New Patient Packet

tHe Center for Cancer Care
WELCOME PATIENT
We have news to share. Our name is changing to “The Center for Cancer Care”. We have partnered with Gwinnett Medical Center to improve and develop a comprehensive and innovative cancer center for our community and patients. There are a few changes in the check-in and billing process, but ultimately the quality care you receive from our physicians and staff you’re familiar with remains the same. This is a quick reference to help explain the partnership as well as some answers to questions you may be having. Any other questions can be answered by our associates. Presenting Consents/Forms Some of our forms have changed and now reflect Gwinnett Medical Center’s agreements/consents. These consent forms will only have to be signed once a year. Here is a list of the forms we’ll go over. Admission/Registration Agreement – This is a consent that allows us to treat you. Please read and then sign and date. Guarantee of Payment – Please read and sign. By doing so, you are guaranteeing payment for treatment and services. You are authorizing us to submit a claim with your insurance carrier. Notice of Privacy Practices Acknowledgment – Please read and sign the bottom of the form indicating that we have offered you our notice of privacy practices, also known as HIPPA. (Mark through the Designation of personal representative) Email Consent Form – This is a consent form that allows us to discuss how we will contact you. Patient History Form – This form will give us a detailed history of your medical background. Notice of Privacy Practices – (take home) This form is for you to keep. Notice of Patient Rights – (take home) – This form gives you a list of your rights as a patient. Indigent Care Trust Fund – (take home) Now, being part of the hospital if you become unable to pay your bill with us you may be eligible for the financial assistance program. Please see one of our benefits counselors if you think you may be eligible. Medicare Co-insurance – (Snellville) (Take home) CMS requires us to notify you that our office is now considered part of an outpatient hospital-based facility. This may change the co-insurance amount you may owe. By signing this document, you acknowledge your visits with us will be submitted to Medicare as an outpatient hospital-based facility and that your co-insurance amount may increase. Center for Cancer Care FAQ Handout (Take home) – Every insurance plan has different policy provisions. We will work with your company to discover the individual benefits your specific plan has to offer. We’ll share with you those details once we’ve contacted them. Your co-pay or co-insurance may differ from the past since you are now being seen in an outpatient hospital-based facility.

PLACE LABEL HERE

NEW PATIENT INFORMATION Center for Cancer Care
DATE: DRUG ALLERGIES:

Please supply the following information. This document will be part of the medical record.
FULL NAME:
(FIRST) (MIDDLE) (LAST) (AGE)

DATE OF BIRTH: HOME ADDRESS:
(NO. & NAME OF STREET)

MARITAL STATUS:
(CITY) (STATE) (ZIP)

HOME PHONE: EMPLOYER: EMAIL: SPOUSE’S NAME: SPOUSE’S DOB: EMPLOYER: EMERGENCY CONTACT (NOT LIVING WITH YOU): ADDRESS:
(NO. & NAME OF STREET)

SOCIAL SECURITY #: BUSINESS #: MOBILE #: MOBILE #: SPOUSE’S SS#: PHONE #:

(CITY)

(STATE)

(ZIP)

TEL #: NAME OF INSURANCE COMPANY: POLICY HOLDER: POLICY #: REFERRING PHYSICIAN: PRIMARY CARE PHYSICIAN: PATIENT’S SIGNATURE:

MOBILE #:

GROUP #:

PHONE #: PHONE #: DATE:

*1-32763*

FORM 1-32763 INITIATED 09/2012

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PLACE LABEL HERE

ADMISSION / REGISTRATION AGREEMENT Center For Cancer Care
CONSENT AND TREATMENT AUTHORIZATION: I hereby apply for and consent to admission and treatment by this Hospital and its Medical Staff, at the CENTER FOR CANCER CARE covering visits for 365 days from the date I sign this agreement, and authorize all routine hospital activities, treatments, examinations, and diagnostic services. I, the undersigned, have read and fully understand this agreement. My signature acknowledges that I have been given the opportunity to satisfy myself by asking questions about the Admission/Registration Agreement. I voluntarily give my consent to hospital care, and I accept the conditions of hospital care. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risks of injury or even death. During the course of my care and treatment, I understand that various types of tests and diagnostic treatment procedures (“Procedures”) may be necessary. I consent to Healthcare Professionals performing Procedures as they may deem reasonably necessary or desirable in the exercise of their professional judgment, including those Procedures that may be unforeseen or not known to be needed at the time this consent is obtained. I consent to the observation and participation of personnel-intraining, representatives, technicians, and students in my care and treatment. I acknowledge that no guarantees have been made to me as to the result of examination or treatment in this hospital. I understand that Procedures may be performed by physicians, nurses, technicians, physician assistants or other healthcare professionals (“Healthcare Professionals”). While routinely performed without incident, there may be material risks associated with each of these Procedures. I understand that it is not possible to list every risk for every Procedure and that this form only attempts to identify the most common material risks and the alternatives (if any) associated with the Procedures. I also understand that various Healthcare Professionals may have differing opinions as to what constitutes material risks and alternative Procedures. The Healthcare Professionals participating in my care will rely on my documented medical history, as well as other information obtained from me, my family or others having knowledge about me, in determining whether to perform or recommend the Procedures; therefore, I agree to provide accurate and complete information about my medical history and conditions; and I understand that I may withdraw my consent for any test or procedure at any time. If I have any questions or concerns regarding these Procedures, I will ask my physician to provide me with additional information. I also understand that my physician may ask me to sign additional Informed Consent documents. The Procedures may include, but are not limited to the following:

(1) Needle Sticks, such as shots, injections, intravenous lines, or intravenous injections (IVs). The material risks
associated with these types of Procedures include, but are not limited to, nerve damage, infection, infiltration (which is fluid leakage into surrounding tissue), disfiguring scar, loss of limb function, paralysis or partial paralysis or death. Alternatives to Needle Sticks (if available) include oral, rectal, nasal, or topical medications (each of which may be less effective) or refusal of treatment. Physical tests, assessments and treatments such as vital signs, internal body examinations, wound cleansing, wound dressing, rang of motion checks, and other similar procedures. The material risks associated with these types of Procedures include, but are not limited to, allergic reactions, infection, severe loss of blood, muscularskeletal or internal injuries, nerve damage, loss of limb function, paralysis or partial paralysis, disfiguring scar, worsening of the condition and death. Apart from using modified Procedures and/or refusal of treatment, no practical alternatives exist. Administration of Medications whether orally, rectally, topically or through the eye, ear or nose. The material risks associated with these types of Procedures include, but are not limited to, perforation, puncture, infection, allergic reaction, brain damage or death. Apart from varying the method of administration and/or refusal of treatment, no practical alternatives exist. Drawing Blood, Bodily Fluids or Tissue Samples such as those done for laboratory testing and analysis. The material risks associated with this type of Procedure include, but are not limited to, paralysis or partial paralysis, nerve damage, infection, bleeding and loss of limb function. Apart from long-term observation and/or refusal of treatment, no practical alternatives exist. Insertion of Internal Tube such as bladder catheterizations, nasogastric tubes, rectal tubes, drainage tubes, enemas, etc. The material risks associated with these types of Procedures include, but are not limited to, internal injuries, bleeding, infection, allergic reaction, loss of bladder control and/or difficulty urinating after catheter removal. Apart from external collection devices or refusal of treatment, no practical alternatives exist.
FORM 2-32643 INITIATED 08/2012 Page 1 of 2

(2)

(3)

(4)

(5)

*2-32643*

PLACE LABEL HERE

CONDITIONS OF ADMISSION Center For Cancer Care
COMPLIANCE WITH HOSPITAL POLICIES AND PROCEDURES: I agree to comply with all hospital policies and procedures, including the hospital "NO SMOKING" policy. PERSONAL VALUABLES: I understand Gwinnett Hospital System provides facilities for the safekeeping of valuables. I hereby release Gwinnett Hospital System from any responsibility due to loss or damage of any valuables or personal belongings that I may keep in my possession, or may be brought to me by other persons. INDEPENDENT CONTRACTORS: The physicians, dentists, oral surgeons, podiatrists and psychologists at the Gwinnett Hospital System are independent contractors of the Hospital and are not its employees or agents. As independent contractors, the physicians, dentists, and oral surgeons, podiatrists, and psychologists are responsible for their own actions. I understand that I may receive separate bills for their services. I also understand that such practitioners who render services to me may not be participating members of my managed care health plan. My plan may consider these services as non-covered services. Consequently, I understand that, in the event that my managed care health plan does not reimburse these non-participating physicians in full for services provided to me, my managed care health plan may make me responsible for any balance that it declined to pay for such services. PATIENT RIGHTS: This hospital will admit and treat all patients without regard to race, national origin, religious creed, age or sex and the same medical criteria for admission are applied to all. In addition your rights include, but are not limited to, the right to be treated with dignity, to know the identity of your caregiver, to participate in decisions regarding your care and to determine the extent to which family members or representatives of your choice participate in your care, to have an advance directive, to privacy, security and communication with people outside the hospital, to access pastoral care and advocacy services, to consent to or decline treatment (including research), to be free of restraints or seclusion imposed as a means of coercion, discipline, convenience or retaliation by staff, and you have a right to access an internal grievance process through contact with the Patient Representative Office of the hospital at 678-312-4399, or to seek external review of your concerns by contacting the Department of Community Health at Two Peachtree St., NW, Atlanta, Ga. 30303-3142, or by phone at 1-800-878-6442.. REQUESTS FOR SPECIAL ASSISTANCE: Our staff wants to communicate effectively with you or other persons participating in your care or treatment who may be deaf/hearing impaired or have other special needs. Sign language and oral interpreters, TDD's (telecommunications device for the deaf), closed captioning for televisions, volume-control telephones, and other auxiliary aids and services are available free of charge to people who are deaf or hard of hearing. Further, the hospital can provide foreign language interpretation services for those patients who require such assistance. For assistance, please contact any hospital personnel or the Patient Representative Office at 678-312-4399. SPECIMEN DISPOSAL: I acknowledge and consent for the hospital to dispose of any specimens, tissue or parts that may be removed from my body during my hospitalization. I understand that if I have a different request for disposal I can speak with my hospital nurse. SIGNED: WITNESS:

_____________________________________ Patient/Patient’s Representative _____________________________________

_______________________ Relationship if other than self

____________________ Date

Reason if unable to sign: ________________________________________________________________________________

For Gwinnett Hospital Use Only: INTERPRETIVE SERVICE USED ON THIS ENCOUNTER Interpreter used - Name or Number____________________________________________________ Date/Time_____________________________ Language __________________________________

FORM 2-32643 INITIATED 08/2012

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PLACE LABEL HERE

CONDITIONS OF ADMISSION Center For Cancer Care

FORM 2-32643 INITIATED 08/2012

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PLACE LABEL HERE

GUARANTEE OF PAYMENT/ ASSIGNMENT OF BENEFITS/ AUTHORIZATION TO PROCESS CLAIMS Center For Cancer Care
GUARANTEE OF PAYMENT/ASSIGNMENT OF BENEFITS: In consideration of the Hospital's advancing credit to me for my hospital care and services, I hereby irrevocably assign and transfer to Gwinnett Hospital System and treating Physicians all benefits and payments now due and payable or to become due and payable to me under any insurance policy or policies, under any replacement policies thereof, under any self-insurance program, under any third-party actions against any other person or entity, or under any other benefit plan or program (hereafter referred to as Benefits) for this or any other period of hospitalization and related outpatient care. I understand and acknowledge that this assignment does not relieve me of my financial responsibility for all hospital charges and treating Physician charges incurred by me or anyone on my behalf, and I hereby accept such responsibility, including but not limited to payment of those fees and charges not directly reimbursed to the Hospital and treating Physicians by any Benefit plan or program. Furthermore, I agree to pay all costs of collection, reasonable attorneys’ fees and court costs incurred in enforcing this payment obligation. AUTHORIZATION TO PROCESS CLAIMS & RELEASE OF INFORMATION: I authorize Gwinnett Hospital System and the independent contractor physicians and/or professional corporations that render services to me to process claims for payment by my insurance carrier on my behalf for covered services provided to me at Gwinnett Hospital System. I authorize the release of necessary information, including medical information, regarding medical services rendered during this admission or any related services or claim, to my insurance carrier(s), including any managed care plan or other payor, past and/or present employer(s), Medicare, CHAMPUS/TRICARE, authorized private review entities and/or utilization review entities acting on behalf of such insurance carrier(s), payers, managed care plans and/or employer(s), the billing agents and collection agents or attorneys of Gwinnett Hospital System and/or the independent contractor physicians and/or professional corporations, my employer's Worker's Compensation carrier, and, as applicable, the Social Security Administration, the Health Care Financing Administration, the Peer Review Organization acting on behalf of the federal government, and/or any other federal or state agency for the purposes(s) of satisfying charges billed and/or facilitating utilization review and/or otherwise complying with the obligations of state or federal law. Authorization is hereby granted to release health record data and/or copies to my attending and/or admitting healthcare professional and/or any consulting healthcare professional and/or any healthcare professional I may be referred to for follow-up care. I further authorize Gwinnett Hospital System and any other healthcare provider or professional rendering services to me to obtain from any source medical history, examinations, diagnoses, treatments and other health or insurance authorization information for the purpose(s) of satisfying charges billed and/or facilitating utilization review, providing medical treatment and/or the evaluation of such treatment, and/or otherwise complying with the obligations of state or federal law. A photocopy of this Authorization may be honored. MEDICARE PATIENT'S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a RELATED Medicare claim. I request that payment of authorized benefits be made on my behalf. I understand my signature covers visits to the CENTER FOR CANCER CARE for 365 days from the date I sign this form.

SIGNED: WITNESS:

______________________________ Patient/Patient’s Representative ______________________________

________________________ _________________ Relationship if other than self Date

Reason If Unable to Sign: __________________________________________________________________

*1-32651*
1

FORM 1-32651 INITIATED 08/2012

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GHS NOTICE OF PRIVACY PRACTICES
THIS 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.
For the purposes of this Notice of Privacy Practices (“Notice”), Gwinnett Hospital System, Inc. (The “Hospital”) and the physicians and other health care providers who are members of the Hospital’s medical staff (the “Medical Staff”) work together in an organized health care arrangement to provide medical services to you when you are a patient in one of the Hospital’s inpatient facilities (including Gwinnett Medical Center, Gwinnett Medical Center – Duluth, Glancy Rehabilitation Center, Gwinnett Women’s Pavilion, Gwinnett Extended Care Center) or outpatient diagnostic and treatment facilities or clinics. However, physicians and other health care providers who are members of the Medical Staff are engaged in the independent practice of medicine and are not employees or agents of the Hospital. The Hospital and the Medical Staff are referred to collectively in this Notice as “GHS.” As health care providers, the GHS providers use confidential personal health information about patients, referred to below as protected health information (“PHI”). GHS protects the privacy of this information, and it is also protected from disclosure by state and federal law. In certain specific circumstances, pursuant to this Notice, patient authorization or applicable laws and regulations, PHI can be used by GHS or disclosed to other parties. Below are categories describing these uses and disclosures, along with some examples to help you better understand each category. Uses and Disclosures for Treatment, Payment and Health Care Operations. GHS may use or disclose your PHI for the purposes of treatment, payment and health care operations, described in more detail below, without obtaining written authorization from you. In addition, the GHS providers may share your PHI as necessary to carry out its treatment, payment and health care operations related to the organized health care arrangement. For Treatment. GHS may use and disclose PHI in the course of providing, coordinating, or managing your medical treatment, including the disclosure of PHI for treatment activities of another health care provider. These types of uses and disclosures may take place between physicians, nurses, technicians, students, and other health care professionals who provide you health care services or are otherwise involved in your care. For example, if you are being treated by a primary care physician, that physician may need to use/disclose PHI to a specialist physician whom he or she consults regarding your condition, or to a nurse who is assisting in your care. For Payment. GHS may use and disclose PHI in order to bill and collect payment for the health care services provided to you. For example, GHS may need to give PHI to your health plan in order to be reimbursed for the services provided to you. GHS may also disclose PHI to its business associates, such as billing companies, claims processing companies, and others that assist in processing health claims. GHS may also disclose PHI to other health care providers and health plans for the payment activities of such providers or health plans. For Health Care Operations. GHS may use and disclose PHI as part of its operations, including for quality assessment and improvement, such as evaluating the treatment and services you receive and the performance of its staff in caring for you, provider training, underwriting activities, compliance and risk management activities, planning and development, and management and administration. GHS may disclose PHI to doctors, nurses, technicians, students, attorneys, consultants, accountants, and others for review and learning purposes, to help make sure GHS is complying with all applicable laws, and to help GHS continue to provide health care to its patients at a high level of quality. GHS may also disclose PHI to other health care providers and health plans for such entity’s quality assessment and improvement activities, credentialing and peer review activities, and health care fraud and abuse detection or
FORM 4-18967 REV. 07/2010

compliance, provided that such entity has, or has had in the past, a relationship with the patient who is the subject of the information. Sharing of PHI Among the Hospital and the Medical Staff. As an organized health care arrangement, the Hospital and the members of the Medical Staff will share with each other PHI that they collect from you as necessary to carry out their treatment, payment and health care operations relating to the provision of care to patients by GHS. Other Uses and Disclosures For Which Authorization is Not Required. In addition to using or disclosing PHI for treatment, payment and health care operations, GHS may use and disclose PHI without your written authorization under the following circumstances: As Required by Law and Law Enforcement. GHS may use or disclose PHI when required to do so by applicable law. GHS also may disclose PHI when ordered to do so in a judicial or administrative proceeding, to identify or locate a suspect, fugitive, material witness, or missing person, when dealing with gunshot and other wounds, about criminal conduct, to report a crime, the location of the crime or victims, or the identity, description, or location of a person who committed a crime, to report a death or injury resulting from a boating accident, or for other law enforcement purposes. For Public Health Activities and Public Health Risks. GHS may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, reports of child abuse or neglect and of other victims of abuse, neglect, or domestic violence, reactions to medications or product defects or problems, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition. For Health Oversight Activities. GHS may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs, and compliance with civil rights laws. Coroners, Medical Examiners, and Funeral Directors. GHS may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law. Organ, Eye, and Tissue Donation. GHS may release PHI to organ procurement organizations to facilitate organ, eye, and tissue donation and transplantation. Research. Under certain circumstances, GHS may use and disclose PHI for medical research purposes. To Avoid a Serious Threat to Health or Safety. GHS may use and disclose PHI, to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public. Specialized Government Functions. GHS may use and disclose PHI of military personnel and veterans under certain circumstances. GHS may also disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special investigations. Workers’ Compensation. GHS may disclose PHI to comply with workers’ compensation or other similar laws. These programs provide benefits for work-related injuries or illnesses.
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Fundraising Activities. Your PHI may be used to contact you in an effort to raise money for the Hospital. Your PHI may be disclosed to a foundation related to the Hospital. Such disclosure would be limited to contact information, such as your name, address and phone number and the dates you required treatment or services at the Hospital. The money raised in connection with these activities would be used to expand and support the Hospital’s provision of health care and related services to the community. If you do not want to be contacted as part of these fundraising activities, please notify the Gwinnett Hospital System Foundation in writing. Appointment Reminders; Health-related Benefits and Services; Marketing. GHS may use and disclose your PHI to contact you and remind you of an appointment at GHS, or to inform you of treatment alternatives or other health-related benefits and services that may be of interest to you, such as disease management programs. GHS may use and disclose your PHI to encourage you to purchase or use a product or service through a face-to-face communication or by giving you a promotional gift of nominal value. Disclosures to You or for HIPAA Compliance Investigations. GHS may disclose your PHI to you or to your personal representative, and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. GHS must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the “Secretary”) when requested by the Secretary in order to investigate GHS’ compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Uses and Disclosures To Which You Have an Opportunity to Object. You will have the opportunity to object to these categories of uses and disclosures of PHI that GHS may make: Patient Directories. Unless you object, GHS may use some of your PHI to maintain a directory of individuals in its facility. This information may include your name, your location in the facility, your general condition (e.g. fair, stable, etc.), and your religious affiliation, and the information may be disclosed to members of the clergy. Except for your religious affiliation, the information may be disclosed to other persons who ask for you by name. Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care. Unless you object, GHS may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care. GHS may also notify those people about your location or condition. Other Uses and Disclosures of PHI For Which Authorization is Required. Other types of uses and disclosures of your PHI not described above will be made only with your written authorization, which with some limitations you have the right to revoke in writing. Regulatory Requirements. GHS is required by law to maintain the privacy of your PHI, to provide individuals with notice of its legal duties and privacy practices with respect to PHI, and to abide by the terms described in this Notice. GHS reserves the right to change the terms of this Notice and of its privacy policies, and to make the new terms applicable to all of the PHI it maintains. Before GHS makes an important change to its privacy policies, it will promptly revise this Notice and post a new Notice in all patient entry locations. You have the following rights regarding your PHI: You may request that GHS restrict the use and disclosure of your PHI. GHS is not required to agree to any restrictions you request, but if GHS does so it will be bound by the restrictions to which it agrees except in emergency situations. Effective February 17, 2010, GHS is required by the Health Information Technology for Economic and Clinical Health Act (the “HITECH Act”) to honor an individual’s request to restrict disclosures of PHI to health plans for
FORM 4-18967 REV. 07/2010

payment or health care operations purposes if the PHI pertains solely to items and services paid for by the individual in full. You have the right to request that communications of PHI to you from GHS be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, or by e-mail rather than regular mail. Your requests must be made in writing and sent to the Privacy Officer. GHS will accommodate your reasonable requests without requiring you to provide a reason for your request. Generally, you have the right to inspect and copy your PHI that GHS maintains, provided that you make your request in writing to the Hospital’s Department of Health Information Management. Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), GHS will inform you of the extent to which your request has or has not been granted. In some cases, GHS may provide you a summary of the PHI you request if you agree in advance to such a summary and any associated fees. If you request paper copies of your PHI or agree to a summary of your PHI, GHS may impose a reasonable fee to cover copying, postage, and related costs. To the extent capable, GHS will comply with your request for a copy of your PHI in an electronic format. If GHS denies access to your PHI, it will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If GHS does not maintain the PHI you request, if it knows where that PHI is located it will tell you how to redirect your request. If you believe that your PHI maintained by GHS contains an error or needs to be updated, you have the right to request that GHS correct or supplement your PHI. Your request must be made in writing to the Hospital’s Department of Health Information Management, and it must explain why you are requesting an amendment to your PHI. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), GHS will inform you of the extent to which your request has or has not been granted. GHS generally can deny your request if your request relates to PHI: (i) not created by GHS; (ii) that is not part of the records GHS maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, GHS will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and GHS’s denial attached; and (iii) complain about the denial. You generally have the right to request and receive a list of the disclosures of your PHI that GHS has made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made prior to April 14, 2003). The list will not include disclosure for which you have provided a written authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations; (ii) made to you; (iii) for the Hospital’s patient directory or to persons involved in your health care; (iv) for national security or intelligence purposes; or (v) to correctional institutions or law enforcement officials. You should submit any such request to the Hospital’s Department of Health Information Management, and within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), GHS will respond to you regarding the status of your request. GHS will provide the list to you at no charge, but if you make more than one request in a year you may be charged a fee for each additional request. You have the right to receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically. You can receive a copy of this Notice at our Web site, http://www.gwinnetthealth.org. To obtain a paper copy of this Notice, please contact the GHS Privacy Officer. You may complain to GHS if you believe your privacy rights with respect to your PHI have been violated by contacting a Hospital Patient Representative or the GHS Privacy Officer and submitting a written complaint. GHS will in no manner penalize you or retaliate against you for filing a complaint regarding GHS’ privacy practices. You also have
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the right to file a complaint with the Secretary of the Department of Health and Human Services. If you have any questions about this Notice, please contact the GHS Privacy Officer by mail at 1000 Medical Center Boulevard, Lawrenceville, Georgia 30046, by telephone at (678) 312-3900 or by email at [email protected]. If you have any questions about your medical records, please contact the Medical Records Department by mail at 1000 Medical Center Boulevard, attn Medical Records, Lawrenceville, GA 30046, or by telephone at (678)-312-4490. Effective Date: April 14, 2003.

FORM 4-18967 REV. 07/2010

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PATIENT E-MAIL CONSENT Center for Cancer Care
Patient name: ____________________________________ E-mail: __________________________________ Patient address: ___________________________________________________________________________ Provider: _________________________________________________________________________________

1) RISK OF USING E-MAIL
Transmitting patient information by e-mail has a number of risks that patients should consider before using e-mail. These include, but are not limited to, the following: A) E-mail can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. B) E-mail senders can easily misaddress an e-mail. C) Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy. D) Employers and on-line services have a right to inspect e-mail transmitted through their systems. E) E-mail can be intercepted, altered, forwarded, or used without authorization or detection. F) E-mail can be used to introduce viruses into computer systems. G) E-mail can be used as evidence in court. H) E-mails may not be secure, including at Center for Cancer Care, and therefore it is possible that the confidentiality of such communications may be breached by a third party. 2) CONDITIONS FOR THE USE OF E-MAIL Provider cannot guarantee but will use reasonable means to maintain security and confidentiality of e-mail information sent and received. Providers are not liable for improper disclosure of confidential information that is not caused by Provider’s intentional misconduct. Patients must acknowledge and consent to the following conditions: A) E-mail is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular E-mail will be read and responded to within any particular period of time. B) E-mail must be concise. The patient should schedule an appointment if the issue is too complex or sensitive to discuss via e-mail. C) All e-mail will usually be printed and filed in the patient’s medical record. D) Office staff may receive and read your messages. E) Provider will not forward patient identifiable e-mails outside of Center for Cancer Care healthcare providers without the patient’s prior written consent, except as authorized or required by law. F) The patient should not use e-mail for communication regarding sensitive medical information. G) Provider is not liable for breaches of confidentiality caused by the patient or any third party. H) It is the patient’s responsibility to follow up and/or schedule an appointment if warranted. 3) INSTRUCTIONS To communicate by e-mail, the patient shall: A) Avoid use of his/her employer’s computer. B) Put the patient’s name in the body of the e-mail. C) Key in the topic (E.G., medical question, billing question) in the same line. D) Inform provider of changes in his/her e-mail address. E) Acknowledge any e-mail received from the Provider. F) Take precautions to preserve the confidentiality of e-mail. 4) PATIENT ACKNOWLEDGEMENT AND AGREEMENT I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between the Providers and me, and consent to the conditions and instructions outlined, as well as any other instructions that the Provider may impose to communicate with patient by e-mail. If I have any questions I may inquire with my treating physician. _____________ Date _____________ Date _______________________________________________________ Patient signature _____________ Time ____________________________________________________ Witness signature

*1-32766*

FORM 1-32766 INITIATED 09/2012

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PATIENT HISTORY Center for Cancer Care
NAME: ________________________________________ PATIENT PROFILE Place of birth: ________________________________ Occupation: _________________________________ Tobacco use: ________________________________ PAST MEDICAL HISTORY (Check if appropriate) Skin cancer Ulcer Thyroid disease Hepatitis Diabetes Intestinal disease Pneumonia Gallbladder disease Tuberculosis Kidney/bladder disease Blood transfusion Venereal disease DATE: __________________________

Highest Grade Completed: _________________ Religion: _______________________________ Alcohol use: ____________________________ Heart attack Other heart disease Lung disease High blood pressure Stroke Seizures Arthritis Head injury Cancer Phlebitis Asthma High cholesterol

LIST ALL MEDICATIONS Drug Dose Frequency 1. __________________________________________________________________________________ 2. __________________________________________________________________________________ 3. __________________________________________________________________________________ 4. __________________________________________________________________________________ 5. __________________________________________________________________________________ LIST ALL PROCEDURES Procedure Date Hospital 1. __________________________________________________________________________________ 2. __________________________________________________________________________________ 3. __________________________________________________________________________________ 4. __________________________________________________________________________________ 5. __________________________________________________________________________________ ALLERGIES NONE DYE LATEX

DRUG: Please List Drug and Reaction: Other: Please List with Reaction: FAMILY HISTORY If Living If Deceased Age Health Age at death Cause Father: _____________________________________________________________________________ Mother: _____________________________________________________________________________ Brother/Sister: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Husband/Wife: _______________________________________________________________________ Children _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

*2-32767*

FORM 2-32767 INITIATED 09/2012

Page 1 of 3

PATIENT HISTORY Center for Cancer Care
Have any blood relatives ever had? (Check if appropriate) Cancer Heart disease Bleeding disorder Diabetes Anemia Kidney disease Have you had any of these in the last three months? NO GENERAL Change in weight Fever / Chills Night sweats SKIN Itching Rash Change in mole GLANDS Heat / cold intolerance X-ray treatments to neck Excessive thirst / urination EENT Change in vision Double vision Difficulty hearing Frequent bloody nose Sinus infection Hoarseness Ringing in ears Sores in mouth HEART / LUNGS Chest pain Cough Coughing blood Shortness of breath Wheezing Irregular / racing heartbeat Black out spells Ankle swelling Aching in legs when walking BLOOD Anemia Unusual dietary craving Excessive bruising / bleeding Enlarged lymph nodes YES NO INTESTINAL Nausea / Vomiting Vomiting blood Difficulty swallowing Abdominal pain / swelling Yellow jaundice Blood in stool / black stool Diarrhea / constipation Change in bowel habits URINARY Burning / painful urination Blood in urine Nighttime urination Change in urine stream Sores on genitals SKELETAL Joint pain / stiffness Back pain NEUROLOGICAL Frequent / severe headache Numbness / tingling Incoordination Limb weakness Psychiatric illness Unusual anxiety / depression Drug / Alcohol addiction FOR WOMEN Bleeding between periods Bleeding since menopause Pain in female organs Breast lump / pain Nipple discharge FOR MEN Lump / pain in testicle Impotence Discharge YES Other: ________________________ _________________________ _________________________

FORM 2-32767 INITIATED 09/2012

Page 3 of 3

PATIENT HISTORY Center for Cancer Care
LEARNING BARRIERS Please check all that apply Cognitive Emotional State Medically Unstable Physical Limitation Cultural Issues Unable to Read Motivation Other NONE

LEARNING PREFERENCES Verbal/Listening Demonstration Written/Reading No Preference

SOCIAL Do you feel safe returning home? Yes No

Do you feel that you have been abused, neglected or exploited by someone close to you? Yes No Do you need help with personal/financial, social problems, obtaining your medications or supplies? Yes No

Completed by: _________________________________ Relationship to patient: ___________________ Form Reviewed by: _____________________________ Date/Time: _____________________________

FORM 2-32767 INITIATED 09/2012

Page 3 of 3

PLACE LABEL HERE

NOTICE PRIVACY PRACTICES and PERSONAL REPRESENTATIVE
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (NPP):
My signature below acknowledges that I have received or have been offered a copy of Gwinnett Health System’s (GHS) Notice of Privacy Practices, and I am aware that I have access to this document on the health system’s website at www.gwinnettmedicalcenter.org. OR In an emergency treatment situation, obtain the NPP acknowledgement as soon as it is reasonably practicable to do so after the emergency situation has ended. ___The Patient is unable to sign because (check one)  Patient is Critical or Unconscious.  Patient Refuses to Sign. ___CERTIFICATION OF GOOD FAITH EFFORTS TO OBTAIN ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES (NPP): I hereby certify that as an associate or agent of GHS, I have made a good faith effort to obtain from the patient or the patient’s authorized representative a written acknowledgment of the GHS NPP in accordance with its Provision of Notice of Privacy Practices, (policy #100-105.)

__________________________________________________________________________
DESIGNATION OF PERSONAL REPRESENTATIVE:
As a patient, you may designate one or more personal representatives. A personal representative may receive Protected Health Information (PHI) about you. PHI includes information about your current medical condition and diagnosis, treatment and prognosis, and billing and payments. Personal representatives will not have access to PHI in the periods that are between treatments or admissions. My personal representative(s) is listed below and my signature of approval. A personal representative may be a spouse, relative, domestic partner, or friend. You can remove or add personal representatives at any time, including during treatment or upon another admission to a GHS facility. _____ (initial) I (Patient) do not wish to designate a personal representative. I understand that the hospital’s healthcare team may designate an interim personal representative, if designating a personal representative will expedite or enhance my care as a patient.

I (Patient) designate the following as my personal representative(s):
_________________________________________________________ (Name of Personal Representative) _________________________________________________________ (Address, if known) _________________________________________________________ (Name of Personal Representative) _________________________________________________________ (Address, if known) ________________________ (Relationship) ________________________ (Telephone number) ________________________ (Relationship) ________________________ (Telephone number)

________________________________________________________ Patient or Authorized Representative Signature ______________________________________ GHS Representative Name __________________________ Department

________________________________________ Date ________________________________________ Position

*1-32434*

FORM 1-32434 INITIATED 07/2012

Page 1 of 1

PATIENT RIGHTS AND RESPONSIBILITIES RIGHTS
All patients and parents of pediatric or neonatal patients shall have the right to: a. impartial access to care regardless of race, creed, sex, national origin, handicap or ability to pay; b. have the right to communication that you can understand. Provide sign language and foreign language interpreters as needed at no cost. Provide information appropriate to your age, understanding, and language. If you have vision, speech, hearing, and/or other impairments, you will receive additional aids and ensure your care needs are met; c. be treated with respect and dignity at all times; d. have a family member, representative, or person of your choice and your physician notified promptly of your admission to the hospital; e. refuse to talk with or see any one not directly involved in your care and treatment; f. wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere with diagnostic procedures or treatment; g. be interviewed and examined in privacy and to have someone of your own gender present, if requested; h. have your care and treatment handled confidentially and be assured that your medical records will be read only by authorized individuals; i. access information contained in your medical records within a reasonable time frame; j. current information concerning your diagnosis (to the degree known), treatment and any known prognosis; k. make decisions about your plan of care, including the assessment and management of pain, prior to and during the course of treatment and the extent to which family members participate in care decisions; l. have diagnostic and treatment decisions based on clinical indications and not on reimbursement; m. be free from restraints or seclusion imposed as a means of coercion, discipline, convenience, or retaliation by staff; n. choose who may visit during a hospitalization, regardless of whether the visitor is a family member, a spouse, domestic partner ( including same-sex domestic partner) or other type of visitor as well as the right to withdraw such consent to visitation at any time; Visitation may be limited at times due to individual clinical treatment o. be placed in protective privacy, when considered necessary, for personal safety; p. receive care in a safe setting, free from abuse and harassment; q. know the identity and professional status of individuals providing service and know which physician or other practitioner is primarily responsible for your care; r. know of the existence of any professional or business relationships among individuals who are treating you, as well as the relationship to any other healthcare or educational institutions involved in your care; s. access people outside the hospital, including pastoral care and advocacy services, by means of visitation and by verbal and written communication, as long as they do not interfere with diagnostic procedures or treatment; t. information necessary to give informed consent prior to the start of procedures for treatment; u. have your Advance Directive, if formulated and provided to the hospital, honored by the hospital system and, if ethical issues arise, have the right to access the Ethics Resource Council; v. request, at your expense, consultations with specialists; w. refuse treatment with the understanding that the hospital system / patient relationship may be terminated with reasonable notice; x. consent or decline to participate in research without fear that future care will be compromised; y. an explanation of the need to transfer to another facility, the alternative to such a transfer and the right to refuse the transfer; z. request and receive itemized an explanation of your total bills for services rendered;

*2-1834*

FORM 2-1834 REV. 08/2012

Page 1 of 2

aa.

information about the hospital’s mechanism for the initiation, review and resolution of patient complaints including the right to: 1. access an internal grievance process through contact with the Patient Representative Department of the hospital, or 2. seek external review of your concerns by contacting either the Department of Human Resources Office of Regulatory Services at Two Peachtree St., NW, Atlanta, Ga. 30303-3142, or by phone at 404-6575700 or the Joint Commission at 1-800-944-6610.

PATIENT RIGHTS AND RESPONSIBILITIES RESPONSIBILITIES
All patients and parents of pediatric or neonatal patients have the responsibility: a. to provide, to the best of your knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives, and other matters relating to your health; b. to ask for pain relief when pain first begins, to report when pain is not relieved and to discuss your pain management plan and pain relief options with your doctors and nurses; c. to follow the treatment plan recommended by the practitioner primarily responsible for your care; d. for your actions if you refuse treatment or do not follow the practitioner’s instructions; e. for assuring that the financial obligations for your healthcare are fulfilled as promptly as possible; f. for following hospital rules and regulations affecting patient care and conduct; g. for being considerate and respectful of the right and property of other patients, visitors, hospital personnel and the hospital system.

PATIENTS WITH SPECIAL NEEDS
Our staff wants to communicate effectively with you or other persons participating in your care or treatment who may be deaf/hearing impaired or have other special needs. The following are available free of charge for those with special needs: • Sign language and oral interpreters • TDDs (telecommunications device for the deaf) • Closed captioning for televisions • Volume-control telephones • Hand held bed controls • Hand held bed controls in Braille • Pressure sensitive nurse call pad • Phone with flashing light for the hearing impaired • Language line services

If you have any questions or concerns regarding Patient Rights and Responsibilities or special assistance, contact the Patient Representative Department at 678-312-4399 or 678-312-1000.

FORM 2-1834 REV. 08/2012

Page 2 of 2

INDIGENT CARE TRUST FUND NOTICE

Do You Need Help to Pay Your Hospital Bill?
Gwinnett Medical Center participates in the Georgia Indigent Care Trust Fund. As our patient, you receive certain benefits under the Trust Fund.

You have a right to:
• • • • • • • The availability of free and reduced-charge services. The availability to gain admittance without pre-admission deposits. Not be transferred solely or insignificant part for economic reasons. The availability of services provided. The terms of eligibility for free and reduced services. The application process for free and reduced-charges. The person or office to whom complaints or questions about the hospital’s participation in or operation of the program may be directed.

Primary care services:
We spend part of the money from the Trust Fund to improve primary care services in our community so that you will have better access to preventive services you need. The services we offer are: Miles and Lib Mason Children’s Clinic, Gwinnett Physicians Group OB Gyn, and several outpatient testing centers.

Help with your hospital bills:
You may be eligible for financial help with your bills for inpatient and outpatient services at our hospital. Under the Trust Fund, we offer a certain amount of free and reduced-charge care each year. Financial assistance information can be obtained by: • Talking with our Benefits Counselor in the Center for Cancer Care • Accessing our website: gwinnettmedicalcenter.org

If you have problems:
If you have any concerns about how we operate programs under the Trust Fund rules, please let us try to work with you to resolve them. However, if you are not satisfied with our handling of your situation, you may contact the Department of Community Health: • Mail: 2 Peachtree St., NW, Atlanta, GA 30303 • Telephone: 404-656-4507 • Web: dch.georgia.gov

Page 1 of 1

tHe Center for Cancer Care
 

Integrated Cancer Center with Gwinnett Medical Center  Why are we doing this?  This relationship is a major step in creating a more comprehensive cancer program for our community.  We  want to make it as easy and convenient as possible for you to get the cancer care you need.   Thanks to our  relationship with Gwinnett Medical Center, we are now able to offer all patients infusion/injection services at  our office locations.  So, if you received infusion treatments at a hospital in the past, you can now receive  these services in our office.  This change will most likely save you some time, and you’ll be able to receive care  from the people who you have come to know and trust.    What’s changing?  As mentioned above, thanks to the relationship between Suburban Hematology Oncology Associates and  Gwinnett Medical Center, we can now offer infusion/injection services at our spacious, modern facilities in  Lawrenceville, Duluth and Snellville. In recognition of the strong ties between our two organizations, the name  of the infusion center at Suburban Hematology Oncology Associates will now become the Center for Cancer  Care, a service of Gwinnett Medical Center.    What isn’t changing?  You will continue to see the same experienced physicians and staff that you have in the past and our  commitment to providing quality care in a comfortable, compassionate setting remains unchanged.  We will  continue to treat you not just as a patient, but as a person, and we will work with you to produce the best  possible outcomes.    What’s more, if you should require inpatient care, you will have convenient access to the excellent diagnostic  and inpatient services at Gwinnett Medical Centers’ hospitals in Lawrenceville and Duluth.       We will also try to take some of the stress out of what can be a very challenging time in your life.  We’ll help  you to understand your treatment options and to get the care you need, regardless of your financial situation  – including connecting you with outside resources to help you cover the costs of treatment.    How will the cost of my care be affected?    Just as your treatment is unique, so is your financial situation.  Our benefits counselors can work with you to  determine your specific responsibilities and the resources, including your insurance provider, to help pay for  the cost of your care.      Can I continue to have my lab work here?  Yes.  We now have the ability to perform more testing within our facility.   
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tHe Center for Cancer Care
 

  Can I continue to see my same doctor?  Yes.  You will continue to see the same physician.  There will not be any changes to your treatment path as a  result of this partnership.  Only you and your doctor will determine what care is appropriate.  Will my insurance co‐payment and co‐insurance amounts change?  The Center for Cancer Care now bills under Gwinnett Medical Center’s tax identification number.  The tax  identification number is used by insurance companies to discover the specific contract with healthcare  providers.  Any plan the hospital is contracted with will be the same as the center.  Every plan is different; the  policy terms are used to determine insurance payment amounts, contractual amounts (the portion your  doctor and center agree to accept), and patient responsibility amounts.  So, you should anticipate a possible  change in your co‐payments and co‐insurance amounts.  Our benefits counselors are here to help you  understand your insurance benefits and provide payment options.  How will I know what I owe?  Our benefits counselors will verify your benefits and determine what will be paid by your insurance company  and provide an estimate of what amount, if any, you will owe.  We will explain your benefit coverage details  and any amount due once we discover you’re individual plan.    In some cases we will not know before your visit exactly what treatment you’ll be receiving.  If an amount due  cannot be determined we will give you the basic policy information such as deductibles and max out of pocket  portions as a starting point.  We will file your insurance and bill you for any remaining balance.  Will the bill come from Gwinnett Medical Center?  The staff that has been filing your insurance claims will continue to prepare and submit your claims to your  insurance company.  If there is a remaining balance, we will mail you a statement. The name on the statement  will be The Center for Cancer Care, a service of Gwinnett Medical Center. We are available to discuss  statements within the center on follow up visits by our associates.  Those bills can only be discussed within the  Center.  Main hospital associates will not have your statement information so it’s important to call the  numbers listed on the statement if you have a question or speak to us in person.   I have Medicare, will I experience any changes?  You will have a new form to read and sign.  It pertains to you acknowledging that you are being treated at a  hospital‐based center which may increase the co‐insurance amount you owe.  The form is a CMS requirement.  I am uninsured will there still be assistance and financial resources available to me?  Yes.  Our benefit counselors will continue to help you find the right financial resources that fit your financial  situation.  Also, the hospital financial assistance program is available. 
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