FIRST MIDDLE GENDER SECONDARY I SUPPLEMENTAL INSURANCE COMPANY STREET ADDRESS
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1 CALIFORNIA ORTHOPAEDIC INSTITUTE MEDICAL ASSOCIATES, Inc. INSTITUTE (PLEASE PRINT & COMPLETE ALL QUESTIONS) PATIENT'S NAME HOME I MAILING ADDRESS LAST FIRST MIDDLE GENDER 0 MALE 0 FEMALE STATE ZIP CODE DATE OF BIRTH SOCIAL SECURITY # PHONE# HOME WORK ADDRESS MARITAL STATUS 0 S 0 M 0 W 0 D 0 SEP EMPLOYER OCCUPATION (INDICATE IF A STUDENT) RESPONSIBLE PARTY IF OTHER: NAME 0 SELF 0 OTHER ADDRESS PHONE RELATIONSHIP EMERGENCY CONTACT NAME PHONE RELATIONSHIP REFERRING MD REFERRED BY, OTHER THAN MD NAME OF INSURANCE COMPANY (PRIMARY) SECONDARY I SUPPLEMENTAL INSURANCE COMPANY STREET ADDRESS STREET ADDRESS CITY, STATE & ZIP CODE CITY, STATE & ZIP CODE GIVE NAME OF POLICY HOLDER GIVE NAME OF POLICY HOLDER GROUP I POLICY NO. SUBSCRIBER/ l.d. NO. GROUP I POLICY NO. SUBSCRIBER/ 1.D. NO. 0 ACCIDENT 0 AUTONEHICLE 0 JOB RELATED 0 OTHER, Explain I hereby authorize California Institute Medical Associates, Inc., to furnish to my insurance company or to a designated attorney, all information which the insurance company or attorney may request. I hereby assign to the above referenced physicians all monies to which I am entitled and/or surgical expense relative to the services rendered by either of them. It is understood that any money received from the abovenamed insurance company, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible. WHETHER MY INSURANCE COMPANY PAYS OR NOT. for all costs incurred by me. I further agree that in the event of non-payment, I will bear the cost of collection and/ or Court cost and reasonable legal fees should such court action be required. I agree that a photocopy of this authorization shall be as valid as the original. Insured or Guardian Signature Patient's Signature
2 INSTITUT E f~ntcrlco11 no.1rd of Orthorw~dk Surgc:r1,1 lljllll"lrn 'i, flcj 11 1 M.f' NOTICE OF DISCLOSURE f 11plr,1n 1I IJJr.ln trl<ji. IJrc.u1 n P1~1c1 ;oo, M D. i l1plr itl 11 Under California Business and Professions Code 654.2, the physicians of California Institute are required to inform you that they have a financial interest in Mission Valley Heights Surgery Center (MVHSC). ldintj,:, $dwlt.:, M.fJ St~vc:n!)if. 1. m.. 11 norjoml<v. M,tJ P1pl,nir11.:: Michael Ii. Oulno, 0.1'1.M. Dl(>lr; mutr:: Should you require outpatient surgery, it is possible that your surgery would be scheduled at MVHSC. By signature below, you are confirming that you have read and understand this notice of disclosure. You may opt to have your surgery performed at a different outpatient facility. An alternative will be discussed with you upon your request. Sincerely, William S. Adsit, M.D. William L. Tontz, Jr., M.D. Michael H. Quinn, D.P.M. L. Randall Mohler, M.D. Jeffrey E. Schultz, M.D. Drew A. Peterson, M.D. Steven Tradonsky, M.D. Patient's signature
3 Qrthopaedic N S Ir 4 1 ii T f!ii Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations I understand that a part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis and surgical information to my bill A means by which a third-party payer can verify that services billed were actually provided And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand that I have the right to view and/or request a Notice of Privacy Practices that provides a more complete description of information uses and disclosures prior to signing this consent. I understand that the organization reserves the right to change their notice and practices, and prior to implementation will post and make available, the revised notice at physical practice site(s). I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I request the following restrictions to the use or disclosure of my health information. I have read and understand the Notice of Privacy Practices. Signature of Patient or Legal Representative Witness Notice Effective
4 INS T I T U T E FINANCIAL POLICY Our office will be happy to bill your primary and secondary insurance carrier as a courtesy if the proper information has been provided. If you do not have insurance, payment is due at the time of service. If you are a Medi-cal patient and do not have your eligibility card, you will be considered a "cash" patient and will be responsible for the balance due. Several insurance companies have a "co-payment" that the patient is responsible for at the time of service. The office will bill the insurance company for the difference and you will not receive a statement. We will bill you for any services that are not covered. Please let the office know if you participate in this type of insurance plan or if you are required to have a referral authorization. If you feel that your insurance company has not responded to your claim, or if you question the amount covered, please contact your insurance company. It is your responsibility to follow-up on claims submitted. We will be happy to assist you if necessary. To our HMO and EPO patients: Please read and sign the following liability statement. I, will assume full financial liability for any non-covered benefit or service denied by my Health Plan. Example: Medical equipment, elective surgeries, etc. Signature Release of Information/ Assignment of Benefits I hereby authorize California Institute to furnish to my insurance company or to a designated attorney, all information which the insurance company or attorney may request. I hereby assign to the above-referenced physicians all monies to which I am entitled and/or surgical expense relative to the services rendered by either of them. It is understood that any money received from the above-named insurance company, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am financially responsible, WHETHER MY INSURANCE COMPANY PAYS OR NOT. for all charges incurred by me. I further agree that in the event of non-payment, I will bear the cost of collection and/or Court cost and reasonable legal fees should such court action be required. I agree that a photocopy of this authorization shall be as valid as the original. Insured or Guardian Signature Patient's Signature :
5 Qrthopaedic N S T T U T E IMAGING CENTER Accredited Magncrit Rtson nte Facility We are required, by law, to disclose the following: (1) California Institute (COi) has ownership in the MRI facility on these premises located in suite 101. (2) You may obtain ancillary services (MRI) from another facility of your choosing and below are five options. (3) Other facilities and their location may be obtained from your insurance company. Please note that COi obtains authorization for your MRI prior to your scan here at our facility. We cannot guarantee that the other facilities are contracted with your insurance company. If you choose another option, please contact your insurance company for assistance. Other options: Open Air MRI - (800) Imaging Healthcare Specialists - 5th & Upas - (619) Imaging Healthcare Specialists - Alvarado Court - (619) Sharp & Children's MRI Center Frost Street - (858) Regents MRI La Jolla Village Drive, Suite (858) We are pleased to provide the MRI service as requested by your physician. If you have questions regarding this information, please ask your doctor or the medical assistant. William S. Adsit, M.D. Jeffrey E. Schultz, M.D. William L. Tontz, Jr., M.D. L. Randall Mohler, M.D. Steven Tradonsky, M.D. Drew A. Peterson, M.D. Michael H. Quinn, D.P.M. Patient Signature DAP:vv 7485 Mission Vollev Rood. Suite l 04. San Diego. California (619) fox: (619)
In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT
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Office Policies Dear Patient: We would like to take the opportunity to explain the policies of our office. Please take notice of the following:
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FURMAN UNIVERSITY SPORTSMEDICINE CENTER
IMPORTANT INSURANCE INFORMATION Dear Parents: Furman University provides an excess coverage policy for our intercollegiate athletes. Incurred medical charges are to be filed with your insurance first.
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
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