Thank you for choosing Zephyr Medical Group. It is our mission to provide you with the highest quality care. We have implemented a no-show policy which enables usto better utilize available appointments for our patients in need of adequate care. The following policy is applied to patients who fail cancel with  less than 24-hours’ advance notice, or who show up more than 15 minutes late. Should you need to cancel  or reschedule an appointment, please contact our office as soon as possible, and no later than 24 hours  prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting  for an appointment.  

Please see our Appointment Cancellation/No Show Policy below:  

• Effective 01/27/2021, any established patient who fails to show or cancel/reschedule an  appointment and has not contacted our office at least 24 hours in advance will be considered a No  Show and charged a $25.00 fee.  

• Any established patient who fails to show or cancels/reschedules an appointment with no 24-hour  notice a second time will be charged a $50.00 fee. 

• If a third No Show or cancellation/reschedule with no 24-hour notice occurs, we reserve the right  to terminate established patient-physician relationship. 

• Any new patient who fails to show for their initial visit without 24-hr notice will not be  rescheduled. The fee is charged to the patient, not the insurance company, and is due at the time  of the patient’s next office visit. 

• As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive  a reminder call or message, the above Policy will remain in effect. We understand there may be  times when an unforeseen emergency occurs, and you may not be able to keep your scheduled  appointment.  

Should you experience extenuating circumstances please contact our Front Office staff at (949) 347 8721,  who may be able to waive the No Show fee. You may contact Zephyr Medical Group Monday to Friday,  from 8AM to 5PM. Should it be after regular business hours Monday through Friday, or a weekend, you  may leave a message.  

I have acknowledged the policy stated above. 

I the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to FARIED BANIMAHD, MD all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the use of this signature on all insurance submissions.

1. Payment is due at the time of service, unless otherwise notified by intake staff members. We accept cash, checks, and credit cards.

2. All copayments, deductibles and noncovered services must be paid in full at the time of the service, unless otherwise notified by intake staff members.

3. Our office will submit claims to your insurance company as a service to you. It is important that you know what your insurance plan covers. Services not covered by your insurance are your responsibility.

4. If your insurance company requires laboratory specimens be sent to a specific lab, it is your responsibility to know the participating lab. Please be aware of the plan requirements.

5. If your insurance is a managed care plan, please review your coverage. If you require services that require a referral, adequate planning is essential. Referrals must be authorized by your doctor and usually requires an office visit. Authorization from managed care plans for your referral may take one or more days. Please be aware that we are unable to accommodate call in requests for referrals. Failure to obtain necessary authorizations often lead to out of pocket expenses. We are happy to assist you in any way with your managed care plan, however our experience with these plans has demonstrated that planning and adequate lead time is essential. Your knowledge of your regulations and benefits will help avoid delays and/or denied claims.

6. In the case of estranged parents or divorced parents, the parent accompanying the child to the visit is responsible to pay for services rendered regardless of coverage arrangements. We will gladly furnish you with statements for reimbursement.

7. Your doctor is here to manage your medical care. The physicians are not experts on insurance and cannot be aware of all financial arrangements. Please discuss insurance problems and financial arrangements with the office staff.

8. If you are experiencing financial difficulties, please discuss this with the office staff. We will gladly work with you to make payment arrangements. Accounts over 30 days past due will be referred to collections department and upon their determination may be referred to legal department for collection. You will be responsible for additional costs of collections, including legal fees, if incurred.

I have read the above acknowledgements and agreements and fully understand the same.

Most patients under the treatment of Buprenorphine medication are well maintained at a daily dose ranging from 16 mg to 24 mg. Beyond that dosage the effects of Buprenorphine plateau meaning there is minimal use to increasing dosage. It may take several weeks to determine the dosage that is best fit for your needs. The first dose is typically 2 mg while under doctor supervision. If you are transferring to Buprenorphine from methadone maintenance, your dose will be tapered until you have been below 30 mg for at least one week. There must be at least 24 hours (preferably longer) between your last methadone dose and the time of your first Buprenorphine. Your doctor will examine you for clear signs of withdrawal before administering the first dose of Buprenorphine which can often be longer than 24 hours in patients using methadone. What has been described above loosely outlines what is typically called induction and stabilization phase of your buprenorphine part of the treatment for opioid dependence. Your doctor will go into much more detail with you regarding your specific plans of care. For your safety, signing this document means that you understand that you will be in communication with your doctor as discussed and follow plan of care including all dose adjustments. Any deviations from the course without discussions with your doctor may be grounds for dismissal from the clinic. This includes adding any other substance into plan of care without informing your physician. Thank you!

I have read and understand these details about Buprenorphine treatment. I wish to be treated with Buprenorphine.

As a participant in the Suboxone protocol for treatment of opioid abuse and dependence, I freely and voluntarily agree to accept this treatment agreement/contract, as follows:

• I understand that Suboxone(buprenorphine/naloxone combination) is an opiate and has the same addictive properties as other opiates, such as heroin, methadone, codeine, morphine and OxyContin. Stopping Suboxone suddenly will result in the same withdrawal symptoms and put me at the same risk of relapse as with other opiates.

• I agree to keep, and be on time to, all my scheduled appointments with the doctor and treatment nurse. If I am delayed or I must reschedule my appointment, I will page the treatment nurse in a timely way.

• I agree to provide urine for the purpose of toxicology screens at any time during my treatment. The results of these tests will be used to assist me in my recovery goals.

• I agree that my medication prescription can be given to me only at my office visits and only by the doctor or treatment nurse. If I miss scheduled office visits, I may not be able to get a Suboxone prescription until the next scheduled visit. 

• I agree to take my medication as the doctor has instructed and not to alter the way I take my medication without first consulting the doctor.

• I agree that the medication I receive is my responsibility and that I will keep it in a safe, secure place, away from children, pets or any person who could potentially abuse it. I understand that lost medication will not be replaced.

• I agree not to sell, share, or give any of my medication to another individual. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated.

• I agree not to obtain any medications from any physicians, pharmacies, or other sources without informing my treating physician. I understand that mixing Suboxone with other medications, especially benzodiazepines (Xanax, Ativan, Valium, Klonopin), alcohol or other drugs of abuse, can be dangerous. I also understand that a number of deaths have been reported among individuals mixing Suboxone with benzodiazepines. 

• I understand that medication alone is not sufficient treatment for my addiction, and I agree to participate in creating and carrying out a recovery treatment plan. This plan will be revised, with my input and as needed, to assist me in my recovery. The treatment plan will include patient education, referrals to relapse prevention programs and active involvement with those programs.

• If I decide to stop Suboxone therapy at any time, I will work with the treatment nurse and doctor to taper slowly (to reduce discomfort and relapse potential) or to transfer to a methadone program. Stopping Suboxone treatment IN NO WAY affects my relationship with my primary care doctor or my care at the Immunology Clinic.

• FOR WOMEN ONLY: I understand that Suboxone has not been approved for use by pregnant women. I agree to use reliable methods to prevent pregnancy while being treated with Suboxone. If I decide to become pregnant, I know that I can safely use methadone.

1. Prescription refill requests must be called into the staff five days in advance and must be approved by physician. In addition, there is NO guarantee of approval upon the request. An appointment is usually necessary.

2. Messages left for refills will not be honored.

3. Early prescriptions request due to lost/stolen medication or scripts must be accompanied by a police report. No exceptions.

4. Emergency prescription requests less than 24-hour notice, if approved, will have a service fee of $25.

Thank you for your cooperation and understanding. I have read the above acknowledgements and agreements and fully understand the same. 

1. I understand that my health care provider wishes me to engage in a telemedicine consultation. I hereby authorize Zephyr Medical Group to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition.

2. My health care provider has explained to me how the video conferencing technology will be used to affect such a consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that

the videoconferencing connections are not adequate for the situation.

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private. Others may also be present during the consultation other than my health care provider and consulting health care provider in order to operate the video equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.

6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise my local practitioner and that the specialist’s responsibility will conclude upon the termination of the video conference

7. I understand that billing will occur from both my practitioner and as a facility fee from the site from which I am presented. I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

8. I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

9. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me

• That I fully understand its contents including the risks and benefits of the procedure(s).

• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

For the Use and Disclosure of Health Information, Payment, or Healthcare Operations. 42 CFR Part 2 HIPAA (Must be completed and returned by patient prior to treatment)

I understand that Zephyr Medical Group originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and my plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment
• A means of communications among the many health professionals who contribute to my care
• A source of information for applying my diagnosis information to my bill
• A means by which a third-party payer can verify that services billed were provided
• A tool for routine healthcare operations such as assessing quality and reviewing the competence healthcare professionals

I understand that Zephyr Medical Group 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 as already action in reliance thereon, I also understand that refusing to sign this consent or revoking this consent, Zephyr Medical Group may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that Zephyr Medical Group reserves the right to change their notice and practices in accordance with Section 164.520 of the Code of Federal Regulations. I understand that as a part of this organization’s treatment, payment or healthcare operations, it may become necessary to disclose any protected health information to another entity, and I consent to such disclosure of these permitted uses.

I understand that I might be denied services if I refuse to consent to a disclosure for purposes of treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I refuse to consent to a disclosure for other purposes.

I understand that my substance use disorder records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. pts 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations