PATIENT INFORMATIONNAME (FIRST, M.I., LAST) SSN BIRTH DATE SEX

MAILING ADDRESS APT# CITY STATE ZIP

HOME PHONE XXX-XXX-XXXX WORK PHONE XXX-XXX-XXXX CELL PHONE XXX-XXX-XXXX EMAIL ADDRESS (EXAMPLE@TEST.COM)

PREFERRED CONTACT METHOD (REQUIRED) MARITAL STATUS RACE ETHNICITY LANGUAGE

PRIMARY EMPLOYER EMERGENCY CONTACT EMERGENCY PHONE

ADDRESS SUITE # TO WHOM MAY WE RELEASE MEDICAL INFORMATION

CITY, STATE, ZIP PRIMARY CARE PHYSICIAN

OCCUPATION STATUS REFERRING PHYSICIAN

GUARANTOR/RESPONSIBLE PARTY (if different than patient)NAME (FIRST, M.I., LAST) SSN BIRTH DATE SEX

MAILING ADDRESS CITY STATE ZIP

HOME PHONE XXX-XXX-XXXX WORK PHONE XXX-XXX-XXXX CELL PHONE XXX-XXX-XXXX EMAIL ADDRESS (EXAMPLE@TEST.COM)

PREFERRED CONTACT METHOD (REQUIRED) RELATIONSHIP TO PATIENT

PRIMARY INSURANCENAME OF INSURANCE COMPANY POLICY #

NAME OF POLICY HOLDER BIRTH DATE GROUP #

RELATIONSHIP TO PATIENT EFFECTIVE DATE GROUP NAME

SECONDARY INSURANCENAME OF INSURANCE COMPANY POLICY #

NAME OF POLICY HOLDER BIRTH DATE GROUP #

RELATIONSHIP TO PATIENT EFFECTIVE DATE GROUP NAME

M F

FT PT NOT EMPLOYED

CELL HOME WORK EMAIL TEXT

TEXTCELL HOME WORK EMAIL

FINANCIAL POLICY: Payment in full or co‐payment is expected at the time of service. Services provided that are not a covered benefit of your health plan will be your responsibility. You may also be required to pay deductible, co‐insurance, supplies, at the time of service. For patients without insurance, payment is due at the time of service. This includes initial urological consultation, office visits, medications, supplies as well as diagnostic and therapeutic procedures. An approximate cost for anticipated services will be provided to you at the time of the scheduling of your appointment or procedure. Payment may be made by cash, check, or credit card. Exceptions to this policy will be made by the urgency and severity of your medical condition and no patient will be denied emergent medical care.

ADDITIONAL OFFICE CHARGES NOT COVERED BY INSURANCE INCLUDE: No‐Show Appointment Fee $25.00 — (Cancellations require 24 hour notice. Discharge from practice occurs after third no-show) Returned Check Fee $25.00 Form Fees (per form) $25.00 — (Forms include: Disability, Life Insurance, Health Insurance, Jury Duty, Work & School Excuses $10.00 Assisted Living Forms, Leave of Absence Forms)

Any questions concerning this policy are to be coordinated through the Administration Office: Urology Associates of the Central Coast, Administration Office, 225 Prado Rd. Ste. D, San Luis Obispo, CA 93401 (805) 786‐2500 ext. 116

CONSENT TO TREATMENT/RELEASE OF INFORMATION: I grant Urology Associates of the Central Coast the authority to administer medical treatment and perform medical procedures as deemed necessary; and the authority to access Private Health Information (PHI) via Health Information Exchanges (HIE) including, but not limited to pharmacy, hospital and other physicians’ records involved in my care. I authorize the release of medical information to my insurer, or the insurer’s agents to process my payments for service. To the best of my knowledge, all of the information above is true and correct.

ASSIGNMENT OF BENEFITS: I hereby assign all benefits payable by my insurance company to Urology Associates of the Central Coast.

Note: This form may be completed manually or on your computer. To complete this form on the computer: 1.Type your answer in each field. 2. Save your work often on your computer or device. 3. Print the completed form and bring it with you to your first appointment.

PATIENT /RESPONSIBLE PARTY SIGNATURE DATE RELATIONSHIP TO PATIENT

PATIENT REGISTRATION

M F

CURRENT MEDICATIONSNAME DOSE FREQUENCY

1.

2.

3.

4.

5.

6.PREFERRED PHARMACY LOCATION

ALLERGIES Do you have any allergies to medications? NAME DOSE FREQUENCY

1.

2.

3.

4.

REVIEW OF SYSTEMS Please check the following if you are experiencing now or have in the past few years. Anxiety Heart Rate (Irregular / Fast)

Appetite Change Hot Flashes

Arm / Leg Numbness Nausea / Vomiting

Back Problems Night Sweats

Blood In Stool Rash

Bone Or Joint Pain Sexual Function Problems

Bruising Or Bleeding (Excessive) Stress At Home / Work (Excessive)

Chest Pain Swallowing Difficulty

Constipation / Diarrhea Urinating Difficulty

Cough (Persistant) Urine Leakage

Depression Vision Trouble

Fainting / Blackout Spells Wheezing / Shortness Of Breath

Feet / Ankle Swelling Weight Change ‐ Unintended

Fever / Chills Other:

Hearing Trouble

PATIENT NAME

BIRTH DATE

HEALTH HISTORY

PAST SURGICAL HISTORY DATE TYPE OF SURGERY

PAST MEDICAL HISTORY (check all applicable) Artificial Joint Kidney Disease

Asthma Kidney Infection

Bladder Infection Kidney - Solitary

Blood Clotting Disorder Kidney Stones

Blood Disease Liver Disease

Blood In Urine Lung Disease

Cancer Type: _________________________________ Mental Disorder

Diabetes Type: _________________________________ Nervous Disorder

Glaucoma Type: _________________________________ Prosthesis Type: _________________________________

Gout Pace Maker

Heart Attack Rheumatic Fever

Heart Disease Seizure

Heart Rhythm - Abnormal Stroke

Heart Valve Ulcers

Hepatitis Venereal Disease

Hernia Other:

High Blood Pressure

HIV AIDS

FAMILY HISTORY Have any of your blood relatives had any of the following conditions: (check all applicable)Mother Father Sister Brother Mother Father Sister Brother

Bleeding Disorder High Blood Pressure

Cancer, Type:______________ Kidney Stones

Diabetes Other________________

HEALTH HISTORYPATIENT NAME

BIRTH DATE

FOR OFFICE USE ONLY

PHYSICIAN’S SIGNATURE DATE

SOCIAL HISTORYAlcohol Use CURRENT PAST NEVER

# DRINKS PER DAY WEEK MONTH

# OF YEARS LAST USED

Tobacco Use CURRENT PAST NEVERTYPE # OF PACKS PER DAY # OF YEARS LAST USED

Drug Use CURRENT PAST NEVERTYPE # OF YEARS LAST USED

PATIENT OCCUPATION STATUS FULL TIME PART TIME DISABLED RETIRED STUDENT NOT EMPLOYED

MARITAL STATUS SINGLE MARRIED LIFE PARTNER SEPARATED NEVER MARRIED DIVORCED WIDOWED

# OF CHILDREN

Exercise YES NOTYPE TIMES PER WEEK

UROLOGYASSOCIATESoftheCENTRALCOASTNOTICEOFPRIVACYPRACTICES

PrivacyOfficer:SamuelB.Kieley,805-786-2500ext105Effec@veDate:July21,2017

THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION.PLEASEREVIEWITCAREFULLY.We understand the importance of privacy and are commi4ed to maintaining the confiden7ality of your medicalinforma7on.Wemadearecordofthemedicalcareweprovideandmayreceivesuchrecordsfromothers.Weusetheserecordstoprovideorenableotherhealthcareproviderstoprovidequalitymedicalcare,toobtainpaymentforservicesprovidedtoyouasallowedbyyourhealthplanandtoenableustomeetourprofessionalandlegalobliga7onstooperatethismedicalprac7ceproperly.Weare requiredby lawtomaintain theprivacyofprotectedhealth informa7onand toprovideindividualswithno7ceofourlegaldu7esandprivacyprac7ceswithrespecttoprotectedhealthinforma7on.Thisno7ce describes howwemay use and disclose your medical informa7on. It also describes your rights and our legalobliga7onswith respect to yourmedical informa7on. If youhaveanyques7onsabout thisNo7ce, please contact ourPrivacyOfficerlistedabove.

A. HowThisMedicalPrac@ceMayUseorDiscloseYourHealthInforma@onThismedicalpracRcecollectshealth informaRonaboutyouandstores it inachartandonacomputer.This isyourmedical record. Themedical record is the property of thismedical pracRce, but the informaRon in themedicalrecordbelongstoyou.ThelawpermitsustouseordiscloseyourhealthinformaRonforthefollowingpurposes:

Treatment.WeusemedicalinformaRonaboutyoutoprovideyourmedicalcare.WedisclosemedicalinformaRontoouremployeesandotherswhoareinvolvedinprovidingthecareyouneed.Forexample,wemayshareyourmedical informaRonwithotherphysiciansorotherhealthcareproviderswhowillprovideserviceswhichwedonotprovide.OrwemaysharethisinformaRonwithapharmacistwho needs it to dispense a prescripRon to you, or a laboratory that performs a test. We may alsodisclosemedicalinformaRontomembersofyourfamilyorotherswhocanhelpyouwhenyouaresickorinjured.

Payment.Weuse anddisclosemedical informaRon about you to obtain payment for the servicesweprovide.Forexample,wegiveyourhealthplantheinformaRonitrequiresbeforeitwillpayus.WemayalsodiscloseinformaRontootherhealthcareproviderstoassisttheminobtainingpaymentforservicestheyhaveprovidedtoyou.

HealthCareOpRons.Wemayuseanddisclosemedical informaRonaboutyoutooperatethismedicalpracRce.Forexample,wemayuseanddisclose this informaRonto reviewand improve thequalityofcarewe provide, or the competence and qualificaRons of our professional staff. Or wemay use anddisclosethisinformaRontogetyourhealthplantoauthorizeservicesorreferrals.WemayalsouseanddisclosethisinformaRonasnecessaryformedicalreviews,legalservicesandaudits,includingfraudandabusedetecRonandcomplianceprogramsandbusinessplanningandmanagement.Wemayalsoshareyour medical informaRon with our “business associates,” such as our billing service, that performadministraRveservices forus.Wehaveawricencontractwitheachof thesebusinessassociates thatcontains terms requiring themtoprotect theconfidenRalityandsecurityofyourmedical informaRon.Although federal law does not protect health informaRonwhich is disclosed to someone other thananotherhealthcareprovider,healthplanorhealthcareclearinghouse,underCalifornialawallrecipientsof health care informaRon are prohibited from re-disclosing it except as specifically required orpermiced by law.Wemay also share your informaRonwith other health care providers, health careclearinghousesorhealthplansthathavearelaRonshipwithyou,whentheyrequestthisinformaRontohelpthemwiththeirqualityassessmentandimprovementacRviRes,theireffortstoimprovehealthorreduce health care costs, their review of competence, qualificaRons and performance of health careprofessionals, their training programs, their accreditaRon, cerRficaRon or licensing acRviRes, or theirhealthcarefraudandabusedetecRonandcomplianceefforts.Wemayalsosharemedical informaRonabout you with the other health care providers, health care clearinghouses and health plans thatparRcipatewithusin“organizedhealthcarearrangements”(OHCA’s)forOHCAs’healthcareoperaRons.OHCAs include hospitals, physician organizaRons, health plans, and other enRRes which collecRvelyprovidehealthcareservices.AlisRngoftheOHCAsweparRcipateinisavailablefromthePrivacyOfficial.

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AppointmentReminders.WemayuseanddisclosemedicalinformaRontocontactandremindyouaboutappointments. Ifyouarenothome,wemayleavethis informaRononyouransweringmachineor inamessage leh with the person answering the phone. We may use your preferred method of contactincluding, but not limited to, automaRc calls, emails, or texts for appointment reminders. You maychooseyourpreferredmeansofappointmentreminderatanyRme.

SignInSheet.WemayuseanddisclosemedicalinformaRonaboutyoubyhavingyousigninwhenyouarriveatouroffice.Wemayalsocalloutyournamewhenwearereadytoseeyou.

NoRficaRonandCommunicaRonwithFamily.WemaydiscloseyourhealthinformaRontonoRfyorassistinnoRfyingafamilymember,yourpersonalrepresentaRveoranotherpersonresponsibleforyourcareaboutyourlocaRon,yourgeneralcondiRonorintheeventofyourdeath.Intheeventofadisaster,wemaydiscloseinformaRontoarelieforganizaRonsothattheymaycoordinatethesenoRficaRonefforts.WemayalsodiscloseinformaRontosomeonewhoisinvolvedwithyourcareorhelpspayforyourcare.If you are able and available to agree or object, we will give you the opportunity to object prior tomaking these disclosures, although we may disclose this informaRon in a disaster even over yourobjecRonifwebelieveitisnecessarytorespondtotheemergencycircumstances.Ifyouareunableorunavailabletoagreeorobject,ourhealthprofessionalswillusetheirbestjudgementincommunicaRonwithyourfamilyandothers.

MarkeRng. We may contact you to give you informaRon about products or services related to yourtreatment, case management or care coordinaRon, or to direct or recommend other treatments orhealth-relatedbenefitsandservicesthatmaybeofinteresttoyou,ortoprovideyouwithsmallgihs.Wemay also encourage you to purchase a product or servicewhenwe see you. If you are currently anenrolleeofahealthplan,wemayreceivepaymentforcommunicaRonstoyouinconjuncRonwithourprovision, coordinaRon, or management of your health care and related services, including ourcoordinaRonormanagementofyourhealthcarewithathirdparty,ourconsultaRonwithotherhealthcare providers relaRng to your care, or if we refer you for health care, but only to the extent thesecommunicaRonsdescribe:1)aprovider’sparRcipaRoninthehealthplan’snetwork,2)theextentofyourcoveredbenefits,or3) concerning theavailabilityofmore cost-effecRvepharmaceuRcals.Wewill notaccept any payment for other markeRng communicaRons without your prior wricen authorizaRonunlessyouhaveachronicandseriouslydebilitaRngorlife-threateningcondiRonandwearemakingthecommunicaRoninconjuncRonwithourprovision,coordinaRon,ormanagementofyourhealthcareandrelatedservices, includingourcoordinaRonormanagementofyourhealthcarewithathirdparty,ourconsultaRonwithotherhealthcareprovidersrelaRngtoyourcare,orifwereferyouforhealthcare.IfwemakethesetypesofcommunicaRonstoyouwhileyouhaveachronicandseriouslydebilitaRngorlife-threateningcondiRon,wewilltellyouwhoispayingus,andwewillalsotellyouhowtostopthesecommunicaRons ifyouprefernottoreceivethem.WewillnototherwiseuseordiscloseyourmedicalinformaRonformarkeRngpurposeswithoutyourwricenauthorizaRon,andwewilldisclosewhetherwereceiveanypaymentsforanymarkeRngacRvityyouauthorize.

RequiredbyLaw.Asrequiredbylaw,wewilluseanddiscloseyourhealthinformaRon,butwewilllimitouruseordisclosuretotherelevantrequirementsofthelaw.Whenthelawrequiresustoreportabuse,neglectordomesRcviolence,orrespondtojudicialoradministraRveproceedings,ortolawenforcementofficials,wewillfurthercomplywiththerequirementsetforthbelowconcerningthoseacRviRes.

PublicHealth.Wemay,andaresomeRmesrequiredbylawtodiscloseyourhealthinformaRontopublichealth authoriRes for purposes related to: prevenRng or controlling disease, injury or disability;reporRngchild,elderordependentadultabuseorneglect;reporRngdomesRcviolence;reporRngtotheFood and Drug AdministraRon problems with products and reacRons to medicaRons; and reporRngdiseaseor infecRonexposure.WhenwereportsuspectedelderordependentadultabuseordomesRcviolence,wewill informyouor yourpersonal representaRvepromptlyunless inourbestprofessionaljudgement, we believe the noRficaRon would place you at risk of serious harm or would requireinformingapersonalrepresentaRvewebelieveisresponsiblefortheabuseorharm.

Health Oversight AcRviRes. We may, and are someRmes required by law to disclose your healthinformaRon to health oversight agencies during the course of audits, invesRgaRons, inspecRons,licensureandotherproceedings,subjecttolimitaRonsimposedbyfederalandCalifornialaw.

JudicialandAdministraRveProceedings.Wemay,andaresomeRmesrequiredby law,todiscloseyourhealth informaRon in the course of any administraRve or judicial proceeding to the extent expresslyauthorizedbyacourtoradministraRveorder.WemayalsodiscloseinformaRonaboutyouinresponseto

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asubpoena,discovery requestorother lawfulprocess if reasonableeffortshavebeenmade tonoRfyyouof therequestandyouhavenotobjected,or ifyourobjecRonshavebeenresolvedbyacourtoradministraRveorder.

LawEnforcement.Wemay,andaresomeRmesrequiredbylaw,todiscloseyourhealthinformaRontoalawenforcementofficialforpurposessuchasidenRfyingorlocaRngasuspect,fugiRve,materialwitnessor missing person, complying with a court order, warrant, grand jury subpoena and other lawenforcementpurposes.

Coroners.Wemay,andaresomeRmesrequiredbylaw,todiscloseyourhealthinformaRontocoronersinconnecRonwiththeirinvesRgaRonsofdeaths.

Organ or Tissue DonaRon. We may disclose your health informaRon to organizaRons involved inprocuring,bankingortransplanRngorgansandRssues.

Public Safety. We may, and are someRmes required by law, to disclose your health informaRon toappropriatepersonsinordertopreventorlessenaseriousandimminentthreattothehealthorsafetyofaparRcularpersonorthegeneralpublic.

Specialized Government FuncRons. Wemay disclose your health informaRon for military or naRonalsecuritypurposesortocorrecRonalinsRtuRonsorlawenforcementofficersthathaveyouintheirlawfulcustody.

Workers’CompensaRon.WemaydiscloseyourhealthinformaRonasnecessarytocomplywithworkers’compensaRonlaws.Forexample,totheextentyourcareiscoveredbyworkers’compensaRon,wewillmakeperiodic reports to your employer about your condiRon.Weare also requiredby law to reportcasesofoccupaRonalinjuryoroccupaRonalillnesstotheemployerorworkers’compensaRoninsurer.

Change of Ownership. In the event that this medical pracRce is sold or merged with anotherorganizaRon,yourhealthinformaRon/recordwillbecomethepropertyofthenewowner,althoughyouwill maintain the right to request that copies of your health informaRon be transferred to anotherphysicianormedicalgroup.

BreachNoRficaRon. In thecaseofabreachorunsecuredprotectedhealth informaRon,wewillnoRfyyouasrequiredbylaw.InsomecircumstancesourbusinessassociatemayprovidethenoRficaRon.WemayalsoprovidenoRficaRonbyothermethodsasappropriate.

Research.WemaydiscloseyourhealthinformaRontoresearchersconducRngresearchwithrespecttowhichyourwricenauthorizaRonisnotrequiredasapprovedbyanInsRtuRonalReviewBoardorprivacyboard,incompliancewithgoverninglaw.

B. WhenThisMedicalPrac@ceMayNotUseorDiscloseYourHealthInforma@onExcept as described in this NoRce of Privacy PracRces, this medical pracRce will not use or disclose healthinformaRonwhichidenRfiesyouwithoutyourwricenauthorizaRon.IfyoudoauthorizethismedicalpracRcetouseordiscloseyourhealthinformaRonforanotherpurpose,youmayrevokeyourauthorizaRoninwriRngatanyRme.

C. YourHealthInforma@onRightsRight to Request Special Privacy ProtecRons. You have the right to request restricRons on certain uses anddisclosuresofyourhealthinformaRonbyawricenrequestspecifyingwhat informaRonyouwanttolimit,andwhat limitaRonsonouruseordisclosureof that informaRonyouhave imposed. If you tell usnot todiscloseinformaRontoyourcommercialhealthplanconcerninghealthcareitemsorservicesforwhichyoupaidinfullout-of-pocket,wewill abide by your request, unlesswemust disclose the informaRon for treatment or legalreasons.Wereservetherighttoacceptorrejectanyotherrequest,andwillnoRfyyouofourdecision.

Right to Request ConfidenRal CommunicaRons. You have the right to request that you receive your healthinformaRoninaspecificwayorataspecificlocaRon.Forexample,youmayaskthatwesendinformaRontoaparRcular e-mail account or to yourwork address.Wewill complywith all reasonable requests submiced inwriRngwhichspecifyhoworwhereyouwishtoreceivethesecommunicaRons.

Right to Inspect and Copy. You have the right to inspect and copy your health informaRon, with limitedexcepRons.Toaccessyourmedical informaRon,youmustsubmitawricenrequestdetailingwhat informaRon

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youwantaccesstoandwhetheryouwanttoinspectitorgetacopyofit.Wewillchargeareasonablefee,asallowedbyCaliforniaandfederallaw.Wemaydenyyourrequestunderlimitedcircumstances.Ifwedenyyourrequesttoaccessyourchild’srecordsortherecordsofanincapacitatedadultyouarerepresenRngbecausewebelieveallowingaccesswouldbereasonablylikelytocausesubstanRalharmtothepaRent,youwillhavearighttoappealourdecision. Ifwedenyyourrequesttoaccessyourpsychotherapynotes,youwillhavetherighttohavethemtransferredtoanothermentalhealthprofessional.Ifyourwricenrequestclearly,conspicuouslyandspecificallyasksustosendyouorsomeotherpersonorenRtyanelectroniccopyofyourmedicalrecord,andwedo not deny the request as discussed above, we will send a copy of the electronic health record as yourequested,andwillchargeyounomorethanwhatitcostsustorespondtoyourrequest.

Right toAmendorSupplement.Youhavea right to request thatweamendyourhealth informaRon thatyoubelieve is incorrector incomplete.YoumustmakearequesttoamendinwriRng,andincludethereasonsyoubelievetheinformaRonisinaccurateorincomplete.WearenotrequiredtochangeyourhealthinformaRon,andwillprovideyouwithinformaRonaboutthismedicalpracRce’sdenialandhowyoucandisagreewiththedenial.WemaydenyyourrequestifwedonothavetheinformaRon,ifwedidnotcreatetheinformaRon(unlessthepersonorenRtythatcreatedtheinformaRonisnolongeravailabletomaketheamendment),ifyouwouldnotbepermicedtoinspectorcopytheinformaRonatissue,oriftheinformaRonisaccurateandcompleteasis.Youalso have the right to request that we add to your record a statement of up to 250 words concerning anystatementoritemyoubelievetobeincompleteorincorrect.

Right toanAccounRngofDisclosures. Youhavea right to receiveanaccounRngofdisclosuresof yourhealthinformaRonmadebythismedicalpracRce,except that thismedicalpracRcedoesnothavetoaccount for thedisclosures provided to you or pursuant to your wricen authorizaRon, or as described in paragraphs 1(treatment), 2 (payment), 3 (health care operaRons), 6 (noRficaRon and communicaRonwith family), and 16(specializedgovernmentfuncRons)ofSecRonAofthisNoRceofPrivacyPracRcesordisclosuresforpurposesofresearchorpublichealthwhichexcludedirectpaRent idenRfiers,orwhichare incident toauseordisclosureotherwisepermicedorauthorizedby law,or thedisclosurestoahealthoversightagencyor lawenforcementofficial to the extent thismedical pracRcehas receivednoRce from that agency or official that providing thisaccounRngwouldbereasonablylikelytoimpedetheiracRviRes.

Youhavea right toapapercopyof thisNoRceofPrivacyPracRces,even if youhavepreviously requested itsreceiptbye-mail. Ifyouwould liketohaveamoredetailedexplanaRonof theserightsor ifyouwould liketoexercise one of more of these rights, contact our Privacy Officer listed at the top of this NoRce of PrivacyPracRces.

D. ChangestothisNo@ceofPrivacyPrac@cesWereservetherighttoamendthisNoRceofPrivacyPracRcesatanyRmeinthefuture.UnRlsuchamendmentismade,wearerequiredby lawtocomplywiththisNoRce.Aheranamendment ismade,therevisedNoRceofPrivacyProtecRonswill apply toall protectedhealth informaRon thatwemaintain, regardlessofwhen itwascreatedorreceived.WewillkeepacopyofthecurrentnoRcepostedinourrecepRonarea,andacopywillbeavailableateachappointment.WewillalsopostthecurrentnoRceonourwebsite.

E. ComplaintsComplaintsaboutthisNoRceofPrivacyPracRcesorhowthismedicalpracRcehandlesyourhealthinformaRonshouldbedirectedtoourPrivacyOfficerlistedatthetopofthisNoRceofPrivacyPracRces.

If you are not saRsfiedwith themanner in which this office handles a complaint, youmay submit a formalcomplaintto:

RegionIXOfficeforCivilRightsU.S.DepartmentofHealth&HumanServices907thStreet,Suite4-100SanFrancisco,CA94103(415)437-8310;(415)437-8311(TDD)(415)437-8329FAXOCRMail@hhs.gov

Thecomplaintformmaybefoundatwww.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf.Youwillnotbepenalizedforfilingacomplaint.

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I, , have received a copy of Urology Associates of the Central Coast Notice of Privacy Practices.

Signature of Patient Date

UROLOGY ASSOCIATES OF THE CENTRAL COAST

RECEIPT OF NOTICE OF PRIVACY PRACTICESWRITTEN ACKNOWLEDGMENT FORM