I understand my signature covers visits to the CENTER FOR CANCER CARE for 365 days from the date I sign this form.

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Alicia Valdéz Serrano
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5 GUARANTEE OF PAYMENT ASSIGNMENT OF BENEFITS AUTHORIZATION TO PROCESS CLAIMS Center For Cancer Care PLACE LABEL HERE GUARANTEE OF PAYMENT / ASSIGNMENT OF BENEFITS: In consideration of the Hospital's advancing credit to me for my hospital care and services, I hereby irrevocably assign and transfer to Gwinnett Hospital System and treating Physicians all benefits and payments now due and payable or to become due and payable to me under any insurance policy or policies, under any replacement policies thereof, under any self-insurance program, under any third-party actions against any other person or entity, or under any other benefit plan or program (hereafter referred to as Benefits) for this or any other period of hospitalization and related outpatient care. I understand and acknowledge that this assignment does not relieve me of my financial responsibility for all hospital charges and treating Physician charges incurred by me or anyone on my behalf, and I hereby accept such responsibility, including but not limited to payment of those fees and charges not directly reimbursed to the Hospital and treating Physicians by any Benefit plan or program. I understand and agree that in order to service my account or to collect any amounts I may owe, the Hospital and treating Physicians or any contractors working on their behalf may contact me by telephone at any telephone number associated with my account, including wireless telephone numbers, which could result in charges to me. I further understand and agree that the hospital and treating physicians or any contractors working on their behalf may contact me using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable. Furthermore, I agree to pay all costs of collection, reasonable attorneys fees and court costs incurred in enforcing this payment obligation. AUTHORIZATION TO PROCESS CLAIMS AND RELEASE OF INFORMATION: I authorize Gwinnett Hospital System and the independent contractor physicians and/or professional corporations that render services to me to process claims for payment by my insurance carrier on my behalf for covered services provided to me at Gwinnett Hospital System. I authorize the release of necessary information, including medical information, regarding medical services rendered during this admission or any related services or claim, to my insurance carrier(s), including any managed care plan or other payor, past and/or present employer(s), Medicare, CHAMPUS/TRICARE, authorized private review entities and/or utilization review entities acting on behalf of such insurance carrier(s), payers, managed care plans and/or employer(s), the billing agents and collection agents or attorneys of Gwinnett Hospital System and/or the independent contractor physicians and/or professional corporations, my employer's Worker's Compensation carrier, and, as applicable, the Social Security Administration, the Health Care Financing Administration, the Peer Review Organization acting on behalf of the federal government, and/or any other federal or state agency for the purposes(s) of satisfying charges billed and/or facilitating utilization review and/or otherwise complying with the obligations of state or federal law. Authorization is hereby granted to release health record data and/or copies to my attending and/or admitting healthcare professional and/or any consulting healthcare professional and/or any healthcare professional I may be referred to for follow-up care. I further authorize Gwinnett Hospital System and any other healthcare provider or professional rendering services to me to obtain from any source medical history, examinations, diagnoses, treatments and other health or insurance authorization information for the purpose(s) of satisfying charges billed and/or facilitating utilization review, providing medical treatment and/or the evaluation of such treatment, and/or otherwise complying with the obligations of state or federal law. A photocopy of this Authorization may be honored. MEDICARE PATIENT'S CERTIFICATION, AUTHORIZATION TO RELEASE INFORMATION, AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a RELATED Medicare claim. I request that payment of authorized benefits be made on my behalf. I understand my signature covers visits to the CENTER FOR CANCER CARE for 365 days from the date I sign this form. SIGNED: Patient/Patient s Representative Relationship if other than self Date WITNESS: * * FORM REV. 10/2014 Page 1 of 1

6 GUARANTEE OF PAYMENT ASSIGNMENT OF BENEFITS AUTHORIZATION TO PROCESS CLAIMS Center For Cancer Care PLACE LABEL HERE Reason If Unable to Sign: * * FORM REV. 10/2014 Page 1 of 1

21 The following Patient Treatment Barriers Assessment Form is for Oncology (cancer) patients only.

22 Evaluación de obstáculos que pueden interferir con el tratamiento del paciente CANCER INSTITUTE Nombre del paciente: Fecha: Fecha de nacimiento: Diagnóstico: Centro de tratamiento: Dirección de correo electrónico: Teléfono: 1. Por favor haga un círculo alrededor del número que mejor represente el nivel de aflicción que ha estado sintiendo la pasada semana, incluyendo hoy. Aflicción extrema e Distress No está afligida(o) o Distress Reproducido con autorización de NCCN Clinical Practice Guidelines in Oncology, (NCCN Guidelines, por sus siglas en inglés) para Manejo de Estrés (V ) National Comprehensive Cancer Network, Inc. Disponible en: NCCN. org. Accesado January 23, Para ver la versión más reciente y completa de NCCN Guidelines, visite la página de NCCN. org. NATIONAL COMPREHENSIVE CANCER NETWORK, NCCN, NCCN GUIDELINES, y todo el contenido de NCCN son marcas regi stradas propiedad de National Comprehensive Cancer Network, Inc. 2. Por favor indique si alguno de los siguientes ha sido un problema para usted durante la pasada semana, incluyendo hoy. Asegúrese de contestar cada uno. SI NO Problemas prácticos Cuido de niños Vivienda Seguro médico Financiero Transportación Empleo/escuela Problemas familiares Atendiéndo a los niños Atendiéndo a su pareja Problemas de fertilidad Problemas de salud familiar Problemas emocionales Depresión Temores Nerviosismo Tristeza Preocupación Pérdida de interés en las actividades habituales Manteniendo las emociones bajo control SI NO Problemas físicos Baño/vestimenta Sangrado Respiración/falta de respiración Cambios en la orina Estreñimiento Diarrea Fiebres Movilizándose Memoria/concentración Fortaleza muscular Náuseas/vómitos Resequedad nasal/congestión Dolor Problemas sexuales Resequedad o picor en la piel Problemas del sueño Expresándose/hablando Abuso de sustancias Hinchazón Cosquilleo/hormigueo en las manos/pies Cansancio Concentración Pérdida del control Preocupaciones sobre nutrición y la alimentación Preocupaciones espirituales/religiosas Significado de la vida Confianza en Dios/religión Dificultad para tragar Indigestión Úlceras en la boca Sabor/cambios en su apetito Cambios con su peso Otros Especifíque: 3. Le gustaría hablar con alguien acerca de alguno de los problemas arriba mencionados? (De ser así, un miembro del equipo del Instituto del Cáncer habrá de contactarle). Si No Item Spanish

23 Patient Treatment Barriers Assessment CANCER INSTITUTE Patient Name: Date: Date of Birth: Diagnosis: Treatment Facility: Address: Phone: 1. Please circle the number that best describes how much distress you have been experiencing in the past week including today. 2. Please indicate if any of the following has been a problem for you in the past week including today. Be sure to check yes or no for each. Extreme Distress e Distress No Distress o Distress Yes No Practical Problem Child Care Housing Insurance Financial Transportation Work/School Family Problems Dealing with children Dealing with partner Fertility problems Family health issues Emotional Problems Depression Fears Nervousness Sadness Worry Loss of interest in usual activities Keeping emotions in control Concentration Loss of control Yes No Physical Problems Bathing/dressing Bleeding Breathing/shortness of breath Change in urination Constipation Diarrhea Fevers Getting around Memory/concentration Muscle strength Nausea/vomiting Nose dry/congested Pain Sexual problems Skin dry/itchy Sleep problems Speech/talking Substance abuse Swelling Tingling in hands/feet Tiredness Reproduced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ) for Distress Management (V ) National Comprehensive Cancer Network, Inc. Available at: NCCN.org. Accessed January 23, To view the most recent and complete version of the NCCN Guidelines, go on-line to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK, NCCN, NCCN GUIDELINES, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc. Spiritual/Religious Concerns Meaning of life Trust in God/Religion Dietary/Nutrition Concerns Difficulty swallowing Indigestion Mouth sores Taste/appetite changes Weight change Other Specify: 3. Would you like to talk to someone about any of the problems you have mentioned above? (If yes, a staff member from the Cancer Institute will contact you.) Yes No

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I understand my signature covers visits to the CENTER FOR CANCER CARE for 365 days from the date I sign this form.

I understand my signature covers visits to the CENTER FOR CANCER CARE for 365 days from the date I sign this form. GUARANTEE OF PAYMENT ASSIGNMENT OF BENEFITS AUTHORIZATION TO PROCESS CLAIMS Center For Cancer Care PLACE LABEL HERE GUARANTEE OF PAYMENT / ASSIGNMENT OF BENEFITS: In consideration of the Hospital's advancing