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Cardinal Station Newburg Center for Primary Care
215 Central Avenue, Suite 100 1941 Bishop Lane, Suite 900 215 Central Avenue, Suite 205
Louisville, KY 40208 Louisville, KY 40218 Louisville, Ky 40208
I:FCMPhyllis HarrisFormsNew Patient Pkg Components
UofL Department of Family & Geriatric Medicine
Dear New Patient,
Welcome to your University of Louisville Physicians Family practice! We
are offering patient-centered medical care and are enthusiastic about our
relationships with our patients. In order to better serve your needs, we are
enclosing several forms and ask that you completely fill each form out.
The first sheet will help us learn more about you; please completely fill out this
form about your family history. The next sheet is titled, “Authorization for the
use and/or Disclosure of Protected Health Information”, and you will need to
completely fill that out for our doctors to treat you to the best of their ability; it
gives us permission to review your medical records from your previous primary
Following, please completely fill out the Registration, Social Services & Consent
Form. Next, you will find our Privacy Notice, followed by an acknowledgement that
you have received and understand our Privacy Policies. Finally, the last form is the
Office Acknowledgements and Policies form. Please read carefully and sign
your name at the bottom of the letter.
Please make sure to bring all of these forms with you to your first office visit.
Do not mail them back to the office. Also, please remember to always
bring your picture ID, current insurance cards and your co-payment. If your
health insurance requires you to select a primary care doctor please do so prior to
your office visit. Please bring in any and all medication you take, in their
original bottles, to your appointment.
If the patient is under 18 years of age he or she must be accompanied by an
adult and will need to bring a copy of their current immunization certificate.
Please arrive 15 minutes ahead of your scheduled appointment time so that if
you have questions about these forms or we need more information, we can
address it all prior to your appointment.
We look forward to seeing you!
University of Louisville Physicians
UofL Family and Geriatric Medicine
AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT
1. CONTRACT ID CODE
PAGE 1 of 1
2. AMENDMENT/MODIFICATION NO.
3. EFFECTIVE DATE
4. REQUISITION/PURCHASE REQ. NO.
5. PROJECT NO. (If applicable)
6. ISSUED BY CODE
7. ADMINISTERED BY (If other than Item 6)
American Embassy Cotonou
Cotonou, Republic of Benin
8. NAME AND ADDRESS OF CONTRACTOR (NO., street,city,county,State,and ZIP Code)
9a. AMENDMENT OF SOLICITATION NO.
9b. DATED (SEE ITEM 11)
10a. MODIFICATION OF CONTRACT/ORDER NO.
10b. DATED (SEE ITEM 13)
11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS
[ X] The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers
is extended, [ ] is not extended
Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following
methods: (a) By completing Items 8 and 15, and returning __1__ copies of the amendment;(b) By acknowledging receipt of this amendment on each
copy of the offer submitted; or(c) By separate letter or telegram, which includes a reference to the solicitation and amendment numbers.
FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF
OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this
amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram
Or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.
12. ACCOUNTING AND APPROPRIATION DATA (If required)
13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS, IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN
A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE
CONTRACT ORDER NO. IN ITEM 10A.
B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying
Office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b)
C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:
D. OTHER (Specify type of modification and authority)
E. IMPORTANT: Contractor [ X] is not, [ ] is required to sign this document and return 1 original copies to the issuing office.
14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)
The purpose of this amendment is to extend the period of submission of the quotations from May 30, 2017
to thru June 6, 2017 no later than 10:00AM.
Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.
15A. NAME AND TITLE OF SIGNER (Type or print)
16A. NAME OF CONTRACTING OFFICER
Sarah E Kahnt
15B. NAME OF CONTRACTOR/OFFEROR
(Signature of person authorized to sign)
16B. UNITED STATES OF AMERICA
(Signature of Contracting Officer)
May 30, 2017
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