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6 St. Francis Primary Care Downtown Patient Name Date of Birth SSN: Home Phone Work Mobile Address City State Zip Code Gender: M/F Race Marital Status: S M D W Hispanic or Non-Hispanic Emergency Contact Name Phone Relationship Patient s Employer Full-time Part-time PRN Retired Address: (Complete this section if insurance subscriber is not self) Subscriber Name DOB SSN Relationship to Patient: Subscriber s Employer Full-time Part-time PRN Retired

7 SF Primary Care Downtown Medication Policy Saint Francis Primary Care DT providers do not routinely prescribe long term, chronic narcotic pain medicines or benzodiazepines. In certain cases, at the discretion of the provider, exceptions may be made, based on individual circumstances. Any patient under this exception will be subject to random urine drug screenings up to four (4) times per calendar year. PAIN MEDICATIONS We are not a pain management practice and will not manage chronic pain. For patients with chronic pain requiring medication management, we will refer to a pain management center. We will not prescribe any schedule II analgesic medications (such as Oxycontin, Fentanyl, Morphine, MS-Contin, Methadone, Dilaudid, Oxycodone, etc ) We will not prescribe schedule III analgesic medications for long term use (such as Tylenol #3, Vicodin, Lortab, Lorcet, Norco, Tramadol, etc ). We may occasionally prescribe a short term schedule III analgesic medications for acute, selflimiting pain, at the discretion of the individual prescribing physician. BENZODIAZEPINES We will not prescribe or refill benzodiazepine medications for long term use (such as Xanax, Valium, Klonopin, Ativan, etc.) For patients with chronic anxiety requiring medication management, we will refer to a mental health professional. ADD/ADHD MEDICATIONS Stimulant medications for Attention Deficit Disorder may, when appropriate, be prescribed for some patients on an ongoing basis. In such cases, however, it is understood that SF Primary Care Downtown will be the ONLY prescribing office for such medications that are DEA schedule II or lll We are not an ADD/ADHD management practice. Stimulant medications for the treatment of ADD/ADHD may be prescribed for a patient with documented diagnosis from a mental health professional, who has failed adequate trial of non-stimulant medications, but routine follow-up visits will be required every 3 months. Only one month prescriptions will be written for these medications. PRESCRIPTION REFILLS There may be a charge in the amount of $15 for prescription refills or other medications prescribed that are not completed during an office visit. Lost prescriptions for schedule II and schedule III medications will not be replaced. Any patient who knowingly fills a schedule II or III medication from another provider in another facility, when SF Primary Care Downtown is also filling such medications on an ongoing basis, will be subject to immediate termination of the patient/ physician relationship without notice, and SF Primary Care Downtown will no longer fill such medications for this patient. I HAVE READ AND UNDERSTAND THESE POLICIES Patient Signature: Date:

8 Saint Francis Primary Care Downtown 317 Saint Francis Drive, Suite 220 Greenville, SC Fax: (toll free) Medical Records Release Authorization Form Patient's Full Name: Patient's Date of Birth: Patient's Social Security No. Patient's Address: Zip The above identified patient is requesting the following information be made available to: (Please list below the name of person/organization of previous provider:) Address of previous provider: The receiver of this information is a : (Circle one please) Physician Dentist Hospital Out Patient Center Clinic Nursing Home Hospice Patient Other (please indicate other such as a name, etc.: Information to be released: (Please check all applicable records to release) -rays and x-ray report Date of Service: From to to Signature of Patient Date Signature of Parent/Guardian Date