MARIO D. ZAMBRANO, M.D. Pediatrics and Adolescent Medicine

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1 MARIO D. ZAMBRANO, M.D. Pediatrics and Adolescent Medicine PATIENT INFORMATION DATE OF BIRTH: GENDER: MALE FEMALE SOCIAL SECURITY # TODA Y'S DATE: PERMANENT ADDRESS: APT#: CITY/STATE/ZIP: ZIP PHONE NUMBER: ( ) D.O.B PARENT OR GUARDIAN ADDRESS: APT#: INFORMA TlON CITY /STATE/ZIP: PHONE NUMBER:( ) PLACE OF WORK: PHONE NUMBER: ( ) RELATIONSHIP TO PATIENT: ADDRESS: PHARMACY PHARMACY NUMBER: INSURANCE INFORMA TlON INSURANCE POLICY # : GROUP#: CLAIM ADDRESS: CITY/STATE/ZIP: PHONE NUMBER: ( ) POLICY HOLDER SOCIAL SECURITY NUMBER: EMERGENCY M CONTACT RELATIONSHIP TO PATIENT: r PHONE NUMBER:( ) Pines Blvd, Suite 102, Pembroke Pines, FL Ph. (954)

Pediatrics and Adolescent Medicine PATIENT INFORMATION DATE OF BIRTH: GENDER: MALE FEMALE SOCIAL SECURITY # TODA Y'S DATE: PERMANENT ADDRESS: APT#: CITY/STATE/ZIP: ZIP

2 ASSIGNMENT OF INSURANCE BENEFITS I hereby authorize direct payment of surgical/medical benefits to: Mario Zambrano MD. for services rendered by her/ him in person or under her/ his supervision. I understand that I am financially responsible for any balance not covered by my insurance. AUTHORIZATION TO RELEASE INFORMATION I hereby authorize Mario Zambrano, MD. to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. I certify that the information given by me in applying for payment is correct. request that payment of authorized benefits be made on my behalf. I authorize release of all records on request. ASIGNACION DE BENEFICIOS DE SEGURO Yo autorizo el pago directo de los beneficios cuirurqicos / medicos a E-Z Pediatrics PAl y 0 Mario Zambrano MD. por los servicios recibidos de ella /el en persona 0 bajo su supervision. Entiendo que soy financieramente responsable por cualquier balance no cubierto por mi segura. AUTORIZACION PARA LlBERACION DE INFORMACION Autorizo a E-Z Pediatrics, PA y I 0 Mario Zambrano MD a liberar cualquier informacion medica 0 incidental que pudiera ser necesaria para propositos de cuidado medico a con proposito de aplicacion para beneficios financieros Certifico que toda la informacion que he dado en correcta/ Autorizo la uberacion de records cuando se requiera. Pido que el pago de beneficios autorizados sea hecho en mi favor. I understand and agree that i am financially responsable for the following fees: No show fee: if you do not call to cancel or reschedule your appointment 24 hours prior to you appointment, you will be charged a $25 no show fee. Forms: there is a charge of $3.00 for any form filled out in this office: WIC, Blue 680, Yellow A set of Blue & Yellow forms $5.00, Sports Physical $5.00, etc., any form having to be filled out andlor signed by the doctor or nurse $5.00. Letters or FMLA applications requested on behalf of the patient and/or parent for any purpose $ Copies of medical records: according to the Florida Administrative Code rule F.S the cost of producing copies of medical records is $1.00 per page for the first 25 pages, 0.25 cents for each additional page. Entiendo y concuerdo que soy financieramente responsable para 105 honorarios siguientes: Faltar visita: si usted no llama a cancelar ni cambiar su cita con 24 horas de anticipacion, usted sera cobrado $25. Formas: hay una cargo de $3.00 para las siguientes formas lienada en esta oficina: WIC, Azul 680, Amarillo Un conjunto de Azul & formas Amarillas $5.00, los Deporte Fisicos $5.00, etc., cualquier otra forma necesitando ser lienado y/o firmado por el medico 0 enfermera $5.00. Cartas 0 las aplicaciones de FMLA solicitaron a favor del paciente y/o el padre para cualquier prop6sito $10,00. Las co pi as de historiales medicos: segun la Florida la regia Administrativa de C6digo F. 458,309 el costo de producir co pi as de historiales medicos son $1.00 por pagina para las primeras 25 paginas, y,25 centavos para cada pagina adicional. Patient Name: PARENT I GUARDIAN (PLEASE PRINT): SIGNATURE: Date:

to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits.

3 E-Z PEDIATRICS, PA MARIO D. ZAMBRANO, M.D., FAAP ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES DATED APRIL 14, 2003 Patient Name: I, (name of parent/guardian ) acknowledge and agree that I have received a copy of EZPEDS Notice of Privacy Practices. Patient / Guardian Signature Date Patient Legal Representative (If applicable) Date Print name of Legal Representative Relationship to Patient For office use only EZPEDS made the following good faith efforts to obtain the above referenced individual's written acknowledgement of receipt of the Notice of Privacy Practices. Name of Representative

4 MARIO D. ZAMBRANO, MD PEDIATRICS AND ADOLESCENT MEDICINE TO ALL MY PATIENTS AND/OR PATIENT'S PARENTS/GUARDIANS Under Florida Law, Physicians are generally required to carry Medical Malpractice Insurance or otherwise demonstrate financial responsibility to cover potential claims for Medical Malpractice. I, your Doctor, have decided not to carry Medical Malpractice Insurance. This is permitted under Florida Law subjected to certain conditions. Florida Law imposes penalties under noninsured Physicians who fail to satisfy adverse judgments arising from claims for medical malpractice. This Notice is provided pursuant to Florida Law. Your Doctor, Mario D. Zambrano, MD I have read this statement and fully understand it: Patient or Patient's Parent/Guardian name: Patient or Patient's Parent/Guardian signature: ----,- Date: A TODOS MIS PACIENTES Y/O PADRES/GUARDIANES DE MIS PACIENTES Bajo las leyes de la Florida, se require general mente que los Medicos tengan un Seguro de Mala Practica Medica, 0 de 10 contrario, demonstrar responsabilidad financiera para cubrir posibles rec1amaciones. Yo, su Medico, he decidido no tener Seguro de Mala Practica Medica. Esto es permitido por las leyes de la Florida sujeto a ciertas condiciones. Las leyes de la Florida imponen multas a los Medicos no asegurados que no satisfagan juicios adversos derivados de rec1amaciones de Mala Practica Medica. Se prove este aviso siguiendo las leyes de la Florida. Su Doctor, Mario D. Zambrano, MD He leido y entiendo perfectamente este aviso: Nombre del Paciente 0 Padre/Guardian del Paciente: Firma del Paciente 0 Padre/Guardian Fecha: del Paciente: I Pines Blvd, Suite 102, Pembroke Pines, FL Tel: Fax:

otherwise demonstrate financial responsibility to cover potential claims for Medical Malpractice. I, your Doctor, have decided not to carry Medical Malpractice Insurance.

5 Pediatrics and Adolescent Medicine Mario D. Zambrano, M.D. PEDIATRIC HEALTH HISTORY FORM Date: Child's Name Date of Birth Male Female Language spoken: English Spanish Other Nameofpe~onilll~go~t~sfurm Relationship with the patient: Mother Father Other BIRTH HISTORY: Mother's age at the time of birth Complications of the pregnancy: Diabetes; High blood pressure; Preterm labor; Infections; sexually transmitted disease; other Drugs taken during pregnancy Alcohol during pregnancy: Yes No; If yes, amount Frequency Delivery: Hospital Name Home Other Type of Delivery: Vaginal; C-section; Reason for C-section. Newborn birth weight lbs. oz Newborn length inches cmts Did the newborn need to go to Neonatal Intensive Care Unit? Yes No. If yes, why How long was the baby in the NICU Infant Complications Jaundice Heart problems Lung problems HIV Deformities injury oxygen feeding problems seizures/tremors kidney; Other If any of the above, explain CHILD'S MEDICAL HISTORY Allergies Yes No If yes, please list. Medical Problems Hospitalizations (when, where, and for what) Trauma/Injuries/Broken bones (when) Medications (please list all medications your child takes, prescription, and non prescription): Has the child been exposed to second hand cigarette smoke? Yes No Please list doctors or clinic the child has received medical care and their specialty:

PEDIATRIC HEALTH HISTORY FORM Date: Child's Name Date of Birth Male Female Language spoken: English Spanish Other Nameofpe~onilll~go~t~sfurm Relationship with the patient: Mother Father Other BIRTH

6 FAMILY HISTORY Do any of the blood relatives of the child have any of the following conditions? Diabetes Heart Disease Cancer High Blood Pressure Kidney/Urinary Disease ' Allergies/Asthma Birth Defects Emotional Illness Mental Retardation Seizures I Liver/Hepatitis Other SOCIAL HISTORY rlease list all persons that live in the house with the child, their age and relationship with the child: -2- ~h~schooldoesyourchild~~nd? ~ What grade is the child currently in? Childactivitiesandhobbies What ethnic background is the family? Religion Does the family practice that religion? Yes No Does the family practice alternative forms of medicine/healing? Yes No Ifyesexplain DEVELOPMENTAL HISTORY Age first walked Age first words Age toilet trained. ~ Child development seems: Normal Slow FEEDING HISTORY Breast Until age Formula Type Until age Is the child enrolled in ~IC (Women Infant and Children food program)? Yes No REVIEW OF SYSTEMS: Yes No Explain Asthma Ear Infections (more than 3 in a year) Nose bleeding Hearing problems Frequent Headaches Vision Problems Regular dental check-ups Heart problems History of Urinary Tract Infections Anemia Bed ~etting Seizures Often acts Unhappy Participate with family activities Participate in sports Sleeps 8 hours Special Fears Menses began Doyou haveanyconcernaboutyourchild? LEAD EXPOSURE QUESTIONNAIRE Does your child live in or regularly visit a house with peeling or chipping paint built before 1960? Yes No Does your child live in or regularly visit a house built before 1960 with recent ongoing or planned renovation? Yes No Does your child have a brother or sister, housemate or playmate being followed or treated for LEAD poisoning? Yes No Does your child live with an adult whose job or hobby involves exposure to LEAD? Yes No (such as ceramics, furniture refinishing, and stained glass work) Does your child live near an active lead smelter, battery recycling plant, or other industry likely to release lead? Yes No

list all persons that live in the house with the child, their age and relationship with the child: -2- ~h~schooldoesyourchild~~nd? ~ What grade is the child currently in?

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MARIO D. ZAMBRANO, M.D. Pediatrics and Adolescent Medicine

MARIO D. ZAMBRANO, M.D. Pediatrics and Adolescent Medicine PATIENT INFORMATION DATE OF BIRTH: GENDER: MALL FEMALE SOCIAL SECI. ;RITY # TODAY'S DATE: PERMANENT unistate/zip: ZIP Anti: PHONE NUMBER: ( )