Welcome to The EnLyv Clinics. Please complete this form, if you have completed any of the information you can skip those sections.

Preffered ways of communication

Emergency contact

Other Doctors/ NP/PA/Specialists information (PROVIDE DETAILS)

Pharmacy INFORMATION

REASON FOR THE VISIT (Skip if you have completed any information in the online form)

Please list ALL allergies (including foods, drugs and environment). Specify type, location, and severity of reaction. If none, check: No Allergies.

Social History (Skip if you have completed any information in the online form)

Do you ever use the following? If yes, how much, how often and for how many years? Tobacco , Alcohol ,explicit Drugs (specify) , Caffeine (Coffee, Tea (specify) , Other

FAMILY HISTORY (Skip if you have completed any information in the online form)

Consent for HIPAA-compliant scribe

For accurate documentation and improved care, a HIPAA-compliant scribe (human or Al tool) is

Listening and recording your conversation with the provider. All information remains secure and

within your medical chart.If you have any concerns, Please let us know. Thank you for your trust!

PATIENT FINANCIAL RESPONSIBILITY FORM

INDIVIDUAL FINANCIAL RESPONSIBILITY

I understand that I am financially responsible for my health insurance deductible, coinsurance, or non-covered service

Co-payments are due at time of service.

If my health plan determines a service to be "not payable", I will be responsible for the complete charge and agree to pay the costs of all services provided.

If I am uninsured, I agree to pay for the medical services rendered to me at time of service.

INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

I hereby authorize and direct payment of my medical benefits to THE ENLYV CLINICS on my behalf for any services furnished to me by their providers.

AUTHORIZATION TO RELEASE RECORDS

I hereby authorize THE ENLYV CLINICS LLC to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.

MEDICARE REQUEST FOR PAYMENT

I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in THE ENLYV CLINICS LLC. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.

HIPAA Compliance Patient Consent Form

Patient Authorization to Share Medical Information with listed person/s

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. This signed form allows The EnLyv Clinics LLC to share and discuss your protected health matters / information (medical or billing) to the person/s (for example: wife/husband. significant other, friend, etc) you list on this form on your behalf. You may remove this authority at any time in writing.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

• The practice reserves the right to change the privacy policy as allowed by law.

• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.

• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent.

(If you did not choose any option above, your signature would imply your consent to allow TEC to use all the above mode of communications)

Thank you again for choosing The EnLyv Clinics for your medical care.