Orthopedic Medical Center2

RESEDA WESTLAKE VILLAGE 18039 Sherman Way, Reseda, CA 91335-4630 1240 S. Westlake Blvd., Suite 237, Westlake Village, CA 91361-1936 Tel 818.708.8100 Fax 818.705-8818 Tel 805.373.3700 Fax 805.371.3717

Account # Patient Name Address Home Phone Work Phone SS Number Cell Phone Marital Status E-Mail LL Date of Birth Sex: Employer

EMERGENCY CONTACT Name:

Phone:

GUARANTOR INFORMATION ( IF PATIENT IS A MINOR) SAME AS PATIENTName Address

SS Number

Date of Birth

HISTORY WHAT TYPE OF INJURY INCURRED? Work Comp. Auto Accident Personal Injury Other EXPLAIN WHAT PORTION OF YOUR BODY WAS INJURED OR REQUIRES TREATMENT?

WHICH SIDE?

HOW DID THE INJURY OCCUR OR WHAT WAS THE ONSET OF CONDITION?

DATE

WHERE DID IT OCCUR? DID YOU RECEIVE PRIOR MEDICAL CARE? WHERE?

IF IN HOSPITAL, NAME OF HOSPITAL FROM: TO:

I AM: Left Handed Right Handed

WHO REFERRED YOU TO THIS OFFICE? Dr. Hospital Relative Friend

NAME PHONE

DO YOU HAVE AN ATTORNEY REPRESENTING YOU? YES NO Name: Address Phone:

PRIMARY CARE PHYSICIAN NAME: Phone Number:

Address Fax Number:

INSURANCE INFORMATION (PRIMARY) Insurance Company Address Phone Contact Policy/Claim/ID # Group # INSURANCE INFORMATION (SECONDARY) Insurance Company Address Phone Contact Policy/Claim/ID Group #

Patient’s Signature Date

Orthopedic Medical Center2

Patient Name: DOB: e-mail address:

We ask because we care. Why are we asking patients about their preferred language, ethnicity, and race? Healthcare organizations will use this information t o learn more about the health needs of our community and better design our services to meet those needs. It will also help us to continue to improve the quality of healthcare we provide to all our patients. Orthopedic Medical Center uses an electronic medical record system that allows electronic prescribing of medications. Medications are sent to your pharmacy through a secure electronic prescription connection (Surescripts) which improves the timely and accurate transmission of your medication information. To optimize the use of this electronic capability, and coordinate your care between us and your specialists, we ask that patients allow us to access their medication history. I consent to allow my provider to access all of my medication history. ____________________ ( Patient’s Initials)

PHARMACY INFORMATION

NAME

ADDRESS STREET CITY STATE ZIP

PHONE NUMBER

FAX NUMBER

Patient Signature: Date:

OFFICE USE ONLY : Entered in the System: Initials

Language Abkhazian French Macedonian Somali

Afar Fulah Malagasy Sotho, Southern

Afrikaans Ganda Malay Spanish Akan Georgian Malayalam Sundanese

Albanian Georgian Maldivian Swahili Amharic German Maltese Swati

Arabic Gikuyu Manx Swedish

Aragonese Greek, Modern (1453-) Maori Tagalog Armenian Greek, Modern (1453-) Maori Tahitian

Armenian Greenlandic Marathi Tajik

Assamese Guarani Marshallese Tamil

Avaric Gujarati Mongolian Tatar

Avestan Haitian Nauru Telugu

Aymara Hausa Ndebele, North Thai Azerbaijani Hebrew Ndonga Tibetan

Bambara Herero Nepali Tigrinya

Bashkir Hindi Northern Sami Tonga (Tonga Islands)

Basque Hiri Motu Norwegian Tsonga

Basque Hungarian Norwegian Bokmal Tswana

Belarusian Icelandic Norwegian Nynorsk Turkish

Bengali Ido Nuosu Turkmen

Bihari languages Igbo Occidental Twi

Bislama Indonesian Occitan (post 1500) Uighur

Bosnian Interlingua Ojibwa Ukrainian

Breton Inuktitut Old Slavonic Urdu

Bulgarian Inupiaq Oriya Uzbek

Burmese Irish Oromo Valencian

Central Khmer Italian Ossetian Venda

Chamorro Japanese Pali Vietnamese Chechen Javanese Persian Volapük

Chichewa Kannada Polish Walloon

Chinese Kanuri Portuguese Welsh

Chuvash Kashmiri Punjabi Western Frisian

Cornish Kazakh Pushto Wolof

Corsican Kinyarwanda Quechua Xhosa

Cree Komi Romanian Yiddish

Croatian Kongo Romansh Yoruba

Czech Korean Rundi Zhuang

Danish Kuanyama Russian Declined to specify Declined to specify Kurdish Samoan

Dutch Kyrgyz Sango

Dzongkha Lao Sanskrit

English Latin Sardinian

Esperanto Latvian Scottish Gaelic

Estonian Limburgish Serbian

Ewe Lingala Shona

Faroese Lithuanian Sindhi

Fijian Luba-Katanga Sinhalese

Finnish Luxembourgish Slovak

French Macedonian Slovenian

Race American Indian or Alaska Native Egyptian Laotian Polish

African English Law Prohibited Polynesian

African American Ethiopian Lebanese Saipanese

Arab European Liberian Samoan

Armenian Fijian Madagascar Scottish

Asian Filipino Malaysian Singaporean

Asian Indian French Maldivian Solomon Islander

Assyrian German Mariana Islander Sri Lankan

Bahamian Guamanian Marshallese Syrian

Bangladeshi Guamanian or Chamorro Melanesian Tahitian

Barbadian Haitian Micronesian Taiwanese

Bhutanese Hmong Namibian Thai Black Indonesian Native Hawaiian or Other

Pacific Islander Tobagoan

Black or African American Iranian Nepalese Tokelauan

Botswanan Iraqi New Hebrides Tongan

Burmese Irish Nigerian Trinidadian

Cambodian Israeili Okinawan Unknown

Carolinian Italian Other Pacific Islander Vietnamese

Chamorro Iwo Jiman Other Race West Indian

Chinese Jamaican Pakistani White

Chuukese Japanese Palauan Yapese

Declined to specify Kiribati Palestinian Zairean

Dominica Islander Korean Papua New Guinean Other Race Dominican Kosraean Pohnpeian Declined to specify

Ethnic Group Andalusian Chilean La Raza Puerto Rican

Argentinean Colombian Latin American Salvadoran

Asturian Costa Rican Law Prohibited South American

Belearic Islander Criollo Mexican South American Indian

Bolivian Cuban Mexican American Spaniard

Canal Zone Declined to specify Mexican American Indian Spanish Basque

Canarian Dominican Mexicano Uruguayan

Castillian Ecuadorian Nicaraguan Valencian

Catalonian Gallego Not Hispanic or Latino Venezuelan

Central American Guatemalan Panamanian Not Hispanic or Latino

Central American Indian Hispanic or Latino Paraguayan Declined to specify Chicano Honduran Peruvian Unknown

Orthopedic Medical Center2FINANCIAL AGREEMENT

PRIVATE INSURANCE POLICY

I authorize the above doctor and/or medical facility to bill my insurance company as a courtesy. I agree to give said doctor information regarding any and all insurance policies which may cover said medical treatment and assign to him the benefits therein.

I further agree to notify said doctor, and pay his billings at such time as I may personally receive payments made directly to myself for these services from my own or any other medical insurance carrier. I do fully realize and understand that I remain personally responsible for said medical services and associated medical billings. If, for any reason, a dispute should arise with my insurance company regarding these claims, I agree that it is my responsibility to rectify the situation; and that if my insurance company needs time to review claims, said office is not obligated to wait for any payment to be issued. Instead, they may, after a reasonable waiting period, request payment from me, and I can receive reimbursement from the insurance company.

Knowing your insurance benefits – including eligibility, covered benefits, and medically necessary procedures is your responsibility; please contact customer services at your insurance company for questions regarding In-Network Status and coverage. You are responsible for any charges not covered by your plan.

I further understand that I will be receiving statements of my account. Such statements will reflect an itemization of charges as well as payments and outstanding balances. I understand that I am personally responsible for the unpaid balance, and I agree to pay said facility such sums in full unless otherwise agreed.

Should the account be referred to an attorney for collection; I agree to pay reasonable attorney’s fees and collection expense.

I certify that I am the patient or an agent duly authorized to execute this agreement, that I have read this agreement, and have received a true and complete copy of it.

MEDICARE PRIMARY INSURANCE ONLY

We are happy to bill your Insurance for you and we do accept assignment. Accepting assignment means that we will accept as payment in full what Medicare and/or Medi-Cal allows for fees charged. You, however will be responsible for paying any deductibles, co- insurances, and non-covered expenses.

Non-covered expenses would include prescribed medications dispensed by this office, dressings, bandages, cast guards, crutches, etc.

We will also bill any secondary insurance for you, such as AARP, but they will also not pay for any expenses not allowed by Medicare and/or Medi-Cal.

Please be sure that you have a complete understanding of what expenses you will be responsible for before signing below.

H.M.O. POLICY

The physicians and Staff are happy to see H.M.O. patients which have been referred to this office for examinations and treatment. As an H.M.O. patient, it is important to remember that ALL SERVICES must be approved by your primary physician and/or the appropriate utilization review personnel. Our contracts with each H.M.O. & I.P.A. vary most notably in regard to such services as x-ray, and dispensing of durable goods. If your H.M.O. covers durable goods we are happy to request authorization for them. You will then be referred to a contracted facility that your H.M.O. specifies. This office will not adjust durable goods dispensed by any other facility.

If diagnostic testing such as M.R.I., Ultrasound, C.T. Scan, Lab tests and in some cases an x-ray needed, we will request to the proper source to help obtain authorization. ·

If you would like this facility to dispense any durable goods that are not covered, or that you are willing to pay for on your own, we will be happy to price that item for you and dispense it at your own request. Please remember however, that payment for durable goods is expected at the time of dispensing.

If Physical Therapy is prescribed we will request authorization for you and you will be sent to a contracted facility that your H.M.O.specifies. It is very important that you receive your therapy in a timely fashion, if you have any concerns please contact your H.M.O. customer service immediately

Please remember that if you do not have authorization prior to receiving any treatment, or if you are not eligible and your insurance company does not cover that treatment, you will be held financially responsible.

CASH PATIENTS (NO INSURANCE)

This is to confirm your agreement to pay the charges you accrue at Orthopedic Medical Center. Beginning with today's charges which would be paid in full at time of services and all future visits to be paid in the same manner.

The approximate charges for today are estimated amount only. The actual fee would depend on the severity of your condition for which you are being examined.

24 HOUR CANCELLATION & “NO SHOW” FEE POLICY

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, Orthopedic Medical Center reserves the right to charge a fee of $30.00 for all missed appointments (“No Shows”) and appointments which are not cancelled with a 24-hour advance notice.

“No Show” fees will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. Multiple “no shows” in any 12 month period may result in termination from our practice.

Patient Name:

Dated: Patient’s Signature

RESEDA WESTLAKE VILLAGE 18039 Sherman Way, Reseda, CA 91335-4630 1240 S. Westlake Blvd., Suite 237, Westlake Village, CA 91361-1936 Tel 818.708.8100 Fax 818.705-8818 Tel 805.373.3700 Fax 805.371.3717

Orthopedic Medical Center2  

I , have received a copy of Orthopedic Medical Center's Notice of Privacy Practices.  

RECEIPT OF NOTICE OF PRIVACY PRACTICES

WRITTEN ACKNOWLEDGEMENT FORM

Patient Signature: Date:

RESEDA WESTLAKE VILLAGE 18039 Sherman Way, Reseda, CA 91335-4630 1240 S. Westlake Blvd., Suite 237, Westlake Village, CA 91361-1936 Tel 818.708.8100 Fax 818.705-8818 Tel 805.373.3700 Fax 805.371.3717