In each category below, if you are not having any difficulties, please simply check "No problems". However, if you are experiencing any of the symptoms listed, PLEASE KINDLY CHECK THE SYMPTOMS THAT APPLY, or explain any that may not be listed.
This questionnaire asks about your symptoms as well as your ability to perform certain activities.
Please answer every question, based on your condition in the last week, by checking the appropriate response.
If you did not have the opportunity to perform an activity in the past week, please make your best estimate of which response would be the most accurate.
It doesn't matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.
We are pleased to have you as a part of our practice, and we look forward to helping you in any way we can on your journey to wellness. Your happiness and health is our number one priority.
Please take a moment to review the following and acknowledge agreement with our policies by signing below. Our office is more than happy to answer any questions or concerns that you may have.
No-Show or Cancellations
We truly respect your time and the efforts that all of our patients make to maintain their scheduled appointments. Out of this respect for other patients’ time, as well as ours, we kindly request that should you need to cancel or reschedule your appointment, please contact our office no less than 24 hours prior to your scheduled appointment time. In the event that the office is not notified, you will be billed for the missed appointment. Similarly, arrivals more than 20 minutes later than the scheduled appointment time will be billed as a missed appointment and rescheduled for the next available consultation. We take pride in the generous time we afford to our patient care and the punctuality of our office, and we ask that you appreciate these policies.
Some of our patients prefer e-mail correspondence and we are happy to communicate in any combination of phone calls, in-person visits, and e-mails. Please allow 2-3 business days for our response to any e-mail correspondence. Please note, as well, that we respect your privacy, and often, specific answers or test results will not be communicated via email. Furthermore, e-mail correspondence is not a substitute for seeking appropriate medical care, and urgent or emergent issues in particular should be addressed to the nearest healthcare facility. E-mail is offered as a convenience for our patients, but we are not liable for any medical information or interpretations conveyed by the content exchanged in our e-mails.
We kindly ask that you remit payment for the visit charges and any associated fees regarding your clinical care at the time of service. All insurance is accepted and will be billed as a courtesy to the patient as either an “in-network” visit or an “out-of-network” visit, depending on the patient’s insurance provider; however, for out-of-network visits, please be aware that specific terms and the insurance company’s contract regarding out-of-network benefits are the patient’s responsibility. Workers’ Compensation claims are not accepted at this time. All patients are responsible for any portion of Dr. Cuéllar’s bill that is not reimbursed by their insurance company, or in total, if no out-of-network benefits are available to the patient. Financing is available for surgical procedures and will be discussed on a case-by-case basis, at the discretion of the surgery center.
Dr. Cuéllar may, at times, utilize electronic communications (i.e. video chat and phone calls) to provide clinical services to her patients without an in-person visit. Appointments such as these are considered telemedicine consultations and therefore will be billed to the patient’s insurance provider accordingly as visits. However, please note that telemedicine appointments may not be covered under your insurance, depending on your plan. It is the patient’s responsibility to check with their insurance provider to verify coverage. By proceeding to provide your signature below, you consent to participate in telemedicine consultations with Dr. Cuéllar when needed.
Limited Liability Affidavit
Please take a moment to review and sign our affidavit regarding liability and legal proceedings regarding your care. A copy of this form once signed will be maintained in your patient record. Please feel free to contact us with any questions or concerns you may have.
Your privacy is of utmost importance and we take great measures to protect it. Please take a moment to review and sign our Notice of Privacy Practices. Under the HIPAA Privacy Rule, our office must obtain your written authorization to use any patient’s protected health information (PHI) for any reasons other than routine treatment, and payment or health care operations. A copy of this form once signed will be maintained in your patient record. Please contact our office with any questions.
Patient Consent for Use and Disclosure of Protected Health Information
I, hereby, give my consent for Dr. Vanessa Gabrovsky Cuéllar MD, Inc. and associated office personnel (referred to collectively from hereon as Dr. Cuéllar), to use and disclose protected health information (PHI) about me to carry out treatment, payment, and health care operations (TPO). The Notice of Privacy Practices provided by Dr. Cuéllar describes such uses and disclosures more completely; by signing below I indicate that I have reviewed and acknowledge the Notice of Privacy Practices.
I have the right to review the Notice of Privacy Practices prior to signing this consent. Dr. Cuéllar reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to firstname.lastname@example.org.
With this consent, Dr. Cuéllar may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Dr. Cuéllar may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, Dr. Cuéllar may send me e-mail correspondence that assists the practice in carrying out TPO, such as appointment reminder cards and patient statements.
I have the right to request that Dr. Cuéllar restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to allow Dr. Cuéllar to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Dr. Cuéllar may decline to provide treatment to me.
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rate share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial office from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.
Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05; however, depositions may be taken without prior approval of the neural arbitrator.
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:
Effective as of the date of first medical services
If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
This notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable health information.
Please review this notice carefully.
A. Our commitment to your privacy:
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
B. If you have questions about this Notice, please contact: Rachel Medina (310) 256-4363
C. We may use and disclose your PHI in the following ways:
The following categories describe the different ways in which we may use and disclose your PHI.
Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.
Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.
Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.
Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.
Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
Release of information to family/friends. Our practice may release your PHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a baby sitter take their child to the pediatrician’s office for treatment of a cold. In this example, the baby sitter may have access to this child’s medical information.
Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.
D. Use and disclosure of your PHI in certain special circumstances:
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.
Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
Law enforcement. We may release PHI if asked to do so by a law enforcement official:
Deceased patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.
Organ and tissue donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Internal Review Board or Privacy Board has determined that the waiver of your authorization satisfies all of the following conditions:
Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.
Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
Workers’ compensation. Our practice may release your PHI for workers’ compensation and similar programs.
E. Your rights regarding your PHI:
You have the following rights regarding the PHI that we maintain about you:
Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Sara Bruno, email@example.com, specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to the office. Your request must describe in a clear and concise fashion:
Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Dr. Vanessa G. Cuéllar 450 N. Roxbury Dr. 3rd Floor, Beverly Hills CA 90210; email: firstname.lastname@example.org; fax: 310-385-9007; in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted Dr. Vanessa G. Cuéllar 450 N. Roxbury Dr. 3rd Floor, Beverly Hills CA 90210; email: email@example.com; fax: 310-385-9007. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
Accounting of disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Dr. Cuéllar 450 N. Roxbury Dr. 3rd Floor, Beverly Hills CA 90210; email: firstname.lastname@example.org; fax: 310-385-9007. All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Dr. Cuéllar 450 N. Roxbury Dr. 3rd Floor, Beverly Hills CA 90210; email: email@example.com; fax: 310-385-9007.
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact [insert name or title and telephone number of the contact person or office responsible for handling complaints]. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.
Again, if you have any questions regarding this notice or our health information privacy policies, please contact Dr. Cuéllar 450 N. Roxbury Dr. 3rd Floor, Beverly Hills CA 90210; email: firstname.lastname@example.org; fax: 310-385-9007.