FINANCIAL POLICY We are committed to providing our patients with the best possible care. We believe that part of good healthcare practice is to establish and communicate a financial policy to our patient. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. For identification purposes. We ask for a copy of your insurance card and identification or license card. PAYMENT: It is expected at the time of our visit. We will accept cash, credit card (Visa or MasterCard). Payment will include any unmet deductible, co-insurance, co-payment amount, or non-covered charges from our insurance company. If you do not carry insurance, or if your coverage is currently under a pre-existing condition clause, payment in full is expected at the time of service. NO INSURANCE: All services are rendered on a cash basis must be paid in full at the time of service. We do offer discounted fees for patients without health insurance. INSURANCE: It is your responsibility to make sure our physician participates in your specific plan, if our physician is not a participating provider for your plan, you may still select our office for your medical care, “out of network” benefits will apply and you will be responsible for balance due. You are responsible for obtaining a properly dated referral/authorization by your insurer and responsible for payment if our claim rejects for the lack of one. Deductibles, coinsurance and co-payments are due at the time of service. MEDICARE: We must have a copy of your Medicare card and any secondary insurance you may have. We do accept assignment on Medicare claims, which means that you will be responsible only for your deductible and 20% of allowed charges. There are certain procedures and supplies that are NON-COVERED services for Medicare patients. If you need such services you will be informed that they are non-covered and if you still wish to receive such services in this office they will be on a cash basis at the time of service. RETURNED CHECKS: A $25 charge will incur. You will be asked to bring cash, or a money order to cover the amount of the check plus the $25 charge. FORM COMPLETION: $20 fee to complete medical forms and patient requested letters. RELEASE OF INFORMATION: I hereby authorize The Urology Center o Southern California Medical Group, Inc. to release to governmental agencies, insurance carriers, or others who are financially liable for such professional and medical care, all information needed to substantiate claim and payment. ACCOUNTING PRINCIPALS: Payment and credits are applied to the oldest charges first, except for insurance payments which are applied to the corresponding dated of service. DIVORCED PARENTS of PATIENTS: By signing below, the adult who signs a minor child into our practice on the day of service accepts responsibility for payment. This office does not promise to send bills or records to the other parent/guardian for issues of payment or communication. We will communicate about treatment and payment with the parent who signs in that day. Parents are responsible between themselves to communicate with each other about the treatment and payment issues. If balances are not collected within 90 days, your account may be turned over to collections agency. I understand that in the event my account is placed in collection status, any additional fees incurred due to this, will be added to my outstanding balance. This includes but is not limited to late fees, collections agency fees, court costs, interest and fines. I understand these additional fees will be my personal responsibility to pay in full. If at any time you should experience financial hardship, please make this office aware of the situation. We may be able to help you by setting up a payment arrangement. I hereby consent to and authorize the administration and prescription of all treatments that may be considered advisable, prudent and necessary, when explained to me. I hereby authorize examination for routine medical, urological, pelvic and rectal examinations as indicated, Blood drawings, Endoscopic, Cystoscopic and any urological examination and biopsies in the office, if necessary and indicated, when explained to me. I authorize treatment for my child brought in by someone else, in such case as I am unable to bring the child personally. I understand that I am financially responsible for all expenses regardless of insurance coverage. I have read and understand the financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time. Signature of Patient (or Guarantor, if applicable): ________________ _________________________ Date:_______________ Print the name of the patient:______________________________________________ Revised 4/1/2014 1820 Fullerton Ave, Suite 260, Corona, CA 92881 • (951) 735-2700 • Fax (951) 735-7564 3975 Jackson Street #308, Riverside, CA 92503  (951) 687-8730  Fax (951) 687-8733 36243 Inland Valley Drive #250  Wildomar, CA 92595  (951) 677-3000  Fax (951) 677-9971

Patient Communication Consent Form

Patient Name (Last, First, Middle Initial):______________________________________ Date of Birth:_________________ I authorize The Urology Center of Southern California and medical staff to discuss my healthcare information (which may include history, diagnosis, labs, test results, treatment and other health information) with the contacts listed below. Name

Relationship to Patient

Contact Information

By my signature below, I acknowledge that I have read and understand the information provided on this consent form. Patient Name:__________________________________________ Patient Signature:_______________________________________

Date:______________

1 The Urology Center of Southern California Patient History and Review of Systems ***Language preferido________________________ Nombre __________________________________________ Fecha _________________________ ¿Cuáles son sus quejas principales? 1.) _______________________________________________________ 2.) _______________________________________________________ 3.) _______________________________________________________ 4.) _______________________________________________________

Si usted ha tenido recientemente lo Siguiente: Circule "sí" o "no": Si dudoso, deje en blanco

Historia Médica Año Sarampión Paperas Varicela Tos ferina Polio Fiebre Escarlatina Difteria Meningitis Infecciosas mono Tuberculosis Exposición a tuberculosis

Si Si Si Si Si Si Si Si Si Si

No No No No No No No No No No

Si

No

Malaria Si No Urticaria Si No Cáncer Si No ¿Qué clase? ……………… Ulcera Si No Artritis Si No Problemas de espalda Si No Bronquitis Si No Pulmonía Si No Pleuresía Si No Asma Si No Enfisema Si No Fiebre reumática Si No Presión alta Si No Enfermedad del corazón Si No Anemia Si No Tendencia a hemorragias Si No Transfusión de sangre Si No Hepatitis Si No Colesterol Alto Si No Hemorroides Si No Infecciones de la vejiga Si No Enfermedad del riñón Si No Alergia al polen Si No Glaucoma Si No Hemorragias Si No Hernia Si No Enfermedades de la próstata Si No Diabetes Si No

Operaciones Año Anginas Si No Apéndice Si No Vesícula Si No Estómago Si No Seno Si No Matriz/ovarios Si No Próstata Si No Hernia Si No La tiroides Si No Varices Si No Hemorroides Si No Corazón Si No Otras _________________ Lesión en: La Cabeza Si No El pecho Si No El abdomen Si No Huesos Si No La Espalda Si No Otras _________________ Alergias a: Tétano antitoxina Si No Penicilina Si No Sulfa Si No Otras _________________ Comidas Si No ____________________ Cosméticos Si No ____________________

Medicinas tomadas regularmente Razón

Fecha de nacimiento_____________ Estado civil: S C V D Hijos: Niños _________ Niñas ________ Ocupación _______________________________________________ Educación____ años ¿Cuántas horas duerme?_________________ Recreación ______________________________________________ Ejercicio _________________________________________________ Promedio por día: De alcohol (el tipo) ___________ cuánto__________ lo dejo ______ De Tabaco (el tipo) ___________ cuánto _________ lo deje ______ Té, Café_____________________________________________

Raza
India Americana
Asiático
Africana americana
Nativa de Hawái o de las islas del Pacifico
Blanca
Desconocido- Rechazar

Etnicidad: _______________________________________________ Historia Familiar – ¿Tiene algún pariente de sangre que tenga cualquiera de lo siguientes? Circulé ‘sí’ o ‘no’ – si ése es el caso, ¿Cual es la relación? Anemia Si No __________________________ Tendencia a hemorragias Si No _________________________ Leucemia Si No __________________________ Infecciones repetidas Si No __________________________ Infecciones incapacitantes Si No __________________________ Enfermedad del corazón Si No __________________________ Enfermedad crónica del pulmón Si No __________________________ Tuberculosis Si No __________________________ Presión alta Si No __________________________ Piedras de riñón Si No __________________________ Asma Si No __________________________ Alergias severas Si No __________________________ Enfermedad mental Si No __________________________ Convulsiones Si No __________________________ Dolores de cabeza o de migraña Si No __________________________ Diabetes Si No __________________________ Gota Si No __________________________ Obesidad Si No __________________________ Problema de la tiroides Si No __________________________ Ulcera péptica Si No __________________________ Diarrea crónica Si No __________________________ Cáncer Si No __________________________ Cáncer de próstata Si No __________________________ Cáncer de la vejiga Si No __________________________ Cáncer del riñón Si No __________________________ Cáncer del seno Si No __________________________ __________________________________________________________ Edad actual o edad de muerte. Si vive, cual es la salud (buena, mala). Si falleció, cual fue la causa. Padre____________________________________________________ Madre____________________________________________________ Hermanos o Hermanas______________________________________ 1._______________________________________________________ 2._______________________________________________________ 3._______________________________________________________ 4._______________________________________________________ Hijos____________________________________________________ 1._______________________________________________________ 2._______________________________________________________ 3._______________________________________________________ 4._______________________________________________________

Farmacia Dosis

__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

Incluya la lista de medicinas adicionales

Historia Social

Indique la farmacia donde obtiene sus medicinas Nombre: __________________________________________________ Dirección: _________________________________________________ Ciudad, Estado, Código Postal: ________________________________ Teléfono: _________________________________________________

2

The Urology Center of Southern California Patient History and Review of Systems General Se cansa fácilmente, debilidad Cambios de peso Sudores nocturnos Fiebre persistente Sensibilidad al calor Sensibilidad al frio

Si Si Si Si Si Si

No No No No No No

Piel Erupciones (sarpullido) Cambio de color Cambio en el cabello Cambio en las uñas

Si Si Si Si

No No No No

Ojos Dificultad para ver Dolor de ojo Ojos inflamados Visión doble Usa lentes

Si Si Si Si Si

No No No No No

Si Si Si

No No No

Oídos Pérdida de audición Zumbido en el oído Secreción

Nariz Pérdida del olor Resfriados frecuentes Obstrucción Secreción excesiva Hemorragias

Si Si Si Si Si

No No No No No

Si Si Si

No No No

Boca Dolor en las encías Dolor de la lengua Problemas dentales

Garganta Desecho postnasal Dolor Ronquera

Si Si Si

No No No

Si Si

No No

Si Si Si Si Si

No No No No No

Si Si Si Si Si Si

No No No No No No

Si Si Si Si Si Si Si Si Si Si Si Si Si

No No No No No No No No No No No No No

Sistema Cardiorrespiratorio Tos persistente Flema Flema con sangre Dolor de pecho o molestia Dolor al respirar Dificultad para respirar al estar acostado Tobillos hinchados Dedos o labio azulados Presión alta de la sangre Palpitaciónes Problemas con las venas

Sistema Gastrointestinal Cambio de apetito Dificultad en tragar Acidez Dolores abdominales Eructos o el exceso de gas Aumento de tamaño del abdomen Náusea Vómito Vómito con sangre Sangrado Rectal Excremento oscuro Orina oscura Ictericia (Piel Amarilla)

Si Si Si Si

No No No No

Si

No

Si

No

Si Si Si Si Si Si Si Si

No No No No No No No No

Si

No

Sistema Genitourinario Aumento de la frecuencia de orinar (día) cada ____horas

Aumento de la frecuencia de orinar (noche) ____ veces Siente necesidad de orinar sin mucha orina Flujo lento Vacío incompleto Dolor o ardor Sangre en la orina Retención urinaria Urgencia Incontinencia de urgencia Pérdida de orina al toser o estornudar ¿Utiliza productos para la

Incontinencia urinaria? Si ____ tuallas al día Secreción uretral Si Secreción vaginal Si Dolor en la punta del pene Si Dolor testicular Si Masa en testiculos Si Impotencia Si Falta de deseo sexual Si Dolor durante relaciones sexuales Si

No No No No No No No No No

Endocrino Problema de tiroides Problemas suprarrenales Tratamiento de cortisona Diabetes

Si Si Si Si

No No No No

Si Si Si Si Si Si

No No No No No No

Si Si Si Si Si Si Si Si Si Si Si

No No No No No No No No No No No

Locomotor

Senos Masa Secreción

Estreñímiento Diarrea Hemorroides Necesidad de laxantes

Calambres musculares Debilidad muscular Dolor en las coyunturas Inflamación de coyunturas Tensión que impide movimiento Deformidad de coyunturas

Sistema Nervioso Dolor de cabeza Mareo Desmayo Convulsiones Nerviosismo Insomnio Depresión Cambio de sensación Pérdida de la memoria Mala coordinación Debilidad o parálisis

Revised 09/2013

Privacy Policy This privacy policy discloses the privacy practices for https://patients.ucosc.com/patientportal/. This privacy policy applies solely to information collected by this web site. It will notify you of the following:  What personally identifiable information is collected from you through the web site, how it is used and with whom it may be shared.  What choices are available to you regarding the use of your data.  The security procedures in place to protect the misuse of your information.  How you can correct any inaccuracies in the information. Information Collection, Use, and Sharing We are the sole owners of the information collected on this site. We only have access to/collect information that you voluntarily give us via email or other direct contact from you. We will not sell or rent this information to anyone. We will use your information to respond to you, regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request, e.g. make a payment for services. Unless you ask us not to, we may contact you via email in the future to tell you about specials, new products or services, or changes to this privacy policy. Your Access to and Control Over Information You may opt out of any future contacts from us at any time. You can do the following at any time by contacting us via the email address or phone number given on our website: • See what data we have about you, if any. • Change/correct any data we have about you. • Have us delete any data we have about you. • Express any concern you have about our use of your data. Security We take precautions to protect your information. When you submit sensitive information via the website, your information is protected both online and offline. Wherever we collect sensitive information (such as credit card data), that information is encrypted and transmitted to us in a secure way. You can verify this by looking for a closed lock icon at the bottom of your web browser, or looking for "https" at the beginning of the address of the web page. While we use encryption to protect sensitive information transmitted online, we also protect your information offline. Only employees who need the information to perform a specific job (for example, billing or customer service) are granted access to personally identifiable information. The computers/servers in which we store personally identifiable information are kept in a secure environment. Updates Our Privacy Policy may change from time to time and all updates will be posted on this page. If you feel that we are not abiding by this privacy policy, you should contact us immediately via telephone at 951-735-2700 or [email protected].

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

I, __________________________________, have received a copy of THE UROLOGY CENTER OF SOUTHERN CALIFORNIA MEDICAL GROUP’s Notice of Privacy Practices.

_______________________________ Signature of Patient

____________________________ Date