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TRANSCRIPT
David L Tharpe MD Thomas W Ozbirn Jr DO Roman R Brantley Jr MD James L Lewis MD John R Brouillette MD Jeffrey H Glaze MD Harold E Giles MD Agata M Przekwas MD Thomas H Watson MD William D Lyndon MD Michael B Hovater MD Benjamin R Broome MD Phillip N Madonia MD Timothy A Williams MD Theodore S Feely MD James C Harms MD
Phone (205)226-5900 Fax (205)226-5937
Alabasler 644 2nd Street NE Suite 201 Alabaster Alabama 35007
Annislon 1430 Christine Ave Anniston Alabama 36207
Bessemer 995 9th Avenue S W Suite 407 Bessemer Alabama 35022
Birmingham 817 Princeton Avenue SW Suite 206 Birmingham Alabama 35211
Cenlreville 405 Belcher Street Centreville Alabama 35042
Clanton 2030 Lay Dam Road Clanton Alabama 35045
Gadsden 405 South 2nd Street Gadsden AL 35901
Gardendale 1603 Decatur Highway Suite 150 Gardendale Alabama 35071
GreysloneJ SI Vincenls 119 7191 Cahaba Valley Road Hoover Alabama 35242
Homewood 2700 Rogers Drive Suite 102 Homewood Alabama 35209
Jasper 3400 Highway 78 East Suite 410 Jasper Alabama 35501
Oneonla 101 Lemley Drive Suite A Oneonta Alabama 35121
Pell City 7063 Veterms Parkway Suite 130 Pell City Alabama 35125
Trussville 7201 Happy Hollow Road Trussville Alabama 35173
Toll free 1-800-489-9031 email mai~a n~hro-~ com
NEPHROLOGY ASSOCIATES PCNAt
Dear __________________________~
Welcome to Nephrology Associates PC We are honored you have chosen to partner with us in your care
Your appointment is scheduled with Dr ________________________ __
at our ______________ office
on _______________________________________________
Please complete the forms in this packet and bring them with you on your appointment day Have your list of medications filled out completely including the strength and how often you take the medicine If for any reason you are unable to complete the items listed above please call our office so that we may assist you
If you are covered by an insurance carrier that require a referral please contact your primary care physician prior to your visit You cannot see the physician without a referral from your prim IT care phy ician
After your initial new patient visit your physician may occasionally request that you see our Certified Registered Nurse Practitioners Please notify our staff if your insurance does not cover physician extenders
Due to having multiple clinic locations please bring your paperwork to yow appointment Do NOT mail your paperwork back to us
IF YOU DO NOT HAVE INSURANCE OR HAVE A COPAY payment is due at time of your visit For your convenience we accept cash check American Express Visa Discover or MasterCard
THERE IS ON PHONE NUMBER FOR ALL LOCATIONS AND PHYSICIANS 205-226-5900 OR TOLL FREE 1-800-489-9031
Nephrology Associates Pe complies with applicable Federal Civil Rights Laws and does not discriminate on the basis of race color national origin age disability or sex
Again thank you for choosing Nephrology Associates Pe We look forward to seeing you soon
Terry Black Practice Administrator
_________ _
Dale ~________
Age __________
PATIENT INFORMATION Pallent Name Last
FI~t Middle
Address
City _______________Slale ___ lJp _____ Phone _______Cell Phone
__________ Preferred Language _________Blrth Dele ____~~Raca Ethnlcity
Retirelt Employed _____ Full time student Par1 hme student _____ Marttal Slatu
Employer Phone
SOCial SecurIty Dnvars Ucense
Parllon responsible for account Relallonshlp
Address
Citymiddot Stele ZIp ___~_ Phone
Employe( Phone
SOCial SeCurlly Dnvers Llcen
Spouse 5 Name Employer Phone
PhonePerson to notiry In case of emergency ---------~~_c__~---c-----0Wade YtIw Iiomo)
IF YOU ARE INSURED BY MEDICARE PLEASE SIGN THE FOLLOWING EXTENDED PATIENT SIGNATURE AUTHORIZATION I tequestlhat payment of aUlhorized Medicare benefits be made on my behalf 0 Nephrology AssoCIates PC fOl any services or Ilems furnished me by thai phys clan I authorize any holdsr of medlcallnrormation about me 10 release any Informallon needed to determine U1etr benefits payable for ralated seNlees
______c~ ~~-~ ____
Signature of benenclary or person Signing ror beneficiary Dele signed
bull INSURANCE POLICY INFORMATION
Insurence Company (Pnmary)
Policy holders name Blrthdale
Employer
Conlr I or group
Relallonshlp of pallenl to policy hOlder ~~~_~~
Insurance Company (5econdary) __~~~_____~~~~=_____~~_____~~~~________
Poll( y holder s name Blrthdate
Emplo~er
Contraci or group
Relallonshlp 01 pallanllO pohcy holder
Referred by
CONSENT FOR TREATMENT I consenllo necessary lrealment cludlng drugs mediCIne perlormance of operal ani end conduct at X ray or otner siudies that may be usad by Ihe attending physiCian his nu~e or alalr
AUTHORIZATION FOR RELEASE OF INFORMATIONmiddot I authorize Nephrology Associates pe 10 furnlh any medical Informahon reQuested by insurance companlBs wlU1 whom I have coverage any public agency whIch may be assIsting In payment of my cara or my employer who Is providIng peyment of my medical biOs due to en on the Job Injury
ASSIGNME NT OF BENEFITSmiddot 1 hereby aullorlz8 payment dlreclly 0 Nephrology Associates PC of benenrs otherwise payabl 10 me IncludIng maJOr medical Insurance and paymanl or surgical or medical beneflls but not 10 exceed the Nephrology Associales PC charges for Ihess services I undermiddot stand that am financlaUy respans ble to Nephrology ASSociates PC for charges not covered by Ihls assignment t authorize the refund of overpaid Insurance benefils where my coverages are subj8C1 Lo coordination of benefits
GUARANTEE OF ACCOUNT For seNlees furnished by Nephrology ASSOCiates PC I hereby guarantee the paymenl of aU accounts for services rendered For paymenl of said accounts for seNlcea I hereby waIve all claims of ellempllon under the Slale of Alabama and agree to pay If necessary all oasts of collecllon IncludIng allameys roe
____________________________ DATE
SIGNATURE ~
AEOAOEA FORM MSF PEARY co middot1O(JJOI100 NEPH ASSOC (12 08)
TO BE COMPLETED BY BENEFICIARY OR AGENT -1hctIoM For Parmenl 0I8eMfIIa And
I01~ Iv me 01 011 mySTATEMENT Dr lIDPAYMENT FOR
__ by01 _~My oI~ 1IIme ~-IIDc AlnIIfGn Md IiMEDICARpound
OF
lit-bull BENEFITS I PQIRIIfoIfIfhrItfaIIIlr2IM2A eo or Oft my lID STATEMENT FOR lWID fIe~ h
oIlfD1tMIMYMEHT oIlftffIIIctII~me OF eny tIIbnM- ___ eo - 01rtEDIGAP wmcbullbullBENmTS
DdtoI8Maftd111) fw 1
ReIaUonlhlp of Agent fD IIenaIIdaryAddrta 01 -reon s-nlf1J Dr BeneftcIaII (SMt C4r State Zip Code)
Reaon Beneftdary Ie Unable 10 SIgn
Nephrology Associates PC
Patient Name __________________________
Your physician at Nephrology Associates Pe will send a note from your visit today to the
physician that referred you to us as well as your primary care physician
Please list below physicians names addresses and fax numbers
1 The physician that referred you today _________________
2 Your primary care physician if different than referring physician
3 Other physician ________________________
Thank you for letting us participate in your care
-- ----- --- ---
- - - -- - --- - - -
PERSOl AL AND MEDICAL HISTORY
NAME __________________________________DATEmiddot___________________
AGE ____ PHO TE 8- HOME_ ----- shy CELL ------- shy ORl( ------- shyDATE OF B IRTII _____________ REFERRING PHYSICIAN ____________
REASOl REFERRED TO KIDNEY DOCTOR ____
CURRENT MEDICATIONS
HtpoundQ LJEiC lJpoundlH CA TIO nOSE
- - - -- I f- shy
~--
- _--
--- --
l I
Ir--- - I
shy
- I
- --- -- ----- J - - - shy - shy - - -shy - shy I I
I
rshy-- shy -- shy -- shy -+shy
I
r -shy
MEDICATIO~ ALLERGIES
DO YOU TAKE OVER THE COUNTER MEDICATIO~S_______________
HAVE YOU EVER BEEN OX DIALYSIS
HAVE YOU EVER HAD A KIDNEY BIOPSY
HAVE YOU EVER BEEN HOSPITALIZED FOR OTHER THAN SURGERIES--------- shy
1
PFSHROS DATA WIZARD FORM
Name o M 0 F DOB(Last First MI)
PAST MEDICAL HISTORY - COMMON DISEASES Do you have a personal history of any of the following
Kidney Disea e
DCKD Stage 1 2 3 4 5 o Transplant
o Cadaveric o Living - Related o Living - Unrelated
o Dialysis DHD OPD
o Polycystic Kidney Disease o Acute Kidney Injury o Glomerulonephritis
Diabetes o Type 1 o Type 2
o Type Unknown
High Blood Pressure
o Essential o Renovascular
o White Coat Hypertension o Conns Syndrome
Ischemic Heart Disease
o Heart attack o Angina o Angioplasty
o Coronary Stent o CABG (Coronary Artery Bypass Graft)
Cancer o Lung o Breast o Prostate (male) o Colon o Melanoma o Bladder
o Lymphoma o Kidney o Thyroid o Leukemia o Endometrial (female) o Pancreatic
Stroke o Stroke
Gout o Gout
PAST MEDICAL HISTORY - ADDITIONAL CONDITIONS oo you have a personaI hi S tory 0 f any 0 f th f IIe oowng
EENT o Blindness o Cataracts
o Hearing Problems o Glaucoma
Cardiovascular
o Atrial Fibrillation o Pacemaker o High Cholesterol
o AICD (Cardiac Defibrillator)
o Valvular Heart Disease o Congestive Heart Failure o Mitral Valve Prolapse
Respl ratory
DCOPD o Chronic Bronchitis o Asthma o Emphysema
o Pneumonia o Tuberculosis o Sleep Apnea
Gastrointestinal
o GERD (Gastric Reflux)
o StomachBowel Ulcers o Gall Bladder Disease o Hepatitis
o Inflammatory Bowel Disease D Irritable Bowel Syndrome o Gluten Intolerance o Lactose Intolerance
Genitourinary o Enlarged Prostate(maJe) o Kidney Stones
o Frequent UTls (Urinary Tractlnfeclions)
08 History o Preeclampsia (female) o Pregnancy Induced Hypertension (female)
o Gestational Diabetes (female) o History of Complicated Pregnancy (female)
Musculoskeletal o Osteoarthritis o Osteoporosis Neurological o Multiple Sclerosis
o Seizures o Parkinsons o Dementia
Psychiatric o Depression o Anxiety Disorder Endocrine o Hypothyroidism
o Hyperparathyroidism o Hyperthyroidism o Adrenal Insufficiency
Hematology o Anemia o Sickle Cell Disease
o Sickle Cell Trait o Blood Transfusion o Thalassemia
ImmunoAllergy o HIV DAIDS
o Rheumatoid Arthritis o Lupus
PAST MEDICAL HISTORY - SURGERY HISTORY
Have any of the following surgeries been performed on you
o Appendectomy 0 Hip Replacement 0 Renal Transplant o CABG 0 Left 0 Bilateral 0 Thyroidectomy o Carotid Endarterectomy 0 Right 0 Tonsillectomy o Cataract Surgery 0 Knee Replacement 0 Valve Replacement 00amp C (female) 0 Left 0 Bilateral 0 AV Fistula o Gall Bladder Removal 0 Right 0 AV Graft o Gastric Bypass 0 Hysterectomy (female) 0 PO Catheter o Hemorrhoidectomy 0 Prostatectomy (male) 0 Other ______ o Hernia Repair 0 Nephrectomy
Other Health Problems Not Listed Above
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
_________ _
Dale ~________
Age __________
PATIENT INFORMATION Pallent Name Last
FI~t Middle
Address
City _______________Slale ___ lJp _____ Phone _______Cell Phone
__________ Preferred Language _________Blrth Dele ____~~Raca Ethnlcity
Retirelt Employed _____ Full time student Par1 hme student _____ Marttal Slatu
Employer Phone
SOCial SecurIty Dnvars Ucense
Parllon responsible for account Relallonshlp
Address
Citymiddot Stele ZIp ___~_ Phone
Employe( Phone
SOCial SeCurlly Dnvers Llcen
Spouse 5 Name Employer Phone
PhonePerson to notiry In case of emergency ---------~~_c__~---c-----0Wade YtIw Iiomo)
IF YOU ARE INSURED BY MEDICARE PLEASE SIGN THE FOLLOWING EXTENDED PATIENT SIGNATURE AUTHORIZATION I tequestlhat payment of aUlhorized Medicare benefits be made on my behalf 0 Nephrology AssoCIates PC fOl any services or Ilems furnished me by thai phys clan I authorize any holdsr of medlcallnrormation about me 10 release any Informallon needed to determine U1etr benefits payable for ralated seNlees
______c~ ~~-~ ____
Signature of benenclary or person Signing ror beneficiary Dele signed
bull INSURANCE POLICY INFORMATION
Insurence Company (Pnmary)
Policy holders name Blrthdale
Employer
Conlr I or group
Relallonshlp of pallenl to policy hOlder ~~~_~~
Insurance Company (5econdary) __~~~_____~~~~=_____~~_____~~~~________
Poll( y holder s name Blrthdate
Emplo~er
Contraci or group
Relallonshlp 01 pallanllO pohcy holder
Referred by
CONSENT FOR TREATMENT I consenllo necessary lrealment cludlng drugs mediCIne perlormance of operal ani end conduct at X ray or otner siudies that may be usad by Ihe attending physiCian his nu~e or alalr
AUTHORIZATION FOR RELEASE OF INFORMATIONmiddot I authorize Nephrology Associates pe 10 furnlh any medical Informahon reQuested by insurance companlBs wlU1 whom I have coverage any public agency whIch may be assIsting In payment of my cara or my employer who Is providIng peyment of my medical biOs due to en on the Job Injury
ASSIGNME NT OF BENEFITSmiddot 1 hereby aullorlz8 payment dlreclly 0 Nephrology Associates PC of benenrs otherwise payabl 10 me IncludIng maJOr medical Insurance and paymanl or surgical or medical beneflls but not 10 exceed the Nephrology Associales PC charges for Ihess services I undermiddot stand that am financlaUy respans ble to Nephrology ASSociates PC for charges not covered by Ihls assignment t authorize the refund of overpaid Insurance benefils where my coverages are subj8C1 Lo coordination of benefits
GUARANTEE OF ACCOUNT For seNlees furnished by Nephrology ASSOCiates PC I hereby guarantee the paymenl of aU accounts for services rendered For paymenl of said accounts for seNlcea I hereby waIve all claims of ellempllon under the Slale of Alabama and agree to pay If necessary all oasts of collecllon IncludIng allameys roe
____________________________ DATE
SIGNATURE ~
AEOAOEA FORM MSF PEARY co middot1O(JJOI100 NEPH ASSOC (12 08)
TO BE COMPLETED BY BENEFICIARY OR AGENT -1hctIoM For Parmenl 0I8eMfIIa And
I01~ Iv me 01 011 mySTATEMENT Dr lIDPAYMENT FOR
__ by01 _~My oI~ 1IIme ~-IIDc AlnIIfGn Md IiMEDICARpound
OF
lit-bull BENEFITS I PQIRIIfoIfIfhrItfaIIIlr2IM2A eo or Oft my lID STATEMENT FOR lWID fIe~ h
oIlfD1tMIMYMEHT oIlftffIIIctII~me OF eny tIIbnM- ___ eo - 01rtEDIGAP wmcbullbullBENmTS
DdtoI8Maftd111) fw 1
ReIaUonlhlp of Agent fD IIenaIIdaryAddrta 01 -reon s-nlf1J Dr BeneftcIaII (SMt C4r State Zip Code)
Reaon Beneftdary Ie Unable 10 SIgn
Nephrology Associates PC
Patient Name __________________________
Your physician at Nephrology Associates Pe will send a note from your visit today to the
physician that referred you to us as well as your primary care physician
Please list below physicians names addresses and fax numbers
1 The physician that referred you today _________________
2 Your primary care physician if different than referring physician
3 Other physician ________________________
Thank you for letting us participate in your care
-- ----- --- ---
- - - -- - --- - - -
PERSOl AL AND MEDICAL HISTORY
NAME __________________________________DATEmiddot___________________
AGE ____ PHO TE 8- HOME_ ----- shy CELL ------- shy ORl( ------- shyDATE OF B IRTII _____________ REFERRING PHYSICIAN ____________
REASOl REFERRED TO KIDNEY DOCTOR ____
CURRENT MEDICATIONS
HtpoundQ LJEiC lJpoundlH CA TIO nOSE
- - - -- I f- shy
~--
- _--
--- --
l I
Ir--- - I
shy
- I
- --- -- ----- J - - - shy - shy - - -shy - shy I I
I
rshy-- shy -- shy -- shy -+shy
I
r -shy
MEDICATIO~ ALLERGIES
DO YOU TAKE OVER THE COUNTER MEDICATIO~S_______________
HAVE YOU EVER BEEN OX DIALYSIS
HAVE YOU EVER HAD A KIDNEY BIOPSY
HAVE YOU EVER BEEN HOSPITALIZED FOR OTHER THAN SURGERIES--------- shy
1
PFSHROS DATA WIZARD FORM
Name o M 0 F DOB(Last First MI)
PAST MEDICAL HISTORY - COMMON DISEASES Do you have a personal history of any of the following
Kidney Disea e
DCKD Stage 1 2 3 4 5 o Transplant
o Cadaveric o Living - Related o Living - Unrelated
o Dialysis DHD OPD
o Polycystic Kidney Disease o Acute Kidney Injury o Glomerulonephritis
Diabetes o Type 1 o Type 2
o Type Unknown
High Blood Pressure
o Essential o Renovascular
o White Coat Hypertension o Conns Syndrome
Ischemic Heart Disease
o Heart attack o Angina o Angioplasty
o Coronary Stent o CABG (Coronary Artery Bypass Graft)
Cancer o Lung o Breast o Prostate (male) o Colon o Melanoma o Bladder
o Lymphoma o Kidney o Thyroid o Leukemia o Endometrial (female) o Pancreatic
Stroke o Stroke
Gout o Gout
PAST MEDICAL HISTORY - ADDITIONAL CONDITIONS oo you have a personaI hi S tory 0 f any 0 f th f IIe oowng
EENT o Blindness o Cataracts
o Hearing Problems o Glaucoma
Cardiovascular
o Atrial Fibrillation o Pacemaker o High Cholesterol
o AICD (Cardiac Defibrillator)
o Valvular Heart Disease o Congestive Heart Failure o Mitral Valve Prolapse
Respl ratory
DCOPD o Chronic Bronchitis o Asthma o Emphysema
o Pneumonia o Tuberculosis o Sleep Apnea
Gastrointestinal
o GERD (Gastric Reflux)
o StomachBowel Ulcers o Gall Bladder Disease o Hepatitis
o Inflammatory Bowel Disease D Irritable Bowel Syndrome o Gluten Intolerance o Lactose Intolerance
Genitourinary o Enlarged Prostate(maJe) o Kidney Stones
o Frequent UTls (Urinary Tractlnfeclions)
08 History o Preeclampsia (female) o Pregnancy Induced Hypertension (female)
o Gestational Diabetes (female) o History of Complicated Pregnancy (female)
Musculoskeletal o Osteoarthritis o Osteoporosis Neurological o Multiple Sclerosis
o Seizures o Parkinsons o Dementia
Psychiatric o Depression o Anxiety Disorder Endocrine o Hypothyroidism
o Hyperparathyroidism o Hyperthyroidism o Adrenal Insufficiency
Hematology o Anemia o Sickle Cell Disease
o Sickle Cell Trait o Blood Transfusion o Thalassemia
ImmunoAllergy o HIV DAIDS
o Rheumatoid Arthritis o Lupus
PAST MEDICAL HISTORY - SURGERY HISTORY
Have any of the following surgeries been performed on you
o Appendectomy 0 Hip Replacement 0 Renal Transplant o CABG 0 Left 0 Bilateral 0 Thyroidectomy o Carotid Endarterectomy 0 Right 0 Tonsillectomy o Cataract Surgery 0 Knee Replacement 0 Valve Replacement 00amp C (female) 0 Left 0 Bilateral 0 AV Fistula o Gall Bladder Removal 0 Right 0 AV Graft o Gastric Bypass 0 Hysterectomy (female) 0 PO Catheter o Hemorrhoidectomy 0 Prostatectomy (male) 0 Other ______ o Hernia Repair 0 Nephrectomy
Other Health Problems Not Listed Above
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
TO BE COMPLETED BY BENEFICIARY OR AGENT -1hctIoM For Parmenl 0I8eMfIIa And
I01~ Iv me 01 011 mySTATEMENT Dr lIDPAYMENT FOR
__ by01 _~My oI~ 1IIme ~-IIDc AlnIIfGn Md IiMEDICARpound
OF
lit-bull BENEFITS I PQIRIIfoIfIfhrItfaIIIlr2IM2A eo or Oft my lID STATEMENT FOR lWID fIe~ h
oIlfD1tMIMYMEHT oIlftffIIIctII~me OF eny tIIbnM- ___ eo - 01rtEDIGAP wmcbullbullBENmTS
DdtoI8Maftd111) fw 1
ReIaUonlhlp of Agent fD IIenaIIdaryAddrta 01 -reon s-nlf1J Dr BeneftcIaII (SMt C4r State Zip Code)
Reaon Beneftdary Ie Unable 10 SIgn
Nephrology Associates PC
Patient Name __________________________
Your physician at Nephrology Associates Pe will send a note from your visit today to the
physician that referred you to us as well as your primary care physician
Please list below physicians names addresses and fax numbers
1 The physician that referred you today _________________
2 Your primary care physician if different than referring physician
3 Other physician ________________________
Thank you for letting us participate in your care
-- ----- --- ---
- - - -- - --- - - -
PERSOl AL AND MEDICAL HISTORY
NAME __________________________________DATEmiddot___________________
AGE ____ PHO TE 8- HOME_ ----- shy CELL ------- shy ORl( ------- shyDATE OF B IRTII _____________ REFERRING PHYSICIAN ____________
REASOl REFERRED TO KIDNEY DOCTOR ____
CURRENT MEDICATIONS
HtpoundQ LJEiC lJpoundlH CA TIO nOSE
- - - -- I f- shy
~--
- _--
--- --
l I
Ir--- - I
shy
- I
- --- -- ----- J - - - shy - shy - - -shy - shy I I
I
rshy-- shy -- shy -- shy -+shy
I
r -shy
MEDICATIO~ ALLERGIES
DO YOU TAKE OVER THE COUNTER MEDICATIO~S_______________
HAVE YOU EVER BEEN OX DIALYSIS
HAVE YOU EVER HAD A KIDNEY BIOPSY
HAVE YOU EVER BEEN HOSPITALIZED FOR OTHER THAN SURGERIES--------- shy
1
PFSHROS DATA WIZARD FORM
Name o M 0 F DOB(Last First MI)
PAST MEDICAL HISTORY - COMMON DISEASES Do you have a personal history of any of the following
Kidney Disea e
DCKD Stage 1 2 3 4 5 o Transplant
o Cadaveric o Living - Related o Living - Unrelated
o Dialysis DHD OPD
o Polycystic Kidney Disease o Acute Kidney Injury o Glomerulonephritis
Diabetes o Type 1 o Type 2
o Type Unknown
High Blood Pressure
o Essential o Renovascular
o White Coat Hypertension o Conns Syndrome
Ischemic Heart Disease
o Heart attack o Angina o Angioplasty
o Coronary Stent o CABG (Coronary Artery Bypass Graft)
Cancer o Lung o Breast o Prostate (male) o Colon o Melanoma o Bladder
o Lymphoma o Kidney o Thyroid o Leukemia o Endometrial (female) o Pancreatic
Stroke o Stroke
Gout o Gout
PAST MEDICAL HISTORY - ADDITIONAL CONDITIONS oo you have a personaI hi S tory 0 f any 0 f th f IIe oowng
EENT o Blindness o Cataracts
o Hearing Problems o Glaucoma
Cardiovascular
o Atrial Fibrillation o Pacemaker o High Cholesterol
o AICD (Cardiac Defibrillator)
o Valvular Heart Disease o Congestive Heart Failure o Mitral Valve Prolapse
Respl ratory
DCOPD o Chronic Bronchitis o Asthma o Emphysema
o Pneumonia o Tuberculosis o Sleep Apnea
Gastrointestinal
o GERD (Gastric Reflux)
o StomachBowel Ulcers o Gall Bladder Disease o Hepatitis
o Inflammatory Bowel Disease D Irritable Bowel Syndrome o Gluten Intolerance o Lactose Intolerance
Genitourinary o Enlarged Prostate(maJe) o Kidney Stones
o Frequent UTls (Urinary Tractlnfeclions)
08 History o Preeclampsia (female) o Pregnancy Induced Hypertension (female)
o Gestational Diabetes (female) o History of Complicated Pregnancy (female)
Musculoskeletal o Osteoarthritis o Osteoporosis Neurological o Multiple Sclerosis
o Seizures o Parkinsons o Dementia
Psychiatric o Depression o Anxiety Disorder Endocrine o Hypothyroidism
o Hyperparathyroidism o Hyperthyroidism o Adrenal Insufficiency
Hematology o Anemia o Sickle Cell Disease
o Sickle Cell Trait o Blood Transfusion o Thalassemia
ImmunoAllergy o HIV DAIDS
o Rheumatoid Arthritis o Lupus
PAST MEDICAL HISTORY - SURGERY HISTORY
Have any of the following surgeries been performed on you
o Appendectomy 0 Hip Replacement 0 Renal Transplant o CABG 0 Left 0 Bilateral 0 Thyroidectomy o Carotid Endarterectomy 0 Right 0 Tonsillectomy o Cataract Surgery 0 Knee Replacement 0 Valve Replacement 00amp C (female) 0 Left 0 Bilateral 0 AV Fistula o Gall Bladder Removal 0 Right 0 AV Graft o Gastric Bypass 0 Hysterectomy (female) 0 PO Catheter o Hemorrhoidectomy 0 Prostatectomy (male) 0 Other ______ o Hernia Repair 0 Nephrectomy
Other Health Problems Not Listed Above
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
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12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
Nephrology Associates PC
Patient Name __________________________
Your physician at Nephrology Associates Pe will send a note from your visit today to the
physician that referred you to us as well as your primary care physician
Please list below physicians names addresses and fax numbers
1 The physician that referred you today _________________
2 Your primary care physician if different than referring physician
3 Other physician ________________________
Thank you for letting us participate in your care
-- ----- --- ---
- - - -- - --- - - -
PERSOl AL AND MEDICAL HISTORY
NAME __________________________________DATEmiddot___________________
AGE ____ PHO TE 8- HOME_ ----- shy CELL ------- shy ORl( ------- shyDATE OF B IRTII _____________ REFERRING PHYSICIAN ____________
REASOl REFERRED TO KIDNEY DOCTOR ____
CURRENT MEDICATIONS
HtpoundQ LJEiC lJpoundlH CA TIO nOSE
- - - -- I f- shy
~--
- _--
--- --
l I
Ir--- - I
shy
- I
- --- -- ----- J - - - shy - shy - - -shy - shy I I
I
rshy-- shy -- shy -- shy -+shy
I
r -shy
MEDICATIO~ ALLERGIES
DO YOU TAKE OVER THE COUNTER MEDICATIO~S_______________
HAVE YOU EVER BEEN OX DIALYSIS
HAVE YOU EVER HAD A KIDNEY BIOPSY
HAVE YOU EVER BEEN HOSPITALIZED FOR OTHER THAN SURGERIES--------- shy
1
PFSHROS DATA WIZARD FORM
Name o M 0 F DOB(Last First MI)
PAST MEDICAL HISTORY - COMMON DISEASES Do you have a personal history of any of the following
Kidney Disea e
DCKD Stage 1 2 3 4 5 o Transplant
o Cadaveric o Living - Related o Living - Unrelated
o Dialysis DHD OPD
o Polycystic Kidney Disease o Acute Kidney Injury o Glomerulonephritis
Diabetes o Type 1 o Type 2
o Type Unknown
High Blood Pressure
o Essential o Renovascular
o White Coat Hypertension o Conns Syndrome
Ischemic Heart Disease
o Heart attack o Angina o Angioplasty
o Coronary Stent o CABG (Coronary Artery Bypass Graft)
Cancer o Lung o Breast o Prostate (male) o Colon o Melanoma o Bladder
o Lymphoma o Kidney o Thyroid o Leukemia o Endometrial (female) o Pancreatic
Stroke o Stroke
Gout o Gout
PAST MEDICAL HISTORY - ADDITIONAL CONDITIONS oo you have a personaI hi S tory 0 f any 0 f th f IIe oowng
EENT o Blindness o Cataracts
o Hearing Problems o Glaucoma
Cardiovascular
o Atrial Fibrillation o Pacemaker o High Cholesterol
o AICD (Cardiac Defibrillator)
o Valvular Heart Disease o Congestive Heart Failure o Mitral Valve Prolapse
Respl ratory
DCOPD o Chronic Bronchitis o Asthma o Emphysema
o Pneumonia o Tuberculosis o Sleep Apnea
Gastrointestinal
o GERD (Gastric Reflux)
o StomachBowel Ulcers o Gall Bladder Disease o Hepatitis
o Inflammatory Bowel Disease D Irritable Bowel Syndrome o Gluten Intolerance o Lactose Intolerance
Genitourinary o Enlarged Prostate(maJe) o Kidney Stones
o Frequent UTls (Urinary Tractlnfeclions)
08 History o Preeclampsia (female) o Pregnancy Induced Hypertension (female)
o Gestational Diabetes (female) o History of Complicated Pregnancy (female)
Musculoskeletal o Osteoarthritis o Osteoporosis Neurological o Multiple Sclerosis
o Seizures o Parkinsons o Dementia
Psychiatric o Depression o Anxiety Disorder Endocrine o Hypothyroidism
o Hyperparathyroidism o Hyperthyroidism o Adrenal Insufficiency
Hematology o Anemia o Sickle Cell Disease
o Sickle Cell Trait o Blood Transfusion o Thalassemia
ImmunoAllergy o HIV DAIDS
o Rheumatoid Arthritis o Lupus
PAST MEDICAL HISTORY - SURGERY HISTORY
Have any of the following surgeries been performed on you
o Appendectomy 0 Hip Replacement 0 Renal Transplant o CABG 0 Left 0 Bilateral 0 Thyroidectomy o Carotid Endarterectomy 0 Right 0 Tonsillectomy o Cataract Surgery 0 Knee Replacement 0 Valve Replacement 00amp C (female) 0 Left 0 Bilateral 0 AV Fistula o Gall Bladder Removal 0 Right 0 AV Graft o Gastric Bypass 0 Hysterectomy (female) 0 PO Catheter o Hemorrhoidectomy 0 Prostatectomy (male) 0 Other ______ o Hernia Repair 0 Nephrectomy
Other Health Problems Not Listed Above
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
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12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
-- ----- --- ---
- - - -- - --- - - -
PERSOl AL AND MEDICAL HISTORY
NAME __________________________________DATEmiddot___________________
AGE ____ PHO TE 8- HOME_ ----- shy CELL ------- shy ORl( ------- shyDATE OF B IRTII _____________ REFERRING PHYSICIAN ____________
REASOl REFERRED TO KIDNEY DOCTOR ____
CURRENT MEDICATIONS
HtpoundQ LJEiC lJpoundlH CA TIO nOSE
- - - -- I f- shy
~--
- _--
--- --
l I
Ir--- - I
shy
- I
- --- -- ----- J - - - shy - shy - - -shy - shy I I
I
rshy-- shy -- shy -- shy -+shy
I
r -shy
MEDICATIO~ ALLERGIES
DO YOU TAKE OVER THE COUNTER MEDICATIO~S_______________
HAVE YOU EVER BEEN OX DIALYSIS
HAVE YOU EVER HAD A KIDNEY BIOPSY
HAVE YOU EVER BEEN HOSPITALIZED FOR OTHER THAN SURGERIES--------- shy
1
PFSHROS DATA WIZARD FORM
Name o M 0 F DOB(Last First MI)
PAST MEDICAL HISTORY - COMMON DISEASES Do you have a personal history of any of the following
Kidney Disea e
DCKD Stage 1 2 3 4 5 o Transplant
o Cadaveric o Living - Related o Living - Unrelated
o Dialysis DHD OPD
o Polycystic Kidney Disease o Acute Kidney Injury o Glomerulonephritis
Diabetes o Type 1 o Type 2
o Type Unknown
High Blood Pressure
o Essential o Renovascular
o White Coat Hypertension o Conns Syndrome
Ischemic Heart Disease
o Heart attack o Angina o Angioplasty
o Coronary Stent o CABG (Coronary Artery Bypass Graft)
Cancer o Lung o Breast o Prostate (male) o Colon o Melanoma o Bladder
o Lymphoma o Kidney o Thyroid o Leukemia o Endometrial (female) o Pancreatic
Stroke o Stroke
Gout o Gout
PAST MEDICAL HISTORY - ADDITIONAL CONDITIONS oo you have a personaI hi S tory 0 f any 0 f th f IIe oowng
EENT o Blindness o Cataracts
o Hearing Problems o Glaucoma
Cardiovascular
o Atrial Fibrillation o Pacemaker o High Cholesterol
o AICD (Cardiac Defibrillator)
o Valvular Heart Disease o Congestive Heart Failure o Mitral Valve Prolapse
Respl ratory
DCOPD o Chronic Bronchitis o Asthma o Emphysema
o Pneumonia o Tuberculosis o Sleep Apnea
Gastrointestinal
o GERD (Gastric Reflux)
o StomachBowel Ulcers o Gall Bladder Disease o Hepatitis
o Inflammatory Bowel Disease D Irritable Bowel Syndrome o Gluten Intolerance o Lactose Intolerance
Genitourinary o Enlarged Prostate(maJe) o Kidney Stones
o Frequent UTls (Urinary Tractlnfeclions)
08 History o Preeclampsia (female) o Pregnancy Induced Hypertension (female)
o Gestational Diabetes (female) o History of Complicated Pregnancy (female)
Musculoskeletal o Osteoarthritis o Osteoporosis Neurological o Multiple Sclerosis
o Seizures o Parkinsons o Dementia
Psychiatric o Depression o Anxiety Disorder Endocrine o Hypothyroidism
o Hyperparathyroidism o Hyperthyroidism o Adrenal Insufficiency
Hematology o Anemia o Sickle Cell Disease
o Sickle Cell Trait o Blood Transfusion o Thalassemia
ImmunoAllergy o HIV DAIDS
o Rheumatoid Arthritis o Lupus
PAST MEDICAL HISTORY - SURGERY HISTORY
Have any of the following surgeries been performed on you
o Appendectomy 0 Hip Replacement 0 Renal Transplant o CABG 0 Left 0 Bilateral 0 Thyroidectomy o Carotid Endarterectomy 0 Right 0 Tonsillectomy o Cataract Surgery 0 Knee Replacement 0 Valve Replacement 00amp C (female) 0 Left 0 Bilateral 0 AV Fistula o Gall Bladder Removal 0 Right 0 AV Graft o Gastric Bypass 0 Hysterectomy (female) 0 PO Catheter o Hemorrhoidectomy 0 Prostatectomy (male) 0 Other ______ o Hernia Repair 0 Nephrectomy
Other Health Problems Not Listed Above
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
PFSHROS DATA WIZARD FORM
Name o M 0 F DOB(Last First MI)
PAST MEDICAL HISTORY - COMMON DISEASES Do you have a personal history of any of the following
Kidney Disea e
DCKD Stage 1 2 3 4 5 o Transplant
o Cadaveric o Living - Related o Living - Unrelated
o Dialysis DHD OPD
o Polycystic Kidney Disease o Acute Kidney Injury o Glomerulonephritis
Diabetes o Type 1 o Type 2
o Type Unknown
High Blood Pressure
o Essential o Renovascular
o White Coat Hypertension o Conns Syndrome
Ischemic Heart Disease
o Heart attack o Angina o Angioplasty
o Coronary Stent o CABG (Coronary Artery Bypass Graft)
Cancer o Lung o Breast o Prostate (male) o Colon o Melanoma o Bladder
o Lymphoma o Kidney o Thyroid o Leukemia o Endometrial (female) o Pancreatic
Stroke o Stroke
Gout o Gout
PAST MEDICAL HISTORY - ADDITIONAL CONDITIONS oo you have a personaI hi S tory 0 f any 0 f th f IIe oowng
EENT o Blindness o Cataracts
o Hearing Problems o Glaucoma
Cardiovascular
o Atrial Fibrillation o Pacemaker o High Cholesterol
o AICD (Cardiac Defibrillator)
o Valvular Heart Disease o Congestive Heart Failure o Mitral Valve Prolapse
Respl ratory
DCOPD o Chronic Bronchitis o Asthma o Emphysema
o Pneumonia o Tuberculosis o Sleep Apnea
Gastrointestinal
o GERD (Gastric Reflux)
o StomachBowel Ulcers o Gall Bladder Disease o Hepatitis
o Inflammatory Bowel Disease D Irritable Bowel Syndrome o Gluten Intolerance o Lactose Intolerance
Genitourinary o Enlarged Prostate(maJe) o Kidney Stones
o Frequent UTls (Urinary Tractlnfeclions)
08 History o Preeclampsia (female) o Pregnancy Induced Hypertension (female)
o Gestational Diabetes (female) o History of Complicated Pregnancy (female)
Musculoskeletal o Osteoarthritis o Osteoporosis Neurological o Multiple Sclerosis
o Seizures o Parkinsons o Dementia
Psychiatric o Depression o Anxiety Disorder Endocrine o Hypothyroidism
o Hyperparathyroidism o Hyperthyroidism o Adrenal Insufficiency
Hematology o Anemia o Sickle Cell Disease
o Sickle Cell Trait o Blood Transfusion o Thalassemia
ImmunoAllergy o HIV DAIDS
o Rheumatoid Arthritis o Lupus
PAST MEDICAL HISTORY - SURGERY HISTORY
Have any of the following surgeries been performed on you
o Appendectomy 0 Hip Replacement 0 Renal Transplant o CABG 0 Left 0 Bilateral 0 Thyroidectomy o Carotid Endarterectomy 0 Right 0 Tonsillectomy o Cataract Surgery 0 Knee Replacement 0 Valve Replacement 00amp C (female) 0 Left 0 Bilateral 0 AV Fistula o Gall Bladder Removal 0 Right 0 AV Graft o Gastric Bypass 0 Hysterectomy (female) 0 PO Catheter o Hemorrhoidectomy 0 Prostatectomy (male) 0 Other ______ o Hernia Repair 0 Nephrectomy
Other Health Problems Not Listed Above
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
Gastrointestinal
o GERD (Gastric Reflux)
o StomachBowel Ulcers o Gall Bladder Disease o Hepatitis
o Inflammatory Bowel Disease D Irritable Bowel Syndrome o Gluten Intolerance o Lactose Intolerance
Genitourinary o Enlarged Prostate(maJe) o Kidney Stones
o Frequent UTls (Urinary Tractlnfeclions)
08 History o Preeclampsia (female) o Pregnancy Induced Hypertension (female)
o Gestational Diabetes (female) o History of Complicated Pregnancy (female)
Musculoskeletal o Osteoarthritis o Osteoporosis Neurological o Multiple Sclerosis
o Seizures o Parkinsons o Dementia
Psychiatric o Depression o Anxiety Disorder Endocrine o Hypothyroidism
o Hyperparathyroidism o Hyperthyroidism o Adrenal Insufficiency
Hematology o Anemia o Sickle Cell Disease
o Sickle Cell Trait o Blood Transfusion o Thalassemia
ImmunoAllergy o HIV DAIDS
o Rheumatoid Arthritis o Lupus
PAST MEDICAL HISTORY - SURGERY HISTORY
Have any of the following surgeries been performed on you
o Appendectomy 0 Hip Replacement 0 Renal Transplant o CABG 0 Left 0 Bilateral 0 Thyroidectomy o Carotid Endarterectomy 0 Right 0 Tonsillectomy o Cataract Surgery 0 Knee Replacement 0 Valve Replacement 00amp C (female) 0 Left 0 Bilateral 0 AV Fistula o Gall Bladder Removal 0 Right 0 AV Graft o Gastric Bypass 0 Hysterectomy (female) 0 PO Catheter o Hemorrhoidectomy 0 Prostatectomy (male) 0 Other ______ o Hernia Repair 0 Nephrectomy
Other Health Problems Not Listed Above
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
FAMILY HISTORY - ILLNESSES am Iymembr~ have any 0 f the f0 IIowng medltil I eaI condorlionsD htuwt0 0 ngot e
Kidney Disea e o Father o Mother
o Sibling o Child
Diabetes o Father o Mother
o Sibling o Child
High Blood Pressure
o Father o Mother
o Sibling o Child
I chemic Heart Disease
o Father o Mother
o Sibling o Child
Cancer o Father o Mother
o Sibling o Child
Strok o Father o Mother
o Sibling o Child
Gout o Father o Mother
o Sibling o Child
ADPKD o Father o Mother
o Sibling o Child
Dementia D Father o Mother
o Sibling o Child
FAMILY HISTORY - STATUS
Father o Living
o Unknown
o Deceased o Age at Oeath o Cause of Death
Mother o Living
o Unknown
o Oeceased o Age at Death o Cause of Death
Other Family History Not Listed Above
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
SOCIAL HISTORY - GENERAL
Current Marital Status
o Married o Widowed o Separated o Divorced o Single
Living Arrangement
o Alone o In Home Caregiver o Family Member o Significant Other o Spouse o Assisted Living Facility
Occupation
o Retired o Unemployed o Employed
o Full - time o Part - time
o Student
List your Current or Former Occupation
Functionall Cognitive
o No Impairment o Memory Deficit o Hearing Loss o Poor Vision or Blindness o Limited Mobility o Transportation Challenges
Advanced Care Planning
o Yes I have a Living o No I do not have a Living Will Will
SOCIAL HISTORY - HABITS
Tobacco Use
o Current or Former User o Cigarettes o Chewing Tobacco o Pipes o SAuff o Cigars
o Never Used o Unknown
If a former user I what year did you quit
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
Complete the following section if you are a current or former cigarette user
How often do you currently smoke or how often did you smoke before you quit
o Every Day 0 Some Days 0 Unknown
How many packs per day do you currently smoke or how many packs per day did you smoke before you quit
How many total years have you used cigarettes
o Current or Former User 0 Never Used o OccasionalSocial o 12 per Day o 3 or more per Day
Alcohol Use If a former user what year did you quit
o Current or Former User o Opium o Marijuana
o Amphetamines o Cocaine o Barbiturates o LSD o Other _ ____ _o Heroin
Recreational o Ecstasy Drug Use o Never Used
If a former user what year did you quit
Other Social History Not Listed Above
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
REVIEW OF SYSTEMS
Constitutional o Fever o Weight Gain o Weight Loss
o Fatigue o Chills o Weakness
HEENT
o Vision Impaired o Eye Pain o Redness o Color Blindness o Double Vision o Hearing Loss o Ear Pain
o Sinus Problems o Sore Throat o Nose Bleeds o Headache o Hoarseness o Tinnitus o Vertigo
Respiratory
o Shortness of Breath o At Rest o With Activity
o Pain with Breathing
o Cough o Wheezing O Blood in Sputum o Night Sweats
Cardiovascular o Chest Pain o Palpitations o Claudication
o Orthopnea OEdema o PND (Paroxysmal Nocturnal Oyspnea)
Gastrointestinal
o Abdominal Pain o Nausea o Diarrhea o Heartburn o Vomiting
o Constipation o Anorexia o Trouble Swallowing o Indigestion
Genitourinary
o Urinary Urgency o Urinary Burning or Pain o Blood in Urine o Urinary Frequency
o Urinary Hesitancy o Foamy Urine o Incontinence o Nocturia
Musculoskeletal
o Back Pain o Neck Pain o Joint Pain o Muscle Pain o Arm Weakness
o Left o Right o Both
o Leg Weakness o Left o Right o Both
Skin o Rash Ditching o Scaling
o Dryness o Color Change
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
Neurological o Numbness o Tremors o Seizures
o Tingling o Fainting
PsychiatrIc o Depression o Insomnia
o Anxiety
Endocrine o Heat Intolerance o Cold Intolerance
o Excessive Thirst o Excessive Urination
Hematology o Bleeding Gums o Easy Bruising
ImmunoAllergy o Seasonal Allergies o Hives
Other Review of Sy tems Not Listed Above
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
---
NEPHROlOGY ASSOC1ATE~ PC
PATUNf CONTACr INF()~MAT(()N SIII-T
PATIENT NAME ________
PATIENT SOCIAL SECURITY NUMBER ___~_
Any physician staff employee or representative of Nephrology Associates PC has my pennission to discuss my
account and medical conditions which may include symptoms treatments diagnosis test results medications or
any other type of protectcd health information with the following persons in order to facilitate and coordinate my
care treatment and payment
- ------shy -------------shy ---------shyName Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I undentand thllt authorizing the release of my infonnation to the above individual(s) is voluntary and does not
affect my access to treatment 1can refuse to sign this fonn I can revoke it by writing to Nephrology Associates
p C or by comr1cting a new fonn at any time This authorization win remajn in effect until I change or revoke
it I undentand thut ifinformation is shared with the above individuals it may be subject to redisclosure by the
individual(~)
_______________DATE ________PATIENT SIGNATURE
COpy OF PRIVACY PRACTICE GIVEN TO PATIENT
6
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
--------
12918
NEPHROLOGY ASSOCIATES PCS NOTIC E OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HO W MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW IT CARE FULL Y
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe di fferent ways thaI we use and disclose medical information For each category of uses or disclosures we will elaborate on the meaning and provide more specific e~ampres if you request Not every use or d isclosure in a category will be listed However all of the ways we arc permilled to use and disclose infonnation will fall within one of the categories We must obtain your authorization before the use and disclosure of any psychotherapy notes uses and disclosures of PHI for marketing purposes and disclosure that constitute a sale of PHI Uses and di sclosures not described in this Notice of Privacy Practices will be made only wi th authorization from the individual For hymenWe may use and disclose medical informat ion about you so that the treatment and services you receive at the Practice may be bi lled to and payment may be collected from you an insurance company or a third party For eumple we may disclose your record to an insurance company so that we can get paid for treating you For TreatmentWe may use medical information about you to provide you with medical treatment or services We may disclose medical information about you to doctors nurses technicians medical students or other personnel who are involved in taking care of you al the Practice or the hospital For example we may disclose medical information about you to people outside the Practice who may be involved in your medical care such as fam ily members c lergy or other persons that are part of you r care For Hulth Care Operattons We may use and disclose medical information about you for health care operations These uses and disclosures arc necessary to run the Practice and ensure that all of our patients receive quality care We may also disclose in formation to doctors nu rses technicians medical students and other Practice personnel for review and learning purposes For example we may review your record to assist our qua lity improvement efforts WHO Will FOl l OW THIS NOTICE This notice describes our Practices policies and procedures and that of any health care professional authorized to enter information into your medical chart any member of a volunteer group which we allow to help you as well as all employees staff and other Practice personnel POLICY REGARDING THE PROTECTION OF PERSONAL INFORMATION We create a record of the care and services you receive at the Practice We need this record in order to provide you with quality care and to comply with certain legal requirements This notice applies to all of the records of your care generated by the Practice whether made by Practice personnel or by your personal doctor The law requires us to make sure that medical information that idenlifies you is kept private give you this notice of our legal duties and privacy practices with respect to medical information abou t you and to fo llow the terms of the notice that is currently in effect Other ways we may use or disclose your protected healthcare information include appointment reminders as required by law for health-related benefits and services to indi viduals involved in your care or payment for your care research to avert a serious thnalto health or safety and for treatment alternatives Other uses and disclosures of your personal information could include disclosure to or for coroners medical examiners and funeral d irectors health oversight activit ies law enforcement lawsuits and disputes military and veterans national security and intelligence activities organ and tissue donation public health risks and workerS compensation
NOTICE OF INDIVIDUAL RIGHTS
You have the following rights regarding medical information we maintain about you Rliht to a Paptr Copy of this Notice You have the right to a paper copy of this notice You may ask us to give you a copy of this notice 8t any time Right to Imprct and CopyYou have the right to inspect and copy medical information that may be used to make decisions about your care We may deny Ja rrequestto inspect and copy in certain very li mited circumstances Right to Amendlf you feel that medIcal information we have about you is incorrect or incomplete you may ask us to amend the information You have the right to request an amendment for as long as the information is kept by or for the Practice To request an amendment your request must be made in writing and submitted to the Privacy Officer and you must provide a reason that supports your request We may deny your request for an amendment Rlgbl to RNUt RrstrictloQsYou have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment payment or health care operations You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care like a family member or friend WeflNnotlllpliMJfDllffItfDp f1fU151 If we do agree we wi ll comply with your request unless the information is needed to provide you emergency treatmenl To request restrictions you must make your request in writing to the Privacy Officer Right to Reguel Removal from fundralslng Communications You have the right to opt out of receiving fundraising communications from the Practice RighI to Restrict Pisclosures to Health Plan You have the right to restrict disclosures of PHI to a health plan if the disclosure is for payment of health care operations and pertains to a health care item or service for which the individual has paid out of pocket in full RIht 10 Reguest ConfidenUal CommunlsaUonsYou have the right to request that we communicate with you about medical mailers in a certain way or at a certain location You must make your request in writing and you must specify how or where you wish to be contacted Biehl 10 an Accountln of Disclosures You have the right to request an accounting of disclosures This is a list of the disclosures we made of medical information about you To request this list or accounting of disclosures you must submit your request in writing to the Privacy Officer CHANGES TO THIS ~ We reserve the right to change this notice We will post a copy of the current notice in the Practices waiting room COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services To file a complaint with the Practice contact the Privacy Officer at (205)226-5925 J5 West lakeshore Drive Suite 200 Homewood Al JS209AII complain Is must be submitted in writing You wI nol be penalized for Rllng a complaInt OTHER USES Of MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the IlIws that apply to use will be mllde only with your wrillen authorization If you provide us permission to use or disclose medical information about you you may revoke that permission in writing at any time If you have any questions about this notice or would like to receive a more detailed cJtplanation please contact our Privacy Officer
I acknowledge by signing below that I have received Ihe Notice of Privacy Practise and NottSC of Indlytdya Rights
Patient or Patient Personal Repr~tdve Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
ADVANCE DIRECTIVE FOR HEALTH CARE (Living Will and Health Care Proxy)
This fonn may be used in the State of Alabama to make your wishes known about what medical
treatment or other care you would or would Dot want if you become too sick to speak for yourself
You are not required to have an advance directive If you do have an advance directive be sure that
your doctor family and friends know you have one and know where it is located
Section 1 Living Will
I _________ being of sound mind and at least 19 years old would like to make the
following wishes known I direct that my family my doctors and health care workers and all others
follow the directions I am writing down I know that at any time I can change my mind about these
directions by tearing up this fonn and writing a new one I can also do away with these directions by
tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to
write them down
I understand that these directions will only be used if I am not able to speak for myself
If I become terminally ill or injured
Terminally ill or injured is when my doctor and another doctor decide that I have a condition that
cannot be cured and that I will likely die in the near future from this condition
Life sustaining treatment - Life sustaining treatment includes drugs machines or medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life sustaining treatment if I am tenninally ill or injured Yes No
Artificially providedood and hydration (Food and water through a tube or an IV) I understand
that if am tenninally ill or injured I may need to be given food and water through a tube or an IV to
keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am tenninally ill or injured
Yes No
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
If I Become Permanently Unconscious
Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable
degree of medical certainty I can no longer think feel anything knowingly move or be aware of being
alive They believe this condition will last indefinitely without hope for improvement and have
watched me long enough to make tha t decision I understand that at least one of these doctors must be
qualified to make such a diagnosis
Life sustaining treatment - Life sustaining treatment includes drugs machines or other medical
procedures that would keep me alive but would not cure me I know that even if I choose not to have
life sustaining treatment I will still get medicines and treatments that ease my pain and keep me
comfortable
Place your initials by either yes or no
I want to have life-sustaining treatment ifI am pennanently unconscious Yes No
Artificially providedfood and hydration (Food and water through a tube or an IV) I understand
that if I become pennanently unconscious I may need to be given food and water through a tube or an
IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me
Place your initials by either yes or no
I want to have food and water provided through a tube or an IV if I am pennanently unconscious
Yes No
Other Directions Please list any other things you want done or not done
In addition to the directions I have listed on this form I also want the following
Ifyou do not have other directions place your initials here
__ No I do not have any other directions
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
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-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
----- ---------
- - ---------- ---------
Section 2 If I need someone to speak for me
This fonn can be used in the State of Alabama to name a person you would like to make medical or
other decisions for you if you become too sick to speak for yoursel f This person i called a health care
proxy You do not have to name a health care proxy The directions in this fonn will be followed
even if you do not name a health care proxy
Place your initials by only one answer
__ I do not want to name a health care proxy (Ifyou check this answer go 0 Section 3)
__ I do want the per on Ii ted below to be my health care proxy I have talked with this person
about my wishes
First choice for proxy ____ ______ ________ _
Relationship to me
Address
City _______________ State ___ Zip ___ ___
Day-time phone number _________ ____________
Night-time phone number _ _ _________________
If this person is not able not willing or not available to be my health care proxy this is my next
choice
Second choice for proxy _____ _ ______________
Relationship to me
Address
______ _________ State _ __ Zip _____ _City
Day-time phone number _ _______________________
Night-time phone number ___ _________ ________
Instructions for Proxy
Place your initials by either yes or no
I want my health care proxy to make decisions about whether to give me food and water through a tube
or an IV Yes No
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
-------------------------------------------------
Place your initials by only one oftheallowing
I want my health care proxy to follow only the directions as listed on this fonn
I want my health care proxy to follow my directions as listed on this fonn and to make any
decisions about things I have not covered in the fonn
I want my health care proxy to make the final decision even though it could mean doing
something different from what I have listed on this fonn
Section 3 The things listed on this form are what I want
I understand the fo llowing
bull If my doctor or hospital does not want to follow the directions I have listed they must see that I get
to a doctor r hospital who will follow my directions
bull If1 am pregnant or if I become pregnant the choices I have made on this form will not be
followed until after the birth of the baby
bull [[the time comes for me to stop receiving life sustaining treatment or food and water through a
tube or an IV I direct that my doctor talk about the good and bad points of doing this aJong with
my wishes with my health care proxy if I have one and with the fo llowing people
Section 4 My signature
Your name
The month day and year of your birth __________________
Your signature
Date signed ______________________ __________________ _
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date
--------------------------------
---------------------------------------------
-------------------
-----------------------
Section s Witnesses (need two witnesses to sign)
I am witnessing this fonn because I believe this person to be of sound mind I did not sign the
persons signature and I am not the health care proxy I am not related to the person by blood
adoption or marriage and not entitled to any part of his or her estate I am at least 19 years of age and
am not directly responsible for paying for his or her medical care
Name of first witness
Signature ________________________________________
Date
Name of second witness
Signature ________________________________________
Date
Section 6 Signature of Proxy
I _____________________________________ am willing to serve as the health care proxy
Signature _______________________________ Date
Signature of Second Choice for Proxy
I ________________ am willing to serve as the health care proxy if the first choice
cannot serve
Signature ____________________________ Date