Our Policy on Forms Completion
Turnure Medical Group, Inc.
If you have a form that needs to be completed by your physician please adhere to
the following guidelines:
ADMINISTRATIVE FORMS: -School entrance, sports & DMV
Most administrative forms require a physical, so please allow adequate time for
scheduling an appointment. Please bring the proper form with you to your
appointment. In most cases your physician will be able to fill out the form during
your appointment. Please have the patient section of your form completed
ahead of time. Finally, be aware that some insurance companies do not cover
physicals. In this case, we do require full payment at the time of your visit.
DISABILITY FORMS:
Our basic fee for these forms is $20.00; however, the fee may be higher relative
to the physician’s time involved to complete the form. Please allow one (1) week
for these forms to be completed by your physician. You have the option of
picking them up or we can mail them directly to you but payment must be
received prior to you receiving these forms. Please note that we do not bill third
parties for these forms. If you need assistance in properly getting reimbursed
please ask for a receipt. Also note that your physician reserves the right to honor
or dishonor your disability claim. It is best to discuss your situation with your
physician prior to making a disability claim. In no event will a disability form be
completed when you have not seen your physician for the reason for your
disability.
Our fee for medical records review or other miscellaneous letters is charged
based on the time involved in compiling the letter. Therefore, the charge is up to
your physician’s discretion.
We hope this information is helpful in clarifying our policies. Thank you in
advance for your cooperation. If you have any questions regarding these policies,
please contact our Office Manager at (916) 624-3500. Thank you.
PATIENT’S PERSONAL HISTORY
Date: _______________
Name____________________________________________
Birth Date___________________________________
Occupation________________________________________
Education___________________________________
Smoker:
Current-social
Never
Former
Current-daily
Marital Status____________________________
Religion_
__________________________________
Past Medical History:
Allergies/Hay Fever
Anemia
Anxiety Disorder
Arthritis/Joint Problems
Back Problems
Bleeding Problems
Blood Transfusions
Childhood Diseases
Clotting Problems
Depression
Diabetes
Eye Problems
Hearing Problems
Heart Attack
Heart Burn
Heart Murmur
Heart Problems
High Blood Pressure
Headaches (Severe)
Kidney Disease
Liver Disease
Lung Disease
Major injuries/illnesses_________________
Seizures
Stroke
Thyroid Disease
Ulcers
Cancer Type:_______________________
___________________________________
Other: _____________________________
___________________________________
Current Medications: including Vitamins and Herbals:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Allergies: (Are you allergic to…?):
Tetanus antitoxin
Penicillin
Sulfa
Other Drugs
PLEASE LIST
yes
yes
yes
yes
no
no
no
no
__________
Foods__________________________________________________
no
yes
Eggs
yes
no
Cosmetics
yes
no
Other
PLEASE LIST
__
______________________________________________
__________
Past Surgeries:
Heart
Thyroid
Breast
Uterus/ Ovary
Hernia
Family History:
Prostate
Hemorrhoids
Appendix
Gallbladder
Tonsils
Skin
Head
Abdomen
Cesarean
Eyes
Back
Any Biopsies
Other
If Living
Health
M F Age
If Deceased
Age At Death
Father
Mother
Brothers/Sisters
Husband/Wife
Sons/Daughters
(Circle sex)
Do you know of any blood relative who has had: (check and give relationship)
Stroke
Epilepsy
Heart Attack
Diabetes
Arthritis
Colitis
Hypertension
Stomach ulcers
Suicide
Asthma
Elevated Cholesterol
Anemia
Migraines
Kidney disease
Thyroid disease
Lifestyle/ Social Issues:
Yes
No
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Do you regularly smoke?
Check: ____Cigarettes ____Pipe ____Cigar
For how many years?
Do you usually drink over 4 cups of coffee per day?
Have you ever been concerned about your alcohol use?
Has a friend, relative, or co-worker ever expressed concern regarding your
use of alcohol or other chemicals?
Have you ever tried to restrict your use of alcohol or other chemicals?
Have you ever used more alcohol than you planned to use?
Do you have difficulty falling asleep?
Do you awaken early in the morning without apparent cause?
Does your home have a smoke detector?
Do you frequently eat fried or fatty foods?
Do you drive without a seatbelt?
Do you engage in sex/intercourse without contraception?
Cause
Immunization / Vaccines:
2nd Measles shot?
Hepatitis B –series of 3 shots?
Had Chickenpox or its vaccine?
Last Tetanus?
Last TB shot test and result?
Last Flu shot?
Screening Tests:
(Please indicate if you’ve had any of the following and the results and date of test done, if known):
EKG
Sigmoid/ Colonoscopy
Cholesterol
PSA (Prostate Specific Antigen)
General:
Please put an X if you frequently have this problem:
Recent weight loss/gain. How much over
what period of time?
Fatigue
Weakness
Fever
Chills/Night Sweats
Insomnia - difficulty falling/asleep
Loss of interest in things you normally enjoy
Excessive Anxiety/Worry
Falls
Depressed/Sad
Phobias
Memory Loss
Head / Eyes / Ears / Nose / Throat:
Frequent Headaches
Dizzy
Fainting/Blackout
Swollen Glands
Eye/Vision Problems
Hearing Problems
Ringing/Buzzing Ears
Nose Bleeds
Allergies/Hay Fever
Mouth Sores
Sore Tongue
Bleeding Gums
Dry Mouth
Hoarseness
Sore Throats
Swallowing Difficulty
Thirst
Frequent Sinus Infections
Cough
Wheeze
Swollen Legs/Feet
Chills/Night Sweats
Shortness of Breath with Normal Activities
Have Coughed Up Blood
Bloody/Black Stools
Abdominal Pain
Heartburn
Yellow Skin/Jaundiced
Appetite Change
Loss of Eating Control
Heart / Lungs:
Chest pain. Tightness
Irregular Heartbeat
Sleep on more than one pillow
Gastrointestinal:
Nausea
Vomiting
Diarrhea
Constipation
Urinary:
Painful Urination
Frequent Urination
Trouble Holding Urine
Difficulty Starting Urination
Bloody/Cloudy Urine
Waking Up at Night to Urinate
Skin:
Rash
Hives
Itching
Easy Bruising
Easy Sun Burning
New/Changing Mole
Hair Loss
Change Skin Texture - Dry or Moist
Musculoskeletal / Neurologic / Vascular:
Joint Pain
Joint Swelling/Redness
Morning Stiffness Longer than 1 hour
Muscle Pain
Muscle/Leg Cramps
Weakness of Arm or Leg
Tremor
Varicose Veins
For All Men:
What form of contraception are you/ your partner using?
Lumps or swelling of testicles?
Problems with impotence?
Discharge from the penis?
For men over 40, date of your last rectal exam?
For All Women:
Number of times pregnant?
Total term births?
Total preterm births?
Total miscarriages?
Total therapeutic abortions?
Complications of pregnancy?
Vaginal discharge or irritation?
Pelvic pain?
Discomfort with intercourse?
Breast discomfort, lumps, or discharge?
Have you ever had an abnormal Pap smear or been treated with colposcopy?
When was your last pap smear?
Do you do regular self breast exams?
Do you take a calcium supplement?
If so, how much?
For Menstruating Women:
Your menstrual periods come every
days and last
days.
Date of last menstrual period
Was it normal?
Are your periods regular?
Do you have bleeding between periods?
Any recent change in your menstrual cycle?
How heavy are your menses?
What method of contraception are you using?
What methods of contraception have you used before?
For Menopausal Women:
How long ago was your last period?
Any vaginal bleeding since menopause?
Date of last mammogram?
Rev. 3/13
Release of Medical Information to Family Members
Turnure Medical Group, Inc.

Raymond Turnure, M.D. Kimberly Perkins, M.D. Thomas Stafford, M.D.
David Couillard, M.D. Vance VanTassell, M.D Darilyn Falck, M.D.
I, authorize Turnure Medical Group to discuss and release all medical information
to family members named below. This includes medical records, x-rays, history,
findings and prognosis pertaining to the medical condition, services rendered, or
treatment given to me. This authorization complies with the Confidentiality of
Medical Information Act, Section 56 ET SEQ of the California Civil Code.
__________________________________________________________________
Name
Relationship
___________________________________________________________________
Name
Relationship
___________________________________________________________________
Name
Relationship
___________________________________________________________________
Name
Relationship
________________________________________
Patient Name (Please Print)
____________________
Date of Birth
___________________________________________________________________
Patient, Parent/Guardian or Power of Attorney Signature
Date
PATIENT DEMOGRAPHIC SHEET
Turnure Medical Group, Inc.
Patient Name: _____________________________________________________ Sex: _______
Last
First
Middle
Street Address: __________________________________Marital Status__________________
City: _______________________________ State: _______________ Zip: ________________
Date of Birth: _______/_______/_______ Social Security: _________-__________-_________
Home Phone: (_______) _______-_________ Work Phone: (_______)_________-__________
Cell Phone: (______)_ _______-_________Email:____________________________________
Occupation: ________________________Employer: _________________________________
Who may we thank for referring you? ____________________________________________
IN CASE OF AN EMERGENCY WHO SHOULD WE CONTACT? (OUTSIDE OF YOUR HOME):
Name:_____________________________________Home: (_______)_______-____________
Relationship:__________________________________Cell: (_______)_______-____________
If you have insurance you would like us to bill please present us with your ID card.
Subscriber Name: _______________________________Date of Birth: ______/______/______
Social Security #:________-________-________Relationship to Patient: ___________________
Sex: _____________Street Address: _______________________________________________
City: ___________________________________State: ____________ Zip: _________________
Home Phone: (_________) ________-________ Work Phone: (________) _________-________
Cell: (________) __________-__________ Email: _____________________________________
Occupation: ____________________________Employer: _______________________________
If responsible party different from subscriber please provide us with that information.
6/15
OUR OFFICE POLICIES
It is our philosophy at Turnure Medical Group that our relationship with you is built upon
mutual trust and open communication. We value you as a patient; therefore, it is in your best
interest that we disclose this information to you.
INSURANCE & PAYMENT POLICY FOR SERVICES
Unless prior arrangements have been made we request full payment at time of service. If we
are contracted with your insurance, as a courtesy we will submit your charges for
reimbursement. Your copayment will be collected and if you have a deductible please be
prepared to make a “good faith” estimated deposit on your account until your deductible has
been satisfied. After billing your insurance you will be responsible for any additional coinsurance or services that were not covered. We recommend that you KNOW YOUR PLAN and
what you are covered for as most plans do not cover everything at 100%. You will also be
responsible for any charges that your insurance does not pay in a timely matter or if your
insurance company were to become insolvent. We cannot, as a third party, become involved in
prolonged insurance negotiations as this is a contract between you and your insurance
company. If your check is dishonored by your bank your account will be assessed a $25 nonsufficient funds fee. Any accounts past due over 30 days will be assessed a late fee of $15 per
month. At times it may be necessary for us to file a complaint against your insurance company
or Labor Union. My signature below indicates that I have given Turnure Medical Group
authorization to file a complaint with the Department of Insurance/Managed Care or the Labor
Board on my behalf.
HMO PLANS-Dr. Couillard (Urology) and Urgent Care are the only physicians in our group that
have an HMO contract with Hill Physicians. All HMO plans require PRIOR AUTHORIZATION
from your primary care physician (with the exception of Urgent Care). IT IS YOUR
RESPONSIBILITY TO OBTAIN THE PRIOR AUTHORIZATION prior to your visit. If you are seen
without Prior Authorization you will owe the entire amount for your visit. There are no
exceptions as Hill Physicians will NOT back date Prior Authorizations.
AUTHORIZATION RELEASE
I authorize Turnure Medical Group to release any medical information including diagnosis, xrays, test results, reports and records pertaining to any treatment or examination rendered to
me. I understand that this medical information may be used for diagnostic, insurance, legal and
research at times when my physician deems it necessary in order to ensure the best medical
care on my behalf. I further understand that any person(s) that receives these medical records
will not release any medical information obtained by this authorization to any other person or
organization without further authorization signed by me for release of information. This office
protects patient’s information in accordance with the Health Insurance Portability &
Accountability Act (HIPAA). My signature below indicates my authorization and acknowledges
that I have received information on our Office Privacy Practices.
Print name: _________________________________________________________________
Signed: _______________________________________________Date:__________________
Patient, Parent/Guardian or Power of Attorney
Patient Demographic Questionnaire
Turnure Medical Group
Name: ______________________________
(Patient Name - Please print)
Date of Birth: _____________________
We are asking for your race and ethnicity because some people of different backgrounds have a
greater risk of developing certain diseases such as high blood pressure, diabetes and heart
disease. It is also important for us to know your preferred spoken language so that we may
communicate clearly with you. This information will be updated in your medical record and will be
kept confidential. Thank you for providing us with this information as it will assist us in continuing to
provide you with the best possible service for your healthcare. We appreciate your participation.
Thank you!
 Race-check the box which best describes you.
Filipino
White/Caucasian
Japanese
Black/African American
Korean
American Indian/Alaska Native
Vietnamese
Asian Indian
Other Asian
Chinese
Native Hawaiian
Guamanian/Chamorro
Samoan
Other Pacific Islander
Other Race
I prefer not to answer

Ethnicity:
Non-Hispanic/Latino
Hispanic/Latino
I prefer not to answer

Please indicate your preferred spoken language.
We are required by law (CA Health & Safety Code AB800, Section 123147) to request this
information.
Spanish
English
Other:_______________________
I prefer not to answer

Communication Preference:

Smoking Status:

Marital Status:
Home Phone
Cell Phone
Quit Smoking
Never Smoked
Current Daily Smoker
Married
Widowed
US Mail
Current Occasional Smoker
Never Married
Legally Separated
Domestic Partner
Annulled
Divorced
Preferred Imaging Facility:
_______________________________________________
Preferred Hospital:
_______________________________________________
Preferred Pharmacy/Location: _______________________________________________
Preferred Lab:
_______________________________________________
_________________________________________________
Signature (Patient, Parent/Guardian or Power of Attorney)
____________________________
Date
Rev. 4/15
Turnure Medical Group
Pre-Authorized Credit Card Agreement
I hereby authorize Turnure Medical Group to charge the card listed below for any
amount owed by me (or my family) after my insurance has been billed.
This amount may be due to deductibles, co-insurance, unpaid co-pays or any
amount that may not be covered by your insurance company. A receipt will be
emailed once the card is charged.
Cardholder’s Full Name:____________________________________________
Billing Address (include zip):_________________________________________
Card Number:____________________________________________________
Exp. Date:_______________________________________________________
Please circle one:
Visa
Mastercard
Discover
HSA
Patient’s Name: __________________________________________________
(Please Print)
Date of Birth:
__________________________________________________
Please list all family members that you would like to add to your credit card:
Name:
Date of Birth:
______________________________________
_______________________
______________________________________
_______________________
______________________________________
_______________________
Phone Number: __________________________________________________
Insurance Plan Type:
Co-Pay Plan
Deductible Plan
Signature: _______________________________________________________
Date:___________________________________________________________
Please provide us your email address and we can email you the receipt
Email:__________________________________________________________
Would you like to be added to our mailing list?
Office Use Only:
CCA/UCC _______
Notes
_______
Scanned _______
Yes
No
Notice of Privacy Practices
Turnure Medical Group, Inc.
This notice describes how medical information about you may be used and disclosed by
Turnure Medical Group and how you can get access to this information. Please read carefully.
What is This Notice and Why is it Important?
Each time you visit our office a record of your visit is made. Typically this record contains a
description of your symptoms, medical history, exam and test results, diagnoses, treatment,
and a plan for future care. This information is referred to as your medical record. This
information serves the following:
 A basis for planning your care and treatment
 Serves as a means of communication among healthcare professionals who contribute to
your care
 Legal document of the care you receive
 Means by which you or your insurance company can verify the services you received
were appropriately billed
 A tool with which we can assess and work to improve the care we provide
Your Health Information Rights
You have the following rights related to your medical and billing records kept:
 Obtain a copy of this notice. You will receive a copy of this notice at your first visit.
Thereafter you may request a copy of this notice or any revisions by asking our staff or
calling us at (916) 624-3500.
 Authorization to use your health information. Before we use or disclose your
health information other than as described below, we will obtain your written
authorization, which you may revoke at any time to stop future disclosure.
 Access to your health information. You may request a copy of your health
information that we keep in your medical or billing record. Your request must be
submitted in writing. We may charge a fee for the costs involved in providing you
access and for your copies.
 Amend your health information. If you believe the information we have about
you is incorrect or incomplete, you may request that we correct the information. Your
request must be in writing.
 Request confidential communications. You may request that when we
communicate with you about your health information, we do so in a specific way (ie. at
a certain mailing address, email or phone number). We will make every reasonable
effort to comply with your request.
 Limit our use of your health information. You may request that we restrict the
use or disclosure of your health information for treatment, payment, healthcare
operations, or any other purpose except when specifically authorized by you, when we
are required by law or in an emergency situation in order to treat you. We will consider
your request and respond, but we are not legally required to agree if we believe your
request would interfere with our ability to treat you or collect payment for our services.

Accounting disclosures. You may request a list of disclosures of your health
information that we have made for reasons other than treatment or payment of
healthcare operations.
Other Responsibilities
We are required by law to protect the privacy of your healthcare information, establish
policies and procedures that govern the behavior of our staff and business associates and
provide this notice about our Privacy Practices and abide by the terms of this notice.
We reserve the right to change our policies and procedures for protecting health
information. When we make a significant change in how we use or disclose your health
information, we will also change this notice. This new notice will be available as a “Waiting
Room Copy” or at the front desk if requested.
Except for purposes related to your treatment, to collect payment for our services, to
perform necessary business functions, or when otherwise permitted or required by law, we will
not use or disclose your health information without your authorization. You have the right to
revoke your authorization at any time. We are unable to take back any disclosure we have
already made with your permission.
Special Situations
 Military and Veterans. If you are a member of the armed forces, we may disclose



your health information as required by military command authorities. We may also
disclose health information about foreign military personnel to the appropriate foreign
military authority.
National Security and Intelligence Activities. We may disclose your health
information to authorized federal officials for intelligence, counterintelligence, and
other national security activities authorized by law.
Protective Service for the President and Others. We may disclose your health
information to authorized officials so they may provide protection to the President and
other governmental leaders, or conduct special investigations.
Regulatory Oversight. We may disclose your health information to appropriate
health oversight agencies, public health authorities or attorneys, when required by law.
Your health information may also be disclosed if a workforce member or business
associate believes in good faith that Turnure Medical Group has engaged in unlawful
conduct or has otherwise violated professional or clinical standards and is potentially
endangering one or more patients, workers or the public.
For More Information or to Report a Problem
If you believe we have not properly protected your privacy, have violated your privacy rights
or you disagree with a decision we have made about your rights, you may contact Dr. Turnure
directly at (916) 624-3500. He can also be contacted with any questions you have or if you
need any additional information. You may also send a written complaint to the U.S.
Department of Health and Human Services. Turnure Medical Group will ensure that the care
you receive at our facility will in no way be impacted if you file a complaint.