Welcome to the practice! Thank you for choosing Novi Internal Medicine & Pediatrics as your Familys Physicians.

We pride ourselves on providing thoughtful medical care for your whole family.
As your physicians we will be responsible for providing you with the following services:

Communication of lab results and other testing in a timely manner Recommending & providing Immunizations to prevent diseases Inpatient (hospital) services at Royal Oak Beaumont Hospital & Providence Park Novi Providing you with educational resources that help you manage your chronic diseases & promote good health Work together with other members of your medical team to share in decisions about your care Save space during our day to accommodate sick visits Have Saturday appointments available for patients that cannot be seen during the week Participate in PATIENT CENTERED MEDICAL HOME to help you accomplish your personal health care goals Have a physician on call & available by phone 24/7 for emergencies

As a patient of our practice:

We recommend you are seen once a year for an ANNUAL PHYSICAL, and adhere to a follow up schedule provided by your physician depending on your personal medical history Please provide our name to all specialists or other physicians to allow us to obtain your records and participate in all aspects of your care Carry a card with you at all times with a list of medications and your physicians name Please allow up a 5 day lead time for referrals and 3 days for refills Attempt to see the same physician for routine health maintenance visits Understand that quality medical care requires face to face time and to this end: o We cannot routinely provide narcotics by phone o We cannot routinely provide antibiotics over the phone o Understand that most medical issues are best addressed in an office visit rather than by phone We hope to partner with you to achieve your best health. Please let your provider know if you have any questions about this information.
Drs. Einhorn, Golden, Leff & Rosenberg

NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC ADULT MEDICAL HISTORY FORM
DOS________ Last Name __________________________ First Name _________________________ DOB__________

History of the Present Illness

What is the reason for your visit today?: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Are you having any problems with pain?: No Yes If yes, describe: _________________________________________________________________________________________________________

Past Medical History

Please list current and past medical problems that you have been treated for: Alcoholism Allergy or Asthma Arthritis Bleeding Disorder Cancer Diabetes Glaucoma Heart Trouble High Blood Pressure High Cholesterol HIV or AIDS Kidney Stones Obesity Reaction to Anesthetic Seizures Stroke Thyroid Disorders

Illness or Medical Problem

Physician Who Treated You

Past Surgical History

Please list your previous surgeries, and the year that you had the surgery done in. Surgery (Any reaction to Anesthetic No Yes) Hospital Year

Current Medications
Please list all medications you are now taking, including those you buy without a doctors prescription (such as aspirin, cold tablets, nutritional supplements, and/or herbal medicines). Name Strength Frequency

J132293 (8/07)

DOS________ Last Name __________________________ First Name _________________________ DOB__________

Allergies and Sensitivities

List any allergies to medications or foods that you may have and indicate how each affects you. Allergic To Reaction Allergic To Reaction

Immunizations
Last Tetanus Booster Last Influenza (flu vaccine) Last Pneumovax (pneumonia) Last Hepatitis B Vaccine Last Skin Test for TB Last Measles Mumps Rubella (booster dose) Date Recommended every 10 years Recommended for age over 65 or with chronic health problems, otherwise optional Recommended for age over 65 or with chronic health problems Required for school-aged children; optional for adults Was it positive or negative? to persons at high risk for having tuberculosis Recommended if exposed

Recommended for women born after 1956 who plan on becoming pregnant

Please indicate with a check any of the following medical problems within your family history: Y=Yourself M=Mother F=Father S/B=Sister or Brother GP=Grandparent Y High Blood Pressure Allergy or Asthma Heart Attack Diabetes High Cholesterol Cancer Arthritis Kidney Stones Bleeding Disorder M F S/B GP A/U Stroke Obesity Alcoholism HIV or AIDS Glaucoma Seizures Thyroid Disorders Reaction to Anesthetic Y

Family History

A/U=Aunt or Uncle M F S/B GP A/U

Social History
Marital Status: Single Occupation: Married Widowed Divorced Number of children: _______________________________ No No Are you currently employed: Yes

Any occupational hazards (like noise or chemical exposures)? Yes

Describe: _________________________________________________________________________________________________ Education (last grade completed in school): ______________________________________________________________________ Do you have a religious affiliation? Yes No (Optional) If yes, what is your affiliation? Yes Yes No _____________ No Have you ever been emotionally or physically abused by your partner or someone important to you? Have you ever been exploited, physically or financially, by someone important to you? No Yes If YES, by whom Yes Yes No No Recent Death Sexual Orientation

Within the last year, have you been bit, slapped, kicked, pushed, shoved or otherwise physically hurt by your partner or ex-partner? Number of times ____________ Does your partner ever force you into sex? Are you afraid of your partner or ex-partner? Care of Aged/Ill Parent/Spouse

Check any that you would like to discuss: Alcohol/Drug use in home Care of Dependent/Grandchild

Other Stress: ____________________________________________________________________________________________

DOS________ Last Name __________________________ First Name _________________________ DOB__________

Nutritional History
Has there been any change in your appetite in the past 6 months? Yes No Yes No Have you gained or lost weight (more than 10 lbs) in 1 month without wanting to? If yes, how much gain or loss? ________________________________ Are you happy with your weight? Yes No Yes No If not, are you on a diet and exercise program? Yes No For women: Are you taking any extra calcium?

Instructions: Check the box for each symptom that you have now or have had in the past three months. Fill in the blank spaces. General: fatigue weakness chills night sweats change in weight, appetite or sleeping habits Eyes: glasses or contacts blank spots in your field of vision excessive tearing or discharge eye pain double vision last eye exam, date: ________________ Ears, Nose, Sinuses, Mouth and Throat: loss or trouble hearing ringing drainage frequent earaches nosebleed post nasal drip blockage of nose sinus pain sore throat hoarseness dentures bleeding gums toothache last dental exam, date: Lungs: Heart: cough wheezing shortness of breath spitting up blood positive TB test last chest X-ray, date: ______________ chest pain palpitations (heart pounding) trouble breathing at night fatigue easily with exercise ankle swelling Musculoskeletal: pain stiffness weakness twitching deformity chronic back pain joint swelling decreased range of motion Vaginal and Urinary (female): vaginal itching or burning vaginal discharge sexually transmitted diseases (examples: herpes, syphilis, chlamydia, gonorrhea, AIDS, etc.) sexual difficulties last menstrual period, date: _____________ problems with menstrual periods last pap smear, date: ______________ methods of contraception: _____________________ pregnancy, number: ___________ problems during pregnancy miscarriages or abortions, number: ____________ pain or frequent urination previous urinary infections blood in urine kidney stones trouble starting stream incontinence (leaking) Genitals and Urinary (male): hernia discharge from penis pain or lump in testicles methods of contraception: ____________________ sexual difficulties sexually transmitted diseases (examples: herpes, syphilis, chlamydia, gonorrhea, AIDS, etc.) pain or frequent urination previous urinary infections blood in urine kidney stones trouble starting stream incontinence (leaking) Hematologic and Lymphatic: easy bruising or bleeding problems swollen lymph nodes Endocrine: excessively hot excessively cold always thirsty always hungry

REVIEW OF SYSTEMS

Skin: itching rash change in color changes in warts, moles, or birthmarks Breast: lumps in breast discharge from nipple last mammogram, date: _______________ Gastrointestinal: vomiting difficulty swallowing stomach or abdominal pain indigestion or heartburn ulcers changes in bowel habits blood in stools (or black stools) hemorrhoids sigmoid or colonoscopy, date: ____________

Nervous System: numbness headaches head injury seizures dizziness or passing out loss of coordination or balance Psychological: nervousness or anxiety depression unable to sleep nightmares memory loss

DOS________ Last Name __________________________ First Name _________________________ DOB__________

Habits and Safety

Are you very active, or get regular exercise? Yes No Yes No Yes No Yes Yes No No Do you always wear your seatbelt when in a motor vehicle?

Do you have home smoke detectors AND check the batteries regularly?

If you are elderly or handicapped, do you feel your home is designed to prevent injuries? Do you have problems with activites of daily living such as bathing, toileting or fixing meals? Do you currently smoke? Yes No

If yes, explain: ________________________________________________________________________________________ If so, how many packs a day ______ and for how many years? ________ If not, were you a former smoker? Do you drink alcoholic beverages? Yes No If you drink, have people ever criticized your drinking? Yes No Yes No Yes Yes No No Yes No Amount per week:__________________

If you drink, have you ever felt bad or guilty about your drinking? Do you have any guns/weapons in the home? Yes No

Have you ever used any recreational drugs (like marijuana, cocaine, heroin, intravenous drugs)?

If yes, can your children get to them?

Education Needs Assessment

Do you have any barriers to learning: None Language/needs interpreter How does the patient best learn? Pictures Vision Hearing Cannot Read Cannot Comprehend Other:_______________________________________________________ Reading Listening Demonstration Other:______________

Pain Screening
1. Do you have pain now? No Yes 2. Do you have any ongoing pain problems? No Yes How long? _______________

If you answered yes to question 1 or 2 above, continue with questions 3-13. 3. Location: ____________________________________ ____________________________________________ Usual 10. What symptoms are associated with your pain: Altered sleep Nausea Appetite Impaired concentration Impaired mobility Depressed Irritable Other: _____________ 11. What do you do to relieve your pain? 4. Intensity (0-10): Now 9. What causes or increases your pain?

5. On a 0-10 scale, what is your level of pain when it is at its best? ____________ 6. On a 0-10 scale, what is your level of pain when it is at its worst? ____________________ 7. On a 0-10 scale, at what level of pain are you able to function as you want? _______________ Key to scale 0 - 0 (check one):

0 1-2 3-4 5-6 7-8 9-10 8. Describe your pain (burning, aching, stabbing, dull, crushing):

12. What meds do you take for pain?

13. Are you satisfied with your pain control? Yes No

__________________________________________________________________________ ____________________________ Signature of Patient/Person Filling Out Form Date

PROVIDER USE ONLY

_________________________________________________________________________ Provider Signature ____________________________ Date

Appt. Date:_____________

NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC

PATIENT REGISTRATION

(Please print information and give your insurance card and drivers license to the receptionist so a copy can be made. Thank you.)

Print Last Name:_____________________________ First Name:______________________ Middle:_______________ Address:_________________________________________ Zip:__________ City:___________________ State:________ Home Phone:______________________ Work Phone:______________________ Cell Phone:______________________ Email:_________________________ Social Security #:_____________________ Date of Birth:_________ Sex: M F Employment Status: Full-Time Married Part-Time Divorced Retired Separated Self-Employed Widowed Unemployed Student

Marital Status: Single

Do you have any Medication Allergies? Please list___________________________________________________________ Emergency Contact: (other than parent/spouse)____________________________ Relationship To You:_______________ Home Phone Number:_________________________________ Pager/Cell Phone:_______________________________ How did you hear about our practice? Beaumont Advertising Insurance www.novidocs.com Welcome Wagon Other:________________

Heard about us through a Family Member, Friend or other Physician? We would like to thank them. Please print their name:_________________________________ Person who should receive bill (guarantor or responsible party) Name:___________________________________ Relationship To Patient:_____________________ Sex: M F Address:_________________________________________ Zip:_________ City:___________________ State:_________ Home Phone:_______________________ Work Phone:______________________ Email:_________________________ Cell Phone:__________________________ Social Security #:_________________________ Date of Birth:_____________ Employer:_________________________________________ Address:_________________________________________ Employment Status of guarantor or responsible party: Full-Time Part-Time Retired Self-Employed Unemployed PRIMARY INSURANCE Social Security #:______________________ Co-Pay:___________ Ins. Name:__________________________________________________________ Policy:_________________________ Ins. Address:________________________________________________________________________________________ Ins. Phone:_________________________ Group #:______________________ Group Name:_______________________ Subscriber Full Name:_________________________ Date of Birth:___________ Relationship to Patient:______________ SECONDARY INSURANCE Social Security #:______________________ Co-Pay:___________ Ins. Name:__________________________________________________________ Policy:_________________________ Ins. Address:________________________________________________________________________________________ Ins. Phone:_________________________ Group #:______________________ Group Name:_______________________ Subscriber Full Name:_________________________ Date of Birth:___________ Relationship to Patient:______________ TERTIARY INSURANCE Social Security #:______________________ Co-Pay:___________ Ins. Name:__________________________________________________________ Policy:_________________________ Ins. Address:________________________________________________________________________________________ Ins. Phone:_________________________ Group #:______________________ Group Name:_______________________ Subscriber Full Name:_________________________ Date of Birth:___________ Relationship to Patient:______________

Print Last Name:_____________________________ First Name:______________________ Date of Birth:____________

Consent for Clinic Services: I request and authorize health care services that my physician(s) or designee advise. These may include diagnostic, radiology and laboratory procedures, routine therapeutic procedures, routine drugs, and routine medical care. To that end, Instructors working at the Facility oversee students and trainee students and trainees may visit or care for me and may review my health care information as part of their education. I will tell my nurse or doctor if I do not want students or trainees involved in my care. I understand the Facility may withdraw from me specimens of blood, urine and other bodily fluids/tissues for diagnostic purposes, and may perform other tests not related to my diagnosis with these specimens, and the Facility may dispose of these specimens as it chooses, by law. Payment: We accept cash, debit cards, Visa, MasterCard, and personal checks, with photo ID. After services have been rendered will bill your insurance company, and any outstanding balances are due within 30 days. Insurance: Remember, your insurance is a contract between you and your insurance company. Novi Internal Medicine and Pediatrics is not responsible for your deductibles, co-payments, co-insurance payments, percentages, deductibles, non-covered services, or services rendered without proper referral authorization, or denied services. If we are providers for your insurance, we will bill your insurance and collect only the patient responsibility. Insurance Deadlines: Many insurance companies have timely filling deadlines. It is your responsibility to inform us of any insurance changes. If we are not provided with accurate information at the time of service, you may be responsible for payment in full for all services rendered. Please contact your insurance company to determine if our practice has a contract with your insurance company. Immunizations: Please inform us if you do not have any immunization coverage, partial, or limited coverage. You may be eligible for Vaccine for Children (VFC) program. Referrals: I understand it is my responsibility to notify us if you may need an authorization and/or a referral within 10 days of your appointment date. You could incur a fee for failure to notify us for a referral or a pre-certification for services. Some insurance companies need pre-certification/authorization prior to services rendered. Your primary care physician has the right to refuse to give you a referral, if they deem it is not medically necessary, per your insurance contract. Co-Payments: All co-payments are expected at time of service and may be asked for prior to seeing your physician. When you signed up with your insurance company, you signed an agreement between you and your insurance company stating co-payment is due at time of service. Returned Checks: All returned checks will be assessed a $25 returned check fee, in addition to the amount of the check. You will have 10 days to clear up the outstanding check. If you do not pay the check, plus the return fee in the specified time, the check will be sent to a collection agency. In addition, we will only accept cash or credit card for any future visits. Missed Appointments: We understand there will be times when a scheduled appointment cannot be kept. If you need to cancel or reschedule an appointment, we request that you notify our office 24 hours in advance. If your appointment is made for same day and you find yourself unable to keep it, please call to cancel within a minimum of two hours notice in order for another patient to be scheduled. If you do not cancel by the deadline, a $25 missed appointment fee will be added to your account. This fee is not payable by your insurance company and will be your responsibility to pay at or before your next appointment time. Collection Agency: Any outstanding balances are due within 30 days of the statement. The second and each subsequent statement may be assessed $5 rebilling fee. All balances reaching 90 days past due may be sent to a collection agency. Should your account be sent to a collection agency, you will be financially responsible for all collection fees and legal fees that our office incures through the process utilized to collect the delinquent balance. Personal Valuables: I understand that the Facility has a safe where patients may store their money and small valuables. I understand that the Facility is not respnsible for loss or damage to any property. No Guarantees or Assurances: The Facility has made no guarantees or assurances about the results of my office care or health care. I understand that a patient will receive the usual and ordinary care rendered in this community, and that no other contract, written or implied, is made. Responsibility & Release of Information: I understand that I am responsible for my bill, and that I assign and transfer to the Facility all health care benefits applicable to my care, and request payments on my behalf for all services provided by the facility. I agree to personally pay for any charges not covered by or collected from any applicable health care benefit charges not covered by or collected from any applicable health care benefit program, including any deductibles and coinsurances. I authorize Novi Internal Medicine and Pediatrics to act as my agent in helping me obtain payment from my insurance company or third party payors for review of quality, utilization, charges or workplace injuries, or employment physicals. Including information as defined by statue and Michigan Department of Public Health Rules and Federal Regulations. This authorization for release of information is effective so long as necessary. This authorization may be revoked at any earlier time unless the facility has already asked or released information in reliance to it.

Signature of Patient or Guardian:__________________________________________________ Date:___________________________ Witnessed by Employee:_________________________________________________________ Date:___________________________

NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC

Notice of Privacy Practices (HIPAA)

1. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 2. WE HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI) We are legally required to protect the privacy of your health information. We call this information protected health information or PHI for short, and it includes information that can be used to identify you that we have created or received about your past, present, or future health or condition, the provision of healthcare to you, or the payment for this health care. We must provide you with this notice about our privacy practices that explains how, when and why we use and disclose your PHI. With some exceptions, we may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure. We are legally required to follow the privacy practices that are described in this notice. However, we reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Before we make an important change to our policies, we will promptly change this notice and post a new notice near the main entrance. You can also request a copy of this notice from the contact person listed in Section 7 below at any time. 3. HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION. We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your prior specific authorization. Below, we describe the different categories of our uses and disclosures and give you some examples of each. 3.1. Uses and Disclosures Relating to Treatment, Payment or Health Care Operations. We may use and disclose your PHI for the following reasons: 3.1.1. For treatment. We may disclose your PHI to physicians, nurses, medical students and other health care personnel who provide you with health care services or are involved in your care. For example, if youre being treated for a knee injury, we may disclose your PHI to the physical therapy department in order to coordinate your care. 3.1.2. To obtain payment for treatment. We may use and disclose your PHI in order to bill and collect payment for the treatment and services provided to you. For example, we may provide portions of your PHI to our billing department and your health plan to get paid for the health care services we provided to you. We may also provide your PHI to our business associates, such as billing companies, claims processing companies and others that process our health care claims. 3.1.3. For health care operations. We may disclose your PHI in order to operate our hospitals, clinics, urgent care and other health care service locations. For example, we may use your PHI in order to evaluate the quality of health care services that you received or evaluate the performance of the health care professionals who provided health care services to you. We may also provide your PHI to our accountants, attorneys, consultants and others in order to make sure we are complying with the laws that affect us. 3.2. Certain Other Uses and Disclosures That Do Not Require Your Consent 3.2.1. When disclosure is required by federal, state or local law, judicial or administrative proceedings, or law enforcement. For example, we make disclosures when a law requires that we report information to government agencies and law enforcement personnel about victims of abuse, neglect or domestic violence; when dealing with gunshot and other wounds, or when ordered in a judicial or administrative proceeding. 3.2.2. For public health activities. For example, we report information about births, deaths and various diseases to government officials in charge of collecting that information, and we provide coroners, medical examiners and funeral directors necessary information relating to an individuals death. 3.2.3. For health oversight activities. For example, we will provide information to assist the government when it conducts an investigation or inspection of a health care provider or organization. 3.2.4. For purposes of organ donation. We may notify organ procurement organizations to assist them in organ, eye or tissue donation and transplants. 3.2.5. For research purposes. In certain circumstances, we may provide PHI in order to conduct research. 3.2.6. To avoid harm. In order to avoid a serious threat to the health or safety of a person or the public, we may provide PHI to law enforcement personnel or persons able to prevent or lessen such harm. 3.2.7. For specific government functions. We may disclose PHI of military personnel and veterans in certain situations. And we may disclose PHI for national security purposes, such as protecting the president of the United States or conducting intelligence operations. 3.2.8. For workers compensation purposes. We may provide PHI in order to comply with workers compensation laws. 3.2.9. Appointment reminders and health-related benefits or services. We may use PHI to provide appointment reminders through the mail or telephone or give you information about treatment alternatives, or other health care services or benefits we offer. 3.2.10. Fundraising activities. We may use PHI to raise funds for our organization. The money raised through these activities is used to expand and support the health care services and educational programs we provide to the community. If you do not wish to be contacted as part of our fundraising efforts, please contact the person listed at the end of this notice. 3.3. Uses and Disclosures to Which You Have an Opportunity to Object 3.3.1. Patient directories. We may include your name, location in this facility, general condition and religious affiliation (if any) in outpatient directory for use by clergy and visitors who ask for you by name, unless you object in whole or in part. 3.3.2. Disclosure to family, friends, or others. We may provide your PHI to a family member, friend or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. 3.3.2.1. Michigan law and/or Federal Regulations require explicit authorization for the disclosure of PHI of patients treated for mental health, substance abuse and HIV/AIDS conditions. 3.4. All Other Uses and Disclosures Require Your Prior Written Authorization In any other situation not described in this section, we will ask for your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke that authorization in writing to stop any future uses and disclosures (to the extent that we have not taken any action relying on the authorization).

4. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI You have the following rights with respect to your PHI 4.1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. We will consider your request but are not legally required to accept it. If we accept your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required or allowed to make. 4.2. The Right to Choose How We Send PHI to You. You have the right to ask that we send information to you at an alternate address (for example, to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). We must agree to your request so long as we can easily provide it in the format you requested. 4.3. The Right to See and Get Copies of Your PHI. In most cases you have the right to look at or get copies of your PHI that we have, but you must make the request in writing. If we dont have your PHI but we know who does, we will tell you how to get it. We will respond to your within 30 days after receiving your written request. In certain situations, we may deny your request. If we do, we will tell you, in writing, our reasons for the denial and explain your right to have the denial reviewed. If you request copies of your PHI, we will charge you a reasonable copying fee. 4.4. The Right to Get a List of the Disclosures We Have Made. You have the right to get a list of instances in which we have disclosed your PHI. The list will not include any of the 4 uses or disclosures listed in section 3.1, 3.2 and 3.3. The list also will not include any uses or disclosures made before April 14, 2003. We will respond within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you $25 for each additional request. 4.5. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reason for the request in writing. We will respond within 60 days of receiving your request. We may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by us, (iii) not allowed to be disclosed, or (iv) not part of our records. Our written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you dont file one, you have the right to request that your request and our denial be attached to all future disclosures of your PHI. If we approve your request, we will make the change to your PHI, tell you that we have done it, and tell others that need to know about the change to your PHI. 4.6. The Right to Get This Notice by E-Mail. You have the right to get a copy of this notice by e-mail. Even if you have agreed to receive notice via e-mail, you also have the right to request a paper copy of this notice. 5. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES If your think that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with: Novi Internal Medicine and Pediatrics, PLLC, HIPAA Privacy Officer - (See section 7 of this notice.). You also may send a written complaint to : Secretary of the Department of Health and Human Services 200 Independence Avenue SW Washington, DC 20201 We will take no retaliatory action against you if you file a complaint about our privacy practices. 6. WHO WILL FOLLOW THIS NOTICE OF PRIVACY PRACTICES This notice describes the practices of the employees, medical staff, externs and volunteers of Novi Internal Medicine and Pediatrics, PLLC. This office follows the terms of this notice. 7. CONTACT INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES. If you have questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact our office at 248-374-0502. All complaints must be submitted in writing to: Novi Internal Medicine and Pediatrics, PLLC Attn: Privacy Officer 39475 Lewis Drive Suite 130 Novi, MI 48377 8. EFFECTIVE DATE OF THIS NOTICE: July 1, 2012

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing below I acknowledge that I have received a copy of this office's Notice of Privacy Practices.

Patient name:______________________________________________________

Patient Signature____________________________________________________

Date:______________________________________________________________

Documentation of Failure to Obtain Signed Acknowledgement

On ______________, 20__ , _________________________________ presented this

Acknowledgment of Receipt of Notice of Privacy Practices Form to: _______________________________________, the Patient. The Patient refused to provide a signature when requested: ____________________________________ (Witness & Date)

NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC

39475 Lewis Drive, Suite 130 Novi, Michigan 48377 Office: (248) 374-0502 Fax: (248) 374-0567

When Your Doctor Needs To Contact You, But You are Not Available

As required by HIPAA (Health Information Portability and Accountability Act) you have a right to nominate one or more persons to act on your behalf of receiving information with respect to your health information that pertains to you. By completing this form you are informing us of your wish to designate the name or names of individuals and telephone numbers where we can leave detailed information about your health care concerns. These individuals can be your spouse, family member or friend. By completing this form you are informing us of your with to designate the named person as your personal representative. You may revoke this designation at any time by signing and dating the revocation of your copy of this form. Authorization Section I designate the following person(s) to receive information about my health care and act as my personal representative with the use and/or disclosure of health information pertaining to me. 1)________________________________________________________________________________________
Print Last Name First Name Telephone Number Other Telephone

2)________________________________________________________________________________________
Print Last Name First Name Telephone Number Other Telephone

The authority of this/these person(s) when acting as my personal representative is restricted to the following functions:__________________________________________________________________________________ I understand that I may revoke this designation at any time by signing the revocation section of my copy. __________________________________________________________________________________________
Signature Date

Revocation Section I hereby revoke this designation of a personal representative. __________________________________________________________________________________________

Signature Date

Authorization to Leave Messages on Voice Mail/Machines I acknowledge that it is my right to refuse detailed messages from my physician or physicians office staff regarding my medical care are left on my voice mail and/or answering machine. This authorization can only be revoked in writing. Yes, please leave me a message Alternate Phone Number Date Date

No, dont leave any specific messages

NOVI INTERNAL MEDICINE AND PEDIATRICS, PLLC

39475 Lewis Drive, Suite 130 Novi, Michigan 48377 Office: (248) 374-0502 Fax: (248) 374-0567

When Your Child Needs To See The Doctor, But You Cannot Be There

Anytime you cannot come to the doctors office with your child, be sure you send the child to the doctors office with an adult (19 years and older), and give that adult written permission to get treatment for your child. By law, a doctor cannot treat a child, except in life or death situations, unless the parent or guardian gives consent. Your childs care, or immunizations, could be needlessly delayed because you cannot get to the office. Therefore, if you cannot come to the office with your child, make sure that the adult that brings your child to the office can make medical decisions for your child. Your child might have a croupy cough and fever. The doctor might want to run a blood test and your child might need a shot. If you are not there, and the adult who brings your child does not have your permission to allow the doctor to run the test or get the shot, your child's treatment will be delayed. You can avoid this by making sure that the adult caregiver has the proper written consent to make medical decisions for your child. You may revoke this designation at any time by signing and dating the revocation of your copy of this form. Outpatient Treatment Permit/Authorization 1)________________________________________________________________________________________
Print Last Name First Name Middle Initial Date of Birth

The undersigned does hereby grant to the individuals listed below (name of two adult individuals who will be responsible for the care of your child or children in your absence) the limited Power of Attorney to act for me and to give the required consents and authorizations for delivery of medical care, diagnoses and treatment, if necessary from________________ (todays date) and to do all other necessary things as I might or could do if personally present, to include but not limited to: Health maintenance visits (routine and immunizations) Acute illness (outpatient care and treatment) Routine office procedures (x-rays, blood tests, etc.) A)________________________________________________________________________________________
Name of Responsible Adult Name of Responsible Adult Phone Number Phone Number

B)________________________________________________________________________________________

__________________________________________________________________________________________
Signature of Parent or Legal Guardian Relationship to Child/ren ____________________________________________________________________________________________________ Address, City, State, Zip Code Telephone Number ____________________________________________________________________________________________________ Witnessed by Employee of Novi Internal Medicine and Pediatrics, PLLC, Louis W. Schwartz, DO, PLLC Date

Revocation Section I hereby revoke this designation of a personal representative. __________________________________________________________________________________________

Signature Date

Authorization to Treat a Minor Child July 2007