OSCAR J. DOMINGUEZ M.D. VANDEN BOSCH MEDICAL CENTER 8600 S.W. 92 STREET SUITE 202 MIAMI,FL 33156 (305)271-0445 [email protected]

PATIENT DEMOGRAPHIC FORM LAST NAME: __________________________FIRST NAME:_______________________MI:____ DOB:_________________

Sex:Male( ) or Female( )

SSN:____________________

MARITAL STATUS: MARRIED( ) OTHER( ) SINGLE( ) EMPLOYMENT STATUS: EMPLOYED( ) UNEMPLOYED( ) DISABLED( ) RETIRED( ) PREFERRED LANGUAGE:_____________________________ SMOKING: CURRENT EVERY DAY SMOKER( ) FORMER SMOKER( )

CURRENT SOME DAY SMOKER( ) NEVER SMOKE( )

RACE/ ETHNICITY: WHITE NON-HISPANIC( ) WHITE HISPANIC( ) HISPANIC OR LATINO( ) BLACK/AA( ) ASIAN( ) AMERICAN INDIAN( ) NON-HISPANIC( ) HAWAIIAN OR PACIFIC ISLAND( ) OTHER( ) RELIGION:_____________________________ ADDRESS: ______________________________APT NO:_______ CITY:____________________STATE:___________ ZIP:________ HOME PHONE:____________________ WORK PHONE:________________ CELL PHONE:______________________ FAX:_________________________ EMAIL ADDRESS:________________________________________________ EMERGENCY CONTACT:___________________________ RELATIONSHIP TO PATENT:________________________ EMERGENCY CONTACT PHONE NUMBER:________________________ HOW WERE YOU REFERRED TO OUR OFFICE:___________________________

Oscar J. Dominguez M.D. Vanden Bosch Medical Center 8600 S.W. 92 Street Ste #202 Miami, FL 33156 305-271-0445 [email protected] ADVANCED DIRECTIVE TYPE: Do you have a living will? YES ( ) NO ( ) IF YOU DO NOT HAVE A LIVING WILL, WOULD YOU BE INTERESTED IN RECEIVING INFORMATION ON ADVANCED CARE PLANNING? YES ( ) _____________ initials required NO ( ) NOT AT THIS TIME Do you have a durable power of attorney? YES ( ) ____________________ legal name NO ( ) NOT AT THIS TIME Do you have a DO NOT RESUSCITATE FORM OR BRACELET in case of an emergency or life support treatment? YES ( )__________________ copy of supporting document required NO ( )__________________ are in agreement with life support treatment and resuscitation in case of a medicaL emergency. I have read and understand this form. I have had the opportunity to ask questions and my questions have been answered to my satisfaction. I understand and agree with the information contained in this form and give my consent for e-mail communications to and from Oscar J Dominguez MD and Vanden Bosch Medical Center. ____________________________________________________________ (Print Name)

____________________________________________________________ (Signature and Date)

PATIENT CARE AGREEMENT I,___________________________IN EXCHANGE FOR RECEIVING TREATMENT FROM DR.OSCAR J. DOMINGUEZ M.D. (INCLUDING ALL MEMBERS OF HIS STAFF),HEREBY ACKNOWELEDGE AND ACCEPT THE FOLLOWING TERMS: PLEASE INITIAL BELOW IN EACH CORRESPONDING LINE. ______1.THAT NEITHER DR.OSCAR J. DOMINGUEZ NOR HIS OFFICE CARRIES MEDICAL MALPRACTICE LIABILITY INSURANCE. ______2.THAT I HAVE BEEN GIVEN AND READ THE PATIENT NOTIFICATION OF NO MALPRACTICE INSURANCE ARE REQUIRD BY STATE. ______3.THAT, WITH EXCEPTION OF ANY COLLECTION ACTION,I AGREE TO SETTLE ANY AND ALL CONTROVERSY OR CLAIM FOR MEDICAL MALPRATICE, WHETHER IN TORT OR CONTRACT, ARISING FROM THE CARE AND TREATMENT RECEIVED FROM DR. OSCAR J.DOMINGUEZ EXCLUSIVELY BY ARBITRATION,THE DECISION OF THE ARBITRATOR SHALL BE FINAL AND BINDING RESOLUTION MAY BE ENTERED AS A JUDGEMENT BY ANY COURT OF COMPETENT JURISDDICTION,AND THAT THE ARBITRATION WILL BE CONDUCTED THEN IN FORCE RULES OF THE AMERICAN ARBITRATION ASSOCIATION. ______4.THAT THE DAMAGES,INCLUDING ECONOMIC AND NON-ECONOMIC DAMAGES,RECOVERABLE IN ARBITRATION AND SHOULD NOT EXCEED UNDER ANY CIRUMSTANCES $100,000. ______5.THAT I AM NOT ENTITLED TO RECOVER PUNITIVE DAMAGES FOR ANY CONTROVERSY OR CLAIM,INCLUDING ANY MEDICAL MALPRACTICE, WHETHER IN TORT OR CONTRACT, ARISING FROM THE CARE AND TREATMENT I RECEIVE FROM DR.OSCAR J. DOMINGUEZ. ______6. THAT EACH PARTY SHALL PAY HIS/HER OWN ATTORNEY'S FEES AND COSTS ARISING FROM ANY LEGAL PROCEEDING INCLUDING ANY ARBITRATION,ARISING FROM ANY AND ALL CONTROVERSY OR CLAIM,INCLUDING ANY CLAIM,INCLUDING ANY MEDICAL MALPRACTICE,WHETHER IN TORT OR CONTRACT, ARISING FROM THE CARE AND TREATMENT RECEIVED FROM DR.OSCAR J. DOMINGUEZ. ______7.THAT DR.OSCAR J.DOMINGUEZ WILL SUB HIS FEE FOR SERVICES TO MY HEALTH CARE INSURANCE COMPANY. IN THE EVENT THAT THE SERVICES PROVIDED BY DR.OSCAR J. DOMINGUEZ ARE NOT COVERED BY ANY OF THESE THIRD PARTIES YOU WILL REMAIN PERSONALLY RESPONSIBLE FOR DR.OSCAR J. DOMINGUEZ'S FEE FOR SERVICES. ______8.THIS AGREEMENT IS ENTERED INTO SUBJECT TORT LAWS OF THE STATE OF FLORIDA, IF ANY PROVISION OF THIS AGREEMENT SHALL BE FOUND BY COURT OF COMPETENT JURISDICTION TO BE UNNENFORCEABLE THE VALIDITY AND ENFORCED REMISING PROVISIONS SHALL NOT BE AFFECTED. “UNDER FLORIDA LAW, PHYSICIANS ARE GENERALLY REQUIRED TO CARRY MEDICAL MALPRACTICE INSURANCE OR OR OTHERWISE DEMONSTRATE FINANCIAL RESPONSIBILITY TO COVER POTENTIAL CLIAMS FOR MEDICAL MALPRACTICE. DR.OSCAR J. DOMINGUEZ HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSUARANCE, THIS IS PERMITTED UNDER FLORIDA LAW SUBJECT TO CERTAIN CONDITIONS.FLORIDA LAW IMPOSES PENALTIES AGAINST NON-INSURED PHYSICIANS WHO FAIL T SATISFY ADVERSE JUDGMENT ARISING FROM CLAIMS OF MEDICAL MALPRACTICE.THIS NOTICE IS PROVIDED TO FLORIDA LAW.” I,AS A PATIENT OF THIS OFFICE AND DR.OSCAR J. DOMIGUEZ,FULLY UNDERSTAND AN ACKNOWLEDGE THE INFORMATION PROVIDED ABOVE.NONETHLESS,I HAVE DECIDED TO STILL BE A PATIENT IN THIS OFFICE AND OF THIS PHYSICIAN. SINCERELY, PATIENT NAME_____________________________________________________ PATIENT SIGNATURE________________________________________________ DATE:______________________________________________________________

Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW THE FOLLOWING NOTICE CAREFULLY. By law, we are required to provide you with our Notice of Privacy Practices (NPP). This Notice describes how your medical information may be used and disclosed by us. It also informs you how you can obtain access to this information. As a patient, you have the following rights: 1. 2. 3. 4. 5. 6.

The right to inspect and copy your information. The right to request corrections to your information. The right to request that your information be restricted. The right to request confidential communications. The right to a report of disclosures of your information; and The right to a paper copy of this Notice.

We want to assure you that your medical/protected health information is secure with us. This Notice contains information about how we will insure that your information remains private. If you have any questions about this Notice, the name and phone number of our contact person is listed on this page. Effective Date of this Notice

04/14/03

Contact Person

Vanden Bosch Medical

Phone Number

305-271-0445

Acknowledgment of Notice of Privacy Practices “I hereby acknowledge that I have received a copy of this practice's NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy rights that I may contact the person listed above. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should it be amended, modified, or changed in any way.” ______________________________________________ Patient or Representative Name (please print) _________________________________________ Patient or Representative Signature

____________ Date

Oscar J. Dominguez M.D. Vanden Bosch Medical Center 8600 S.W. 92 Street Ste #202 Miami, FL 33156 305-271-0445 [email protected] Patient Name:

_________________________________________________________________

E-mail Address: _________________________________________________________________ Date of Birth:

________________________

Phone Number: ________________________ Oscar J. Dominguez, MD, offers patients the opportunity to communicate by e-mail. This form provides information about the risks of e-mail, guidelines for e-mail communication and how we will use e-mail communication. It also will be used to document your consent for us to communicate with you by e-mail. RISKS Communication by e-mail has a number of risks which include, but are not limited to, the following: o E-mail can be circulated, forwarded and stored in paper and electronic files. o Backup copies of e-mail may exist even after the sender or the recipient has deleted his/her copy. o E-mail can be received by unintended recipients. o E-mail can be intercepted, altered, forwarded or used without authorization or detection. o E-mail senders can easily type in the wrong e-mail address. o E-mail can be used to introduce viruses into computer systems. HOW WE WILL USE E-MAIL 1) We will limit e-mail correspondence to established patients who are adults 18 years or older, or the legal representatives of established patients. 2) We will use e-mail to communicate with you only about non-sensitive and nonurgent issues such as: o Questions about prescriptions, use of glasses or contact lenses, etc. o Routine follow-up questions,

Appointment scheduling, and/or Billing questions. Laboratory questions. All e-mails to or from you will be made a part of your medical record. You will have the same right of access to such e-mails as you do to the remainder of your medical file. 4) Your e-mail messages may be forwarded to another office staff member as necessary for appropriate handling. 5) We will not disclose your e-mails to researchers or others unless allowed by state or federal law. Please refer to our Notice of Privacy Practices for information as to permitted uses of your health information and your rights regarding privacy matters. o o o 3)

IN A MEDICAL EMERGENCY, DO NOT USE E-MAIL…CALL 911. Also, do not use e-mail for urgent problems. If you have an urgent problem, call our office at 305-271-0445 or go to an urgent care facility. GUIDELINES FOR E-MAIL COMMUNICATION 1) Include the general topic of the message in the “subject” line of your e-mail. For example, “advice,” “prescription,” “appointment” or “billing question.” 2) The e-mail message should not be timesensitive. While we try to respond to email messages daily, it may take up to three (3) working days for us to respond to your message. Urgent messages or needs should be relayed to us using regular telephone communication.

3) Include your name and phone number in the body of the message. 4) Review your message to make sure it is clear and that all relevant information is included before sending. 5) Send us an e-mail confirming receipt of our message after you have received and read an e-mail message from us. 6) If your e-mail requires a response from us, and you have not heard back from us CONSENT

within three (3) working days, call our office to follow-up to determine if we received your e-mail. 7) Take precautions to protect the confidentiality of e-mail, such as safeguarding your computer password and using screen savers. 8) Inform us of changes in your email address.

I, ___________________________________,

I understand that either I or Oscar J Dominguez MD and Vanden Bosch Medical Center may stop using e-mail as a means of communication upon my written request.

am: ____ ____

(print name)

a) an established patient of Oscar J Dominguez MD and Vanden Bosch Medical Center b) the legal representative of an established patient, _______________________________ (print

patient’s

name)

I may want to communicate with Oscar J Dominguez MD/Vanden Bosch Medical Center and the office staff by e-mail. I understand the risks of communicating by e-mail, in particular the privacy risks explained in this form. I understand that Oscar J Dominguez MD and Vanden Bosch Medical Center cannot guarantee the security and confidentiality of e-mail communication. Oscar J Dominguez MD and Vanden Bosch Medical Center will not be responsible for messages that are not received or delivered due to technical failure, or for disclosure of confidential information unless caused by intentional misconduct. I understand that I may also communicate with Oscar J Dominguez MD and Vanden Bosch Medical Center by telephone or during a scheduled appointment, and that e-mail is not a substitute for care that may be provided during an office visit. Appointments should be made to discuss any new issues or any sensitive medical information.

I understand that I may revoke this consent at any time by so advising Oscar J Dominguez MD and Vanden Bosch Medical Center in writing. My revocation of consent will not affect my ability to obtain future health care nor will it cause the loss of any benefits to which I am otherwise entitled. I have read and understand this form. I have had the opportunity to ask questions and my questions have been answered to my satisfaction. I understand and agree with the information contained in this form and give my consent for e-mail communications to and from Oscar J Dominguez MD and Vanden Bosch Medical Center.

_____________________________________ (print name)

_____________________________________ (signature) _____________________________________ (date)

Oscar J. Dominguez M.D. Vanden Bosch Medical Center 8600 S.W. 92 Street Ste #202 Miami, FL 33156 Tel: 305-271-0445

Fax: 305-273-7960

[email protected]

Referral to Specialists: You are responsible for knowing what your insurance requires prior to seeing any specialist. Request your referral at least two (2) weeks in advance through our referral department. Once the referral is ready you will be called to pick it up. Once we refer you, please follow step by step instructions provided. Your insurance plan has in-network Specialists that are available to you in the Provider Handbook. What you must do to get a referral 1.) Call the specialist office and get an appointment. (You must give our office at least a two (2) weeks notice prior to your appointment. 2.) Make sure that the Specialist accepts your insurance. If the Specialist you choose is no longer an in-network provider for your insurance plan, you must call your insurance plan and choose a Specialist in your plan or you may be liable for uncovered visit(s) by your insurance plan. 3.) Call Dr. Dominguez office to request your referral, you must have: ◦ Name of the Specialists ◦ Specialty ◦ Date of appointment ◦ Name of your insurance plan ◦ Why are you being referred to Specialist

Name of Patient: ______________________________ Patient Signature: _____________________________

Date: _______/_______/_______