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First Urology, PSCNotice of Privacy PracticesPatient Portal - Upon your request or consent, we will make your medical chart available to you via ourpatient portal at mymedicallocker.com. This site is maintained and supported by our EMR vendor. This portalwill allow you to view your clinical summary from your office visits as well as additional information regardingyour care. If you have questions or issues with using your portal account, please contact First Urology IT at812.282.3899, ext. 5555 or portal@1sturology.com.Your Written Authorization is required for Other Uses and DisclosuresUses and disclosures for marketing purposes and disclosures that constitute a sale of PHI can only be madewith your written authorization. Other uses and disclosures of PHI not covered by this Notice or the laws thatapply to us will be made only with your written authorization. If you do give us an authorization, you mayrevoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclosePHI under the authorization. Disclosures that we made in reliance on your authorization before you revoked itwill not be affected by the revocation.Special Protections for HIV, Alcohol and Substance Abuse, Mental Health, and Genetic InformationSpecial privacy protections apply to HIV-related information, alcohol and substance abuse, mental health, andgenetic information. Some parts of this general Notice of Privacy Practices may not apply to these kinds of PHI.Please check with our Privacy Officer for information about the special protections that do apply. For example,if we give you a test to determine if you have been exposed to HIV, we will not disclose the fact that you havetaken the test to anyone without your written consent unless otherwise required by law.Your Rights Regarding Your PHIYou have the following rights, subject to certain limitations, regarding your PHI:Right to Inspect and Copy - You have the right to inspect and/or receive a copy of PHI that may beused to make decisions about your care or payment for your care. But you do not have a right toinspect or copy psychotherapy notes. We may charge you a fee for the costs of copying, mailing orother supplies associated with your request. We may not charge you a fee if you need the informationfor a claim for benefits under the Social Security Act or any other state or federal needs-based benefitprogram. We may deny your request in certain limited circumstances. If we do deny your request, youhave the right to have the denial reviewed by a licensed healthcare professional who was not directlyinvolved in the denial of your request, and we will comply with the outcome of the review.Right to an Electronic Copy of Electronic Medical Records - If your PHI is maintained in one or moredesignated record sets electronically (for example an electronic medical record or an electronic healthrecord), you have the right to request that an electronic copy of your record be given to you ortransmitted to another individual or entity. We may charge you a reasonable, cost-based fee for thelabor associated with copying or transmitting the electronic PHI. If you chose to have your PHItransmitted electronically, you will need to provide a written request to this office listing the contactinformation of the individual or entity who should receive your electronic PHI.Right to Receive Notice of a Breach - We are required to notify you by first class mail or by e-mail (ifyou have indicated a preference to receive information by e-mail), of any breach of your Unsecured PHI.Right to Request Amendments - If you feel that PHI we have is incorrect or incomplete, you may askus to amend the information. You have the right to request an amendment for as long as theinformation is kept by or for us. A request for amendment must be made in writing to the PrivacyOfficer at the address provided at the beginning of this Notice and it must tell us the reason for yourrequest. We may deny your request if it is not in writing or does not include a reason to support theThis was published and becomes effective on 7/1/2013.Page 4 of 6Version  3.0

First Urology, PSCNotice of Privacy Practicesrequest. In addition, we may deny your request if you ask us to amend information that (1) was notcreated by us, (2) is not part of the medical information kept by or for us, (3) is not information that youwould be permitted to inspect and copy, or (2) is accurate and complete. If we deny your request, youmay submit a written statement of disagreement of reasonable length. Your statement ofdisagreement will be included in your medical record, but we may also include a rebuttal statement.Right to an Accounting of Disclosures - You have the right to ask for an “accounting of disclosures,”which is a list of the disclosures we made of your PHI. We are not required to list certain disclosures,including (1) disclosures made for treatment, payment, and health care operations purposes, (2)disclosures made with your authorization, (3) disclosures made to create a limited data set, and (4)disclosures made directly to you. You must submit your request in writing to our Privacy Officer. Yourrequest must state a time period which may not be longer than 6 years before your request. Yourrequest should indicate in what form you would like the accounting (for example, on paper or by email). The first accounting of disclosures you request within any 12-month period will be free. Foradditional requests within the same period, we may charge you for the reasonable costs of providingthe accounting. We will tell you what the costs are, and you may choose to withdraw or modify yourrequest before the costs are incurred.Right to Request Restrictions - You have the right to request a restriction or limitation on the PHI weuse or disclose for treatment, payment, or health care operations. You also have the right to request alimit on the PHI we disclose about you to someone who is involved in your care or the payment for yourcare, like a family member or friend. We are not required to agree to your request. If we agree, we willcomply with your request unless we terminate our agreement or the information is needed to provideyou with emergency treatment.Right to Restrict Certain Disclosures to Your Health Plan - You have the right to restrict certaindisclosures of PHI to a health plan if the disclosure is for payment or health care operations andpertains to a health care item or service for which you have paid out of pocket in full. We will honorthis request unless we are otherwise required by law to disclose this information. This request must bemade at the time of service.Right to Request Confidential Communications - You have the right to request that we communicatewith you only in certain ways to preserve your privacy. For example, you may request that we contactyou by mail at a special address or call you only at your work number. You must make any such requestin writing and you must specify how or where we are to contact you. We will accommodate allreasonable requests. We will not ask you the reason for your request.Right to a Paper Copy of This Notice - You have the right to a paper copy of this Notice, even if youhave agreed to receive this Notice electronically. You may request a copy of this Notice at any time.You can get a copy of this Notice at our website: http://www.1sturology.com.How to Exercise Your RightsTo exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer at theaddress listed at the beginning of this Notice. We may ask you to fill out a form that we will supply. To get apaper copy of this Notice, contact our Privacy Officer by phone or mail.Version  3.0This was published and becomes effective on 7/1/2013.Page 5 of 6

First Urology, PSCNotice of Privacy PracticesChanges to This NoticeThe effective date of the Notice is stated at the beginning. We reserve the right to change this Notice. Wereserve the right to make the changed Notice effective for PHI we already have as well as for any PHI we createor receive in the future. A copy of our current Notice is posted in our office and on our website.ComplaintsIf you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary ofthe Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at theaddress listed at the beginning of this Notice. All complaints must be made in writing and should besubmitted within 180 days of when you knew or should have known of the suspected violation. There will beno retaliation against you for filing a complaint.Version  3.0This was published and becomes effective on 7/1/2013.Page 6 of 6

First Urology, PSCNotice of Financial ResponsibilityThank you for choosing First Urology, PSC for your health care needs. The patient financialpolicy has been developed to assist in answering questions regarding patient and insuranceresponsibility for services rendered. Your understanding of and compliance with our patientfinancial policy is important.Please read the policy below and if you have any questions call the Insurance department at(812) 206-8188.Proof of InsuranceAll patients must complete our patient information form before seeing the physician. It is your responsibilityto ensure that we have your correct information and an up-to-date copy of your insurance card.Updated Change of Information & CoverageWe will ask you to update this whenever you have a change in address, employment, insurance, etc.However, it is your responsibility to make us aware of these changes in a timely manner. If you fail to provideus with the correct updated information, you will be responsible for the entire cost of the services renderedand immediate payment will be expected.Co-payments, Deductibles & Co-insuranceAll co-payments, deductibles & co-insurance must be paid at the time of service. Payment is part of yourcontract agreement with your insurance plan. Our failure to collect payment may be a violation of billingcompliance.Non-covered ServicesPlease be aware that some or perhaps all of the services you receive may not be covered by your insuranceplan. You will be responsible for any non-covered services.ReferralsSome insurance plans require a referral from a primary care physician to obtain services of a specialist. Thesehealth plans will not pay for services rendered without a referral. It is your responsibility to obtain a referralprior to treatment.AuthorizationsObtaining a prior authorization for services is not a guarantee of payment of benefits. A prior authorizationmeans that the information given at that time meets the medical necessity for the services but is not aguarantee of payment. Your insurance plan will confirm to you that even though the services may beauthorized, the services may not be covered under your plan and a decision for payment will not berendered until the claim is submitted.Version  2.0Approved  on  6/11/2013Page  1  of  2

First Urology, PSCNotice of Financial ResponsibilityClaims SubmissionWe will submit your claims and assist you in any way we can to help get your claims paid. Your insuranceplan may request information directly from you. Your failure to timely comply with your insurance plan'srequest may result in your claim denying and if so, will result in our seeking full reimbursement from you forservices rendered. Your insurance benefit is a contract between you and your insurance plan.Fraud laws prohibit us from changing your procedure and/or diagnosis codes "just to get your claim paid."In addition to charges related to your office visit, there may be separate charges for professional servicesrendered by other, non-First Urology, PSC providers. For example, if your urologist orders additionaldiagnostic imaging or laboratory testing, there may be separate charges from the organizations renderingthose services.Surgical FeesWe will contact your insurance company to determine insurance benefits prior to any scheduled surgery. Ourbusiness office will contact you prior to your surgery if you have any out-of-pocket expenses (deductibles,coinsurance, etc.) that may be your responsibility. While we make every effort to get up to date out-ofpocket costs from your insurance company, the amount quoted is subject to change in accordance with yourinsurance benefits. Payment of these fees are expected prior to time of service, unless other arrangementshave been made with the business office.Non-paymentOnce insurance has processed your claim and there remains a patient balance due, you will receive astatement from our vendor, Millennia Patient Services (MPS). MPS will assist you with establishing a paymentplan, if you are unable to pay in full. Please be aware that if a balance remains unpaid, we reserve the rightto turn your account over to a collection agency. Questions for MPS can be directed to (866) 270-8965.Payment MethodsWe accept cash, personal check, money order, cashier’s check, MasterCard, Visa and Discover as payment forservices rendered.Returned ChecksA returned check fee of 30 will be added to your account for every check returned.No Show PolicyIf you are unable to keep your appointment, please let us know as soon as possible so we can offer thatappointment time to another patient. We reserve the right to charge a fee for appointments not cancelled atleast 24 hours in advance.Version  2.0Approved  on  6/11/2013Page  2  of  2

First Urology, PSCPatient Information Form(﴾Please Print)﴿Patient InformationFull Name Account #:LanguageEthnicityRace American Indian or Alaska Native Asian Not Hispanic or Latino Black or African American Hispanic or Latino Native Hawaiian or Other Pacific IslanderDate of Birth / / Age Sex: Male Female WhiteSocial Security #Home AddressStreetPreferred Method of ContactCity Home PhoneState Mobile Phone EmailZip LetterHome Phone (﴾ )﴿ Work Phone (﴾ )﴿ Mobile Phone (﴾ )﴿Home Email Fax # (﴾ )﴿ Please create an account for me at MyMedicalLocker.com (﴾See attached info)﴿EmployerSpouse’s Full Name Date of Birth / /Spouse’s Social Security # Spouse’s Work Phone (﴾ )﴿Spouse’s EmployerPrimary Care Physician Office #Responsible PartyIf you are providing the information above for a patient under the age of18 years old, please complete this section.Child’s Father’s Name SSN DOB / /Father’s Address (﴾if different from above)﴿StreetFather’s EmployerCityStateZipFather’s Work Phone (﴾ )﴿Child’s Mother’s Name SSN DOB / /Mother’s Address (﴾if different from above)﴿StreetMother’s EmployerCityStateZipMother’s Work Phone (﴾ )﴿Please Note: It is the policy of this office that the parent accompanying the child for treatment will beheld responsible for all bills. We cannot bill the other parent.Version  2.0This was published and becomes effective on 6/10/2013.Page 1 of 2

Patient NameAccount #:Emergency InformationName Home Phone (﴾ )﴿Work Phone (﴾ )﴿PrivacyReceipt of Notice of Privacy Practices Written Acknowledgement (﴾Please Initial)﴿I was provided a Notice of Privacy Practices by First Urology, PSC to read and keep as my own.I declined a copy that was offered to me, but I am aware of my rights.I authorize the release of any medical or incidental information necessary to provide continuity of my(﴾the patient’s)﴿ medical care and to process my (﴾the patient’s)﴿ medical insurance.I agree to receive additional information regarding opportunities in advancing my medical care.My Protected Health Information may be disclosed to: Self Only Spouse/Partner: Parent/Guardian: Other:I give permission for First Urology, PSC to leave a message regarding test results on my: Home Answering Machine/Voice Mail Mobile Voice Mail Work Voice MailFinancialFinancial Policy (﴾Please Initial)﴿I acknowledge that I was provided a Notice of Financial Policy by First Urology, PSC to read and keepas my own. I understand that I am financially responsible for any balance.For any services rendered, I authorize the assignment of benefits (﴾payments)﴿ from my insurance tocome directly to First Urology, PSC.Financial Interest Disclosure (﴾Please Initial)﴿One or more First Urology physician(﴾s)﴿ is/are investors in Physicians’ Medical Center, RadiotherapyClinics of Kentuckiana, Owensboro Lithotripsy and Louisville Lithotripsy. You may choose to be referred toanother entity. First Urology physicians are proud of the quality of care these entities provide for our patients.InsuranceDo you have medical insurance? Yes - Please provide copy of card at time of service. Co-payment is required at time of service. No - Payment is expected at time of service. We accept Cash, Check, Visa, or MasterCard.Signed   Date / /Version  2.0This was published and becomes effective on 6/10/2013.Page 2 of 2

First Urology, PSCPatient Medical History(﴾Please Print)﴿Patient Name DOB / / Date / / Account #Doctor for Today’s VisitHistory of Present IllnessReview of SystemsDescribe the urologic problems you are experiencing and why you are here.Have you experienced any of the below symptoms in the past 2 weeks or sinceyour last visit?Constitutional SymptomsFever Yes NoCardiovascularChest Pain Yes NoHematologicEasy Bruising Yes NoGenitourinaryLeak Urine or Wet Yourself (﴾Incontinence)﴿VitalsCons pa on Yes No Yes No Yes NoNeurologicalDecreased  Sensa on YesEar/ Nose/ Throat/ MouthHearing Loss YesMusculoskeletal YesNew  Bone  PainImmunologic YesLatex  AllergyWeightinslbsAllergiesozsBlood Pressure/ mmHGPulseBPM NoTemperature List all of the allergies that you have, including latex.MedicationsList all of the medications that you currently take. Not currently taking medications.Medication and Dose1.2.3.4.5.6.7.8.Social HistoryAlcohol Use Never drinks No No No known drug allergies. Allergic toTobacco Use Never smoked NoTo be filled in by office staff.HeightftRespiratoryShortness of BreathGastrointestinalPlease answer the below questions to the best of your ability. Every day/ Occasional smoker Former smokerPacks Per DayPacks Per DayYears SmokedYears SmokedDate Quit Every day/Occasional drinker Former drinkerTypeTypeDrinks per weekDrinks per weekDate QuitMD ReviewedDate / /Recreational Drug Use Yes Type NoSexually Active Yes NoPage  1  of  2

Patient NamePast Medical HistoryAnemiaAsthma, EmphysemaBladder/ Kidney Infect.Bleeding DisorderBlood Clots Yes Yes Yes Yes YesSurgical and HospitalHistoryAccount #Answer each item to

If you have questions or issues with using your portal account, please contact First Urology IT at 812.282.3899, ext. 5555 or portal@1sturology.com. Your Written Authorization is required for Other Uses and Disclosures Uses and disclosures for marketing purposes and disclosures that constitute a sale of PHI can only be made