PATIENT INFORMATION - Dr. Perry Mansfield

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PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CREGISTRATION FORM(Please Print)Today’s date:Primary Care Physician:PATIENT INFORMATIONPatient’s last name:First:Is this your legal name? YesMiddle:If not, what is your legal name? Mr. Mrs. Dr. Miss Ms.Marital status (Check one)Single / Mar / Div / Sep / WidBirth date:(Former name): No/Street address:/Social Security no.:City:Occupation:Employer:State:)Employer phone no.:Chose clinic because/Referred to clinic by (please check one box): Friend FZIP Code:( Family Mphone no.:(P.O. box:Sex:Age: Close to home/work Dr. websiteE-mail:) Insurance Plan Hospital Internet SearchCell Phone:INSURANCE INFORMATION(Please give your insurance card to the receptionist.)Person responsible for bill:Birth date:/Is this person a patient here?Occupation:Home phone no.:/ YesEmployer:Address (if different):( NoEmployer address:Employer phone no.:(Is this patient covered byinsurance?Please indicate primary InsuranceSubscriber’s name: YesSubscriber’s S.S. no.: SelfName of secondary insurance (if applicable):Patient’s relationship to subscriber: Self) NoBirth date:/Patient’s relationship to subscriber:) SpouseGroup no.:Co-payment:/ Child OtherSubscriber’s name: SpousePolicy no.:Group no.: ChildPolicy no.: OtherIN CASE OF EMERGENCYName of local friend or relative (not living at same address):Relationship to patient:Home phone no.:Work phone no.:(())The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understandthat I am financially responsible for any balance. I also authorize Perry Mansfield M.D. Inc or insurance company to release any informationrequired to process my claims.Patient/Guardian signatureDate

PATIENT HEALTH SURVEY (Page 1 of 2)Patient Name: (LAST, FIRST, MIDDLE)Date:Please indicate in your own words the reason for your visit today:Explain:Check YES if you are experiencing any of the symptoms or conditions below:GENERALFeversChillsSweatsLoss of AppetiteFatigueWeight ChangeEYESBlurringDiplopia (double Vision)IrritationDischargeVision LossIncreased Sensitivity to LightEARS/NOSE/THROATEaracheEar DischargeTinnitus (ringing in ears)Decrease in HearingSinus TroubleNasal CongestionNose BleedsSnoringFacial Pain / PressureSore ThroatHoarsenessDysphagia (trouble swallowing)Y? RESPIRATORYCoughDyspnea (difficulty breathing)Excessive SputumHemoptysis (coughing blood)WheezingCARDIOChest PainDifficulty Breathing During ExerciseHeart ConditionPalpitationsSyncope (loss of consciousness)Peripheral Edema iarrheaAcid RefluxAbdominal PainGENITOURINARYIncontinenceDysuria (pain during urination)Urinary frequency / UrgencyHEMATOLOGIC/LYMPHATICAbnormal BruisingBleedingEnlarged GlandsDRUG ALLERGIES (note reactions/side-effect) No Known Drug AllergiesMEDICATIONS (with dose and frequency)PHARMACY NAME, NUMBER, LOCATION:Y? ENDOCRINEThyroid ProblemsALLERGIC / IMMUNOLOGICHay FeverAllergiesHIV PositiveMUSCOLOSKELETALBack Pain or Neck PainJoint PainJoint SwellingTMJSKINRashItchingSuspicious Lesion/MoleNEUROLOGICWeaknessSyncope (fainting)TremorsVertigo (dizziness)PSYCHIATRICDepressionAnxietyMemory LossMental DisturbanceENVIROMENTAL ALLERGIES No Known AllergiesY?

PATIENT HEALTH SURVEY (Page 2 of 2)PAST MEDICAL HISTORY: Have you had or do you have any of the followingTransfusion Tuberculosis Asthma COPD/Emphysema Heart Disease Heart Attack Congestive Heart Failure Atrial Fibrillation Hypertension Hypercholesterolemia Injury to ear, nose, throat Specify site and treatment forcancer, tumor or growth:YESYESYESYESYESYESYESYESYESYESYES NONONONONONONONONONONOStrokeDiabetesMigraines / HeadachesKidney InfectionKidney StonesBladder InfectionVenereal DiseaseProlonged AntibioticsSinusitisThyroid DisorderArthritis YESYESYESYESYESYESYESYESYESYESYES NONONONONONONONONONONOFibromyalgiaAbnormal bleedingAnemiaHepatitisUlcer, gastritis, refluxWeight LossFits/ ConvulsionsSeizuresTumor*Cancer*HIVHISTORY OF ar:FAMILY HISTORY (note relationship)Heart AttackCancer (w/type)StrokeAsthmaImmunodeficiencyBleeding DisorderSOCIAL HISTORY: Y Y Y Y Y Y N N N N N NHypertensionAllergiesDiabetesHearing LossSinus DiseaseOtherHave you ever smoked or chewed tobacco?If you currently smoke How Long?If you quit . YYYYYY N N N N N N YES NOHow muchPacks per day.Year you quit:Do you drink alcoholic beverages? YES NOHow often?Do you or have you ever used drugs? YES NOPlease list:How Long?SOURCE OF INFORMATION IF OTHER THAN PATIENT:DATE:SIGNATURE OF PERSON OR PATIENT ACQUIRING INFORMATION:DATE: YESYESYESYESYESYESYESYESYESYESYES NONONONONONONONONONONO

San Deigo Regional Head and Neck Center Inc.PERRY T. MANSFIELD, M.D. Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CPERRY T. MANSFIELD M.D. INCPatient Name: (LAST, FIRST, MIDDLE)Date:Height WeightAge Male / FemaleSTOP-BANG Sleep Apnea QuestionnaireSTOPDo you SNORE loudly (louderthan talking or loudenough to be heard throughclosed doors)?Do you often feel TIRED,fatigued, or sleepy duringdaytime?Has anyone OBSERVED youstop breathing duringyour sleep?Do you have or are you beingtreated for high bloodPRESSURE?YesNoYesNoYesNoYesNoBMI more than 35kg/m2?YesNoAGE over 50 years old?YesNoNECK circumference 16inches (40cm)?YesNoGENDER: Male?YesNoTOTAL SCORE0BANGHigh risk of OSA:Yes 5 – 8Intermediate risk of OSA:Yes 3 – 4Low risk of OSA:Yes 0 - 2

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CDIVISION OF OTOLARYNGOLOGY/ HEAD AND NECK SURGERY/HEAD & NECK SURGERYAUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATIONThis authorization allows the healthcare provider(s) named below to release confidential medical information and records.Note: Information and records regarding treatment of minors, HIV, psychiatric/ mental health conditions, or alcohol/ substance abusehave special rules that require specific authorization.AUTHORIZATION:I hereby authorize:Physician/ Healthcare FacilityTo release information on (patient’s name) (DOB) regarding my medicalhistory, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care provider that the above named health care provider may hold,by means of mail, fax, or other electronic methods.NEUROSURGERYSanjay Ghosh, MDScott P. Leary, MDAlois Zauner, MDAmanda W Gumbert, PA-CFelix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MDMichael J. O'Leary, MDTo: Perry MansfieldM.D.Inc./ San Diego Regional Head and Neck Inc.Name3590 Camino Del Rio North Suite 100AddressSan DiegoCA92108CityStateZip codeThe medical information/ records will be used for the following purpose:This authorization is:[ X ] Unlimited (all records, excluding Substance Abuse, Mental Illness, HIV Diagnosis/ Treatment)[ ] Limited to the following medical information:I also consent to the specific release of the following records:Drug/Alcohol/ Substance Abuse (initial)HIV Diagnosis/ Treatment (initial)Psychiatric/ Mental Health(initial)Genetic Information(initial)Test for Antibodies to HIV(initial)Brian H. Weeks, MDBrianna Harris, MDDURATION: This authorization shall be effective immediately and remain in effect until canceled in writtingSeerat Poonia, MDR. Stuart Weeks, MDEmeritusAnnette Kiviat, PA-CJeannine Shively, PA-COPTHALMOLOGY/RESTRICTIONS:Permissions for further use or disclosure of this medical information is not granted unless another authorization is obtainedfrom me or unless such disclosure is specifically required or permitted by law.A photocopy of facsimile of this authorization shall be considered as effective and valid as the original.I have been advised of my right to receive a copy of this authorization.NEURO-ORBIT-PLASTICSKimberley Cockerham, MDCindy Ocran, MDSignature of patient or legal/ personalRepresentative patientRelationship if other than patientPatient’s Name (PRINT)DateNEUROLOGYIan M. Purcell, MD, PhDMonali Patel, MDLOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: C.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CDIVISION OF OTOLARYNGOLOGY/ HEAD AND NECK SURGERY/HEAD & NECK SURGERYBROKEN APPOINTMENTS POLICYWe will make every effort to accommodate your scheduling needs. In return we ask that you help usby keeping your scheduled appointments, and by notifying us in advance if you are unable to do so.We currently have a waiting list for appointments and when you give us advance notice ofappointment changes, this helps us accommodate other patients. We appreciate your consideration.Please read and sign our policy as indicated below:BROKEN APPOINTMENTS POLICY:NEUROSURGERYSanjay Ghosh, MDScott P. Leary, MDAlois Zauner, MDPATIENTS WHO FAIL TO ARRIVE FOR THEIR SCHEDULED APPOINTMENTS WITHOUT PRIORNOTIFATION TO OUR OFFICE MAY BE CHARGED A FEE OF 50.Amanda W Gumbert, PA-CFelix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-C This “broken appointment” fee is NOT RECOVERABLE from your insurance plans andwill be charged to the patient. Repeated “broken appointments” may negatively impact your healthcare and resultin notification to your referring physician of disengagement from our practice. Pleasebe kind enough to call in advance, preferably 24 hours in advance if you need tocancel or reschedule an appointment.OTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MDMichael J. O'Leary, MDBrian H. Weeks, MDBrianna Harris, MDSeerat Poonia, MDR. Stuart Weeks, MDEmeritusAnnette Kiviat, PA-CJeannine Shively, PA-CThank you for your assistance and courtesy towards other y Cockerham, MDCindy Ocran, MDPatient Name (Print)NEUROLOGYIan M. Purcell, MD, PhDMonali Patel, MDI have read and agree to the “Broken Appointment” Policy.LOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111Patient or Legal Guardian SignatureDateCORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: C.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CDIVISION OF OTOLARYNGOLOGY/ HEAD AND NECK SURGERY/HEAD & NECK SURGERYFinancial PolicyWe cannot guarantee your benefits or eligibility with your insurance plan. Your insurance plan is a contractbetween you and your insurance company.Upon completion of our patient Registration Form and your Assignment of Benefits, we will extend thebenefit offered by your insurance company and file for reimbursement. We will handle the necessaryinsurance filing paper work for you. All payments are expected at the time of visits for services not coveredNEUROSURGERYby your insurance plan.Sanjay Ghosh, MDScott P. Leary, MDAlois Zauner, MDIf your insurance company pays only a portion of the bill or denies the claim, an explanation should beAmanda W Gumbert, PA-CFelix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MDMichael J. O'Leary, MDBrian H. Weeks, MDBrianna Harris, MDSeerat Poonia, MDR. Stuart Weeks, MDmade to you, their policy holder. Reduction or rejection of your claim by your insurance does not relieve youof the financial obligation. We will notify you if this occurs and we will request payment in full.I have read the above and I understand and agree to the San Diego Regional Head and Neck Center Inc./Perry T. Mansfield, M.D., Inc. Financial Policy. I authorize the release of any medical information necessaryto process insurance claims and to comply with medical reviews and audits. I further authorize payment ofmy benefits be made to Perry T. Mansfield, M.D., Inc. for services provided to me. I understand that theultimate responsibility for payment of services remains mine.EmeritusAnnette Kiviat, PA-CJeannine Shively, PA-COPTHALMOLOGY/NEURO-ORBIT-PLASTICSKimberley Cockerham, MDPrint Name of Patient or Responsible PartyDateCindy Ocran, MDNEUROLOGYIan M. Purcell, MD, PhDMonali Patel, MDLOCATIONSSignature of Patient or Responsible Party*A Copy of this signature is valid as the originalMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: C.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CDIVISION OF OTOLARYNGOLOGY/ HEAD AND NECK SURGERY/HEAD & NECK SURGERYSenta CT scanner/ ChEARS Audiology/ AmerisleepDiagnostics/ E-PrescribeIn the circumstance that a San Diego Regional Head and Neck Center/Perry T. Mansfield, M.D.Inc. physician determines that you require further radiology or audiology evaluation or are inneed of a Sleep Study and recommends that you have this preformed at Senta Imaging, LLC orNEUROSURGERYChEARS Audiology or Amerisleep Diagnostics, please be aware that they may have financialSanjay Ghosh, MDScott P. Leary, MDinterest in the aforementioned entities.There are other facilities available in our community whereAlois Zauner, MDAmanda W Gumbert, PA-Cthe same procedure(s) can be performed, and you do have the option to use one of theseFelix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MDalternates. You will not be treated any differently regardless of the entity you choose to betreated. If you have any questions regarding this, please feel free to contract our office at (619)810-1111. We do electronic prescribing and require your written consent for viewing your RxMichael J. O'Leary, MDBrian H. Weeks, MDhistory.Brianna Harris, MDSeerat Poonia, MDR. Stuart Weeks, MDPatient Name (Please print)EmeritusAnnette Kiviat, PA-CJeannine Shively, PA-COPTHALMOLOGY/NEURO-ORBIT-PLASTICSKimberley Cockerham, MDCindy Ocran, MDNEUROLOGYIan M. Purcell, MD, PhDMonali Patel, MDI have read and agree to the above and understand that Perry T. Mansfield, M.D. Inc. has afinancial interest in the aforementioned entities.LOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: 619-229-4938Patient Signature/ Legal C.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CDIVISION OF OTOLARYNGOLOGY/ HEAD AND NECK SURGERYAcknowledgment of Receipt of Notice of PrivacyPractices San Diego Regional Head and NeckCenter Inc. and Perry T. Mansfield, M.D. Inc.I hereby acknowledge that I received a copy of this Notice of Privacy Practice. Ifurther acknowledge that a copy of the current notice will be posted in the reception area.I would like to receive a copy of any amended Notice of Privacy Practices by e-mail at:E-mail address:NEUROSURGERYSignature:Date:Sanjay Ghosh, MDScott P. Leary, MDPatients Name:Alois Zauner, MDAmanda W Gumbert, PA-CFelix Regala, PA-CCassie Petit, PA-CDate of Birth:Phone Number:Deb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MDMichael J. O'Leary, MDBrian H. Weeks, MDBrianna Harris, MDSeerat Poonia, MDR. Stuart Weeks, MDEmeritusAnnette Kiviat, PA-CIf not signed by patient, please indicate:Relationship:Jeannine Shively, PA-CParent of Guardian of minor patient.OPTHALMOLOGY/Guardian or Conservator of an incompetent patient.NEURO-ORBIT-PLASTICSKimberley Cockerham, MDBeneficiary or personal representative of deceased patientCindy Ocran, MDNEUROLOGYIan M. Purcell, MD, PhDPatient Name:Date:Monali Patel, MDLOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: C.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CINFORMED CONSENT FOR TELEHEALTH SERVICESTelemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individualpatient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists,and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of thefollowing: NEUROSURGERYSanjay Ghosh, MDPatient medical recordsMedical imagesLive two-way audio and videoOutput data from medical devices and sound and video filesElectronic systems used will incorporate network and software security protocols to protect the confidentiality of patientidentification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional orunintentional corruption.Scott P. Leary, MDAlois Zauner, MDAmanda W Gumbert, PA-CResponsibility for the patient care should remain with the patient’s local clinician, as does the patient’s medical record.Felix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MDMichael J. O'Leary, MDBrian H. Weeks, MDBrianna Harris, MDSeerat Poonia, MDR. Stuart Weeks, MDEmeritusExpected Benefits: Improved access to medical care by enabling a patient to remain in his/her local healthcare site (i.e. home) while the physicianconsults and obtains test results at distant/other sites. More efficient medical evaluation and management. Obtaining expertise of a specialist. Minimizing patients and healthcare specialists’ exposure to rapidly disseminating, contagious diseases such as the COVID-19(i.e., coronavirus disease) pandemic, especially in the setting of the current social interaction nationwide restrictions.Possible Risks:Annette Kiviat, PA-CJeannine Shively, PA-COPTHALMOLOGY/As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not belimited to:NEURO-ORBIT-PLASTICSKimberley Cockerham, MDCindy Ocran, MDNEUROLOGYIan M. Purcell, MD, PhDMonali Patel, MD In rare cases, the consultant may determine that the transmitted information is of inadequate quality, thus necessitating a faceto-face meeting with the patient, or at least a rescheduled video consult;Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or otherjudgment errors;LOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: C.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CINFORMED CONSENT FOR TELEHEALTH SERVICES (cont.)By checking the box associated with “Informed Consent”, you acknowledge that you understand and agree with the following:NEUROSURGERYSanjay Ghosh, MDScott P. Leary, MDAlois Zauner, MDAmanda W Gumbert, PA-CFelix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MD1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and thatno information obtained in the use of telemedicine, which identifies me, will be disclosed to researchers or other entities withoutmy written consent.2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at anytime, without affecting my right to future care or treatment.3. I understand the alternatives to telemedicine consultation as they have been explained to me, and in choosing to participate in atelemedicine consultation, I understand that some parts of the exam involving physical tests may be conducted by individuals atmy location, or at a testing facility, at the direction of the consulting healthcare provider.4. I understand that telemedicine may involve electronic communication of my personal medical information to other medicalpractitioners who may be located in other areas, including out of state.5. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can beguaranteed or assured.6. I understand that telemedicine does not replace an in-person medical or allied health practitioner’s face-to-face evaluation incases of urgent or emergent medical conditions, and does not exclude the necessity of a direct physician’s consultation and/oroffice visit, urgent care or emergency room evaluations.7. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Othersmay also be present during the consultation other than my healthcare provider and consulting healthcare provider in order tooperate the video equipment. The above-mentioned people will all maintain confidentiality of the information obtained. I furtherunderstand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1)omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medicalpersonnel to leave the telemedicine examination room; and/or (3) terminate the consultation at any time.Patient Consent to the Use of TelemedicineMichael J. O'Leary, MDBrian H. Weeks, MDBrianna Harris, MDSeerat Poonia, MDR. Stuart Weeks, MDEmeritusAnnette Kiviat, PA-CJeannine Shively, PA-COPTHALMOLOGY/NEURO-ORBIT-PLASTICSI have read and understand the information provided above regarding telemedicine and all of my questions have been answered tomy satisfaction.I have read this document carefully, and understand the risks and benefits of the teleconferencing consultation and have had myquestions regarding the procedure explained and I hereby give my informed consent to participate in a telemedicine visit under theterms described herein.By signing this form, I hereby state that I have read, understood, and agree to the terms of this document.Kimberley Cockerham, MDCindy Ocran, MDPatient Name:Date:NEUROLOGYIan M. Purcell, MD, PhDMonali Patel, MDSignature:LOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: C.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CPhotography/Electronic Medical Record ConsentPurpose: I consent to the taking of photographs, slides, recording of films and/or creation of multimedia items of parts of my ENT body part I am being treated for, such as nasal cavity or face, inconnection with the ENT surgery procedure(s) to be performed by Perry T. Mansfield, M.D. Inc.physicians. I authorize the use and disclosure of the photographs and images of me for thefollowing purposes: Uploaded to my electronic medical records Submitted to my insurance company for authorization requests; via online insurance portals,fax or email insurance provides for submission. Emailing of your photos obtained to your personal email, if requested , Please PRINT the emailaddress they maybe sent to:NEUROSURGERYSanjay Ghosh, MDConfidentiality please note: Your photos will not be shared with anyone other than yourinsurance company for request of authorizations . They will remain a permanente part ofyour electronic medical record.Scott P. Leary, MDAlois Zauner, MDAmanda W Gumbert, PA-CFelix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYNotice: San Diego Regional Head and Neck Center Inc. and Perry T. Mansfield, M.D. Inc., as well asmany other organizations and individuals such as doctors, nurses, dentists, hospitals and health plansare required by law to keep your health information confidential. I understand that if I haveauthorized the emailing of my photo's it may breach the HIPAA confidentiality act, as email is not aknown secure method.Perry T. Mansfield, MDMichael J. O'Leary, MDBrian H. Weeks, MDBrianna Harris, MDSeerat Poonia, MDR. Stuart Weeks, MDEmeritusAnnette Kiviat, PA-CJeannine Shively, PA-COPTHALMOLOGY/Your Rights: I understand that I have the right to have the nasal endoscopy, filming or photographystop at any time. Giving permission for us to use these items is voluntary, however please note: someinsurance companies require us to submit proof of abnormalities for authorization consideration. Imay refuse to give permission without any penalty or loss of care or services. My treatment,payment, enrollment and eligibility for benefits do not depend on my signing this permission form.If I have any questions about my rights, I may contact Eric Espia at 3590 Camino del Rio North,Suite 103 San Diego, CA 92108 or via phone at: 619- 810-1111NEURO-ORBIT-PLASTICSKimberley Cockerham, MDCindy Ocran, MDNEUROLOGYIan M. Purcell, MD, PhDExpiration: Unless I revoke my permission earlier, this authorization expires on. If nodate is indicated, this authorization will expire fifty years after the date of my signing this form.Monali Patel, MDPatient Initials:LOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: 619-229-4938Page 1/2WWW.PERRYMANSFIELDMD.COMWWW.SENTACLINIC.COM

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.Perry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CI give permission for these multimedia items to be taken or made and used: Photographs,audiotapes/audioclips, radiographs and other medical images, other multimedia items, andany other health information regarding my medical condition or surgical interventionrequired to improve my health.NEUROSURGERYSanjay Ghosh, MDScott P. Leary, MDAlois Zauner, MDAmanda W Gumbert, PA-CRevoking your permission: I understand that I may change my mind and withdraw my permission foruse of the photographs, films or other materials at any time, without any penalty or loss of care orservices. To revoke my permission, I must write a letter, sign it and deliver it to SENTA Clinic 3590Camino del Rio North, Suite 100 San Diego, CA 92108. The revocation letter will take effect whenSENTA Clinic receives it, except to the extent that Perry T. Mansfield, M.D. Inc., or others havealready relied on it. If the multimedia items have been shared with your insurance or emailed to youat your request, it may not be possible to recall them.Felix Regala, PA-CCassie Petit, PA-CDeb Frantz, PA-COTOLARYNGOLOGY/HEAD & NECK SURGERYPerry T. Mansfield, MDMichael J. O'Leary, MDBrian H. Weeks, MDBrianna Harris, MDSeerat Poonia, MDI agree that San Diego Regional Head and Neck Center Inc. and Perry T. Mansfield M.D. Inc. willown any and all rights in the multimedia items listed above. I waive any and all right that I may havein the use of my likeness, photograph, appearance in these multimedia items.I have read this consent about the use of multimedia items that contain my health information. Iunderstand the permissions I am giving. My questions have been answered to my satisfaction and Iagree to what this form says.R. Stuart Weeks, MDEmeritusAnnette Kiviat, PA-CJeannine Shively, PA-COPTHALMOLOGY/NEURO-ORBIT-PLASTICSKimberley Cockerham, MDSignature of Patient or Legal RepresentativeDatePrinted name of Legal Representative (if applicable)Relationship to PatientSignature of Witness or InterpreterDateSignature of Person Obtaining ConsentDateCindy Ocran, MDNEUROLOGYIan M. Purcell, MD, PhDMonali Patel, MDLOCATIONSMESA COLLEGE7625 Mesa College DriveSuite 305ASan Diego, CA 92111CORPORATE &MAILING ADDRESSMISSION VALLEY3590 Camino Del Rio NSuite 100San Diego, CA 92108PH: 619-810-1111FX: 619-229-4938Page 2/2 SENTA Clinic Photography Consent

PERRY T. MANSFIELD, M.D. Inc.San Deigo Regional Head and Neck Center Inc.SENTA CLINICNOTICE OF NON-DISCRIMINATIONPerry T. Mansfield, MDBrianna Harris, MDKimberly Cockerham, MDSeerat Poonia, MDAnnette Kiviat, PA-CDiscrimination is Against the LawSan Diego Regional Head and Neck Center Inc./ Perry T. Mansfield M.D. Inc. complies withapplicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin,age, disability, or sex. Senta Clinic does not exclude people or treat them differently bec

PERRY T. MANSFIELD, M.D. Inc. Perry T. Mansfield, MD Brianna Harris, MD Seerat Poonia, MD Annette Kiviat, PA-C www.PERRYMANSFIELDMD.COM WWW.SENTACLINIC.COM NEUROSURGERY Sanjay Ghosh, MD Scott P. Leary, MD Alois Zauner, MD Amanda W Gumbert, PA-C Felix Regala, PA-C Cassie Petit, PA-C Deb Frantz, PA-C OTOLARYNGOLOGY/ HEAD & NECK SURGERY Perry T .

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