Del Mar Surgical - New Patient Paperwork Form

Initial Patient Forms
Thank you for selecting our healthcare team. We strive to provide you with the best care possible.

To help us meet your healthcare needs, please fill out this form. It should take about 20-30 minutes to fill out. If you have insurance, please have your insurance card ready.

If you have any questions or need assistance, please ask us. We will be more than happy to help.

Ready to get started?

Olde Del Mar Surgical
PATIENT HIPAA MEDICAL RELEASE FORM

The department of Health and Human Services has established a “Privacy Rule” to help ensure that personal health care information is protected. This rule provides a standard for health care providers to obtain their patients consent for uses and disclosures of health information.

We will do all we can to ensure and protect the privacy of your personal health records. When it is appropriate and necessary, we will provide requested information - but only to those who are in need of it in order to participate in your plan of care.

You may refuse to consent to the disclosure of your information. Under the law, we have the right to refuse to treat you if you choose to exercise this option. You may also request the termination of information sharing at a later date. Any refusal of consent to disclosure must be done in writing. The full text copy of our HIPAA Notice is readily available upon request.

Your signature authorizes the release of necessary medical information to your care team and those individuals you list below. Your signature also acknowledges the understanding of Olde Del Mar Surgical’s HIPAA policy as applicable to you and your plan of care.
I AUTHORIZE MY MEDICAL INFORMATION RELEASE TO:
Print Name*
Date of Birth*

MonthDayYear
Date
Signature*

Clear
Signature of Parent/Guardian/Legal Representative

Clear
Date*

MonthDayYear
Date
**If this authorization changes, it is the patient’s responsibility to contact our office**

Boost Bariatrics
Olde Del Mar Surgical
Patient Acceptance of Financial Responsibility

Olde Del Mar Surgical will bill your insurance company for professional charges rendered in the office and at the facility. In the event that services rendered are not covered by your insurance company, you will be required to make payment to Olde Del Mar Surgical. Balances owed may include, but are not limited to:
- Office visit co-payments: payment of your co-pay is required on the date of service
- Annual deductibles
- Patient share of costs (i.e. coinsurance)
- Services that are not covered by your health plan
Your insurance company may require a prior authorization for initial office and/or follow up visits, certain surgical procedures, radiology exams, labs, prescriptions and/or other professional services provided to you. As a courtesy, we will contact your insurance company for authorization of services. However, it is your responsibility to understand what your insurance policy covers and assure that you have benefits and/or authorization for services. We may request your help in following up on your own for authorization requests and/or any delayed payments.

We have found that patients can sometimes be their own best advocates in facilitating a more timely approval of professional services and expedite payment of services. We suggest staying in communication with your insurance company to confirm authorization or payment has been made for services rendered or requested. Should you have any questions you can reach Jocelyn in our billing department at (858) 272-8853. Should you and Jocelyn come to a financial payment agreement for services rendered, but you fail to notify Jocelyn of any changes and become noncompliant, the agreement made will be null and void and full balance due immediately.

We look forward to seeing you at your next appointment and value the importance of regularly scheduled visits for your overall health and wellness. Thank you.

Late Arrival/No Show-Cancellation Policy

Late Arrival Policy:
- We will do our best to see you at your scheduled appointment time. You should expect to be rescheduled if you are more than 15 minutes late.
No Show/Cancellation Policy:
- We require that you give our office 24-hour notice in the event that you need to cancel or reschedule your appointment.
If you fail to show up to your scheduled appointment and/or cancel with less than 24-hours notice, you will be charged a $50.00 no show/cancellation fee for each cancellation or no show.

Patient agrees and acknowledges that the $50.00 charge is pre-authorized in the event of a cancellation or no show.

I have read the above and understand my financial obligation and late arrival/no show policy.
Printed Name*
Date*

MonthDayYear
Date
Signature*

Clear
Signature of Parent/Guardian/Legal Representative

Clear

Release of Medical Records
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Last four digits of social
I authorize Olde Del Mar Surgical to release copies of my medical records created during the course of my treatment at this facility.
Please Initial to confirm the above *
I authorize blanks to release copies of my medical records created during the course of my treatment at this facility to Olde Del Mar Surgical.
Please Initial to confirm the above *
I authorize the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim to release copies of all my medical records, meaning every page in my record, including but not limited to: radiology, pathology, lab results, operative note, hospital records, progress note, etc.

Approximate Dates of Service for requested Medical Records: blanks
I understand the information is released for continued patient care and may not be provided in whole or in part to any other agency, organization, or person. I hereby waive my/his/her rights to the privileges of confidentiality with respect to any HIV test result or mental health information or drug/alcohol information that may be contained in the medical record. The Healthcare Provider, its employees, and officers and attending physicians are released from legal responsibility or liability for the release of information to the extent stated and authorized herein. Records may be faxed to expedite continuing care.
Signature of Patient *

Clear
Date

MonthDayYear
Date
Signature of Parent/Legal Representative

Clear
Date

MonthDayYear
Date

Notice of Privacy Practice
THIS NOTICE DESCRIBED HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This act gives you, the patients, significant new rights to understand and control how yor health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records for information for the following but not limited to payments, diagnosis, procedures, office notes, operative notes, radiology and laboratory results, etc.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that.
Patient Signature*

Clear
Date

MonthDayYear
Date

CMS Open Payment Database Notice
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For information purposes only, a URL is provided to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturing of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
Patient Signature*

Clear
Date

MonthDayYear
Date
Signature of Patient Representative

Clear

Patient Registration Form
Patient Demographics
Primary Language*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your home address different from your billing address?*

YesNo
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number*
If Not Applicable type (000) 000-0000
Cell Number*
If Not Applicable type (000) 000-0000
Email*
example@example.com
Emergency Contact Name

First NameLast Name
Relationship to Emergency Contact
Emergency Contact Phone Number
If Not Applicable type (000) 000-0000
Employer Name*
Type N/A if Not Applicable
Occupation*
Type N/A if Not Applicable
Referring Physician
Type N/A if Not Applicable
Referring Physician Number
If Not Applicable type (000) 000-0000
Referring Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician*
Type N/A if Not Applicable
Primary Care Physician Number*
If Not Applicable type (000) 000-0000
Primary Care Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have insurance?*

YesNoI will be Self-Pay
Primary Insurance Information
Primary Insurance*
Policy # / ID Number*
Group Number*
Primary Insurance Holder's Name*

First NameLast Name
Primary Insurance Holder's Date of Birth*

MonthDayYear
Date
Primary Insurance Holder's Social Security Number*
Primary Insurance Holder's Phone*
If Not Applicable type (000) 000-0000
Relationship to Patient*
Primary Insurance Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have secondary insurance?*

YesNo
Secondary Insurance
Policy # / ID Number
Group Number
Insurance Holder's Name

First NameLast Name
Insurance Holder's Date of Birth

MonthDayYear
Date
Insurance Holder's Social Security Number
Insurance Holder's Phone
If N/A type (000) 000-0000
Relationship to Patient
Insurance Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I consent to any medical treatment or physical examination required for myself or the minor named above for whom I am legally responsible. I authorize release of medical information necessary to process claims for health insurance and disability benefits, and request that payment be made directly to my physician for services rendered. A copy of this authorization will be accepted to be as valid as the original. There will be a fee of $15 for any returned check.
Initials*
Date*

MonthDayYear
Date
Signature*

Clear

	Yes	N/A	Year	Comments
C-section
Gallbladder removal
Colectomy
Colonoscopy
Flexible sigmoidoscopy
Hemorrhoidectomy
Hysterectomy
Gastric bypass
Gastric sleeve
Lap band
Liver biopsy
Liver transplant
Tubal ligations
Hernia
Other

	Yes	N/A	Relationship to you
Alcohol abuse
Arthritis
Asthma
Cancer
COPD
Depression
Diabetes
Drug abuse
Heart disease
High Cholesterol
High Blood Pressure
Kidney Disease
Mental Illness
Prostate Issues
Stroke (CVA)
Obesity
Other

Initial Patient Forms

Olde Del Mar Surgical

Olde Del Mar Surgical

Release of Medical Records

Notice of Privacy Practice

CMS Open Payment Database Notice

Patient Registration Form

Patient History Questionnaire