubal ligation Date: □ Appendectomy □ Back surgery □ Bowel □ Fibroid removal □ Gallbladder □ Tonsillectomy Other: Breast Cancer □ Yes □ No Family Member: Ovarian Cancer □ Yes □ No Family Member: Colon Cancer □ Yes □ No Family Member: Other: List all medications taken daily Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: Dose: Frequency: ePrescribing is defined as a physician’s ability to electronically send an accurate, error free, and understandable prescription directly to a pharmacy. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. Benefits data are maintained for health insurance providers by organizations known as Pharmacy Benefits Managers (PBM). PBMs are third party administrators of prescription drug programs whose primary responsibilities are processing and paying prescription drug claims. They also develop and maintain formularies, which are lists of dispensable drugs covered by a particular drug benefit plan. The Medicare Modernization Act (MMA) 2003 listed standards that have to be included in an ePrescribe program. These include: • Formulary and benefit transactions-- Gives the prescriber information about which drugs are covered by the drug benefit plan. • Medication history transactions--Provides the physician with information about medications the patient is already taking prescribed by any provider, to minimize the number of adverse drug events. By signing this consent form you are agreeing that Women’s Health Associates of Southern Nevada can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes. Patient Name (printed): Date of Birth: / / Signature of Patient (or representative): Date: / / Relationship (If other than patient): Consent Denied: Date: / / We provide an online Patient Portal to make managing your health care simple and convenient. Our secure portal is a helpful resource to: • Request appointment times • Pay statement balances and bills • Request prescription refills • Access patient forms before your appointment • Ask non-emergency medical questions • Request test results We still welcome your phone calls, but we offer this service to you as a convenient way to communicate with your care center. The Patient Portal may also be used to contact you. Please fill out the information below and we will send an invitation to the email you provide. Once you receive the email, click the hyperlink and follow the prompts to set up your account. Be sure to mark us as a safe sender so the emails aren’t filtered into your junk folder. If you created a Portal account before January 1, 2018, you need to create a new account with our improved system. Please note your first and last name must reflect exactly how they are listed in our system to activate your account. Should you have any login issues in the future, you can request your username and reset your password through the website. Preferred Email: Patient name: (Please print clearly) Patient DOB: / / The communication of health care information plays an essential role in ensuring that individuals receive prompt and effective health care. Due to the nature of these communications and the various environments in which individuals receive health care, the potential exists for an individual’s health information to be disclosed incidentally. The HIPAA Privacy Rule permits certain incidental uses or disclosures of protected health information to occur when the provider has in place reasonable safeguards and minimum necessary policies and procedures to protect an individual’s privacy. Women’s Health Associates of Southern Nevada understands there may be times when a patient will need to discuss their protected health information over the phone. As a reasonable safeguard you are personally required to select a password for your protected health information. You will be required to provide the password prior to discussing any of your protected health information with our staff over the phone. Should you require a family member or friend to contact our office to discuss any of your protected health information, they will need this password. It is very important that you maintain the integrity of your password. In the event you become concerned that you may have shared your password inadvertently, please contact our office immediately to begin the process of changing your password. My personally selected password to discuss any protected health information over the phone is: (Password must be less than 20 characters) I understand that I can only change my password in person. I further understand that it is my responsibility to maintain the integrity of my personally selected password. I authorize the disclosure of my protected health information in the above manner. Patient Name / / Patient/Health Care Agent/Guardian/Relative Signature Date Women’s Health Associates of Southern Nevada Las Vegas, NVTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.