New Patient Packet v15

A Message from Dr. Choll Kim and Team

We welcome you to our Excel Spine Center family and we thank you for choosing us for your spinal care needs. Our team is committed to providing our patients with the highest level of personalized care. We strive to surpass your expectations and gain your overall satisfaction, but in order to do so, we need to obtain as much information as possible ahead of time to review and prepare for your appointment.

Please bring the following to our office on the day of your appointment:

This completed New Patient Packet

Any records and reports pertaining to your spine (EMG reports, injection reports, operative reports)

Any CD's of your new radiographic images that our office ordered (MRI and/or x-rays)

Any CD's of ALL previous imaging studies (MRI, x-rays, CT scan, etc

You may email your New Patient Packet and records to Courtney@ExcelSpine.com prior to your appointment. You may also have any medical records faxed to our office at (619) 333-6029.
The enclosed paperwork is mandatory for your initial consultation to take place. Without receipt of this document and your imaging studies on CD, your appointment will not be confirmed, and we will need to reschedule. This is to ensure that you receive the best possible care at your initial consultation.

Please do not hesitate to call us with any questions; our office phone number is (619) 344-6918. If you have any specific questions regarding your appointment, please contact Courtney, our New Patient Coordinator, by phone at (619) 229-5346 or by email at Courtney@excelspine.com. We look forward to seeing you!
ADDRESS : 6719 Alvarado Road, Suite 304, San Diego, CA 92120

PATIENT REGISTRATION
PATIENT INFORMATION:
Patient Full Name:*
First and Last Name
Date of Birth:*

MonthDayYear
DOB
Sex:

MaleFemale
Marital Status:

MarriedSingle
Home Address:*
Street address
City:*
State:*
Zip Code:*
Home Phone:
Cell Phone:
Email:*
example@example.com
Social Security #:
HOW DID YOU FIND OUT ABOUT US?
Doctor:
First and Last Name
Attorney:
First and Last Name
Insurance:
Previous Patient:
First and Last Name
Google: (Key words)
Other:
EMERGENCY CONTACT INFORMATION:
Contact Name:
Relationship:
Contact Phone Number:
Please enter a valid phone number.
INSURANCE INFORMATION:
Please email a copy of the front and back of your insurance card to courtney@excelspine.com
Subscriber Name:
Insurance Carrier:
Subscriber ID #:
Plan Type:

HMOPPO/POS

CONDITIONS OF REGISTRATION AND AGREEMENT FOR PATIENTS OF EXCEL SPINE CENTER
CONSENT FOR TREATMENT

I hereby consent to the rendering of care, including diagnostic procedures and treatments, as my physician(s) consider appropriate and necessary. I understand that I will be informed of the risks of any proposed procedures and treatment. I understand that I should decline treatment unless such risks are explained to my satisfaction.

RELEASE OF INFORMATION

I acknowledge receiving Excel Spine Center's Notice of Privacy Practices, detailing how my protected health information may be used and disclosed as permitted under federal and state laws. I have read and understand the contents of the Notice, the terms of which are incorporated in and considered part of this Agreement. Additional copies of the Notice are available upon request.

ELIGIBILITY AND ASSIGNMENT OF INSURANCE BENEFITS

I understand that Excel Spine Center may or may not be a participating provider with my insurance carrier and it is my responsibility to verify this status with my insurance company.

I understand that Excel Spine Center will file all insurance claims as a courtesy. I hereby authorize my current insurance carrier to pay Excel Spine Center out of any benefits due on this claim. I agree that any additional requests for information from my insurance company regarding coverage, coordination of benefits, dates of injury, or any related questions will be answered by me in a timely manner, or the balance due will become my responsibility.

If Excel Spine Center is not a participating provider with my insurance, or if coverage is denied for any reason, I agreeto pay for services as of the date they are rendered. Excel Spine Center does not take responsibility for the refusal of any insurance company to pay for testing or treatment due to lack of insurance benefits.

| hereby authorize payment of any and all Medicare benefits to Excel Spine Center for any services furnished to me. I also authorize Excel Spine Center to release my medical information to the Centers for Medicare and its agents.

FINANCIAL AGREEMENT

I understand that I am financially responsible for all charges incurred for services rendered by Excel Spine Center whether or not they should be paid by insurance or by someone else.

Co-payments, co-insurance, payments for non-covered services and/or deductibles are due at the time of visit. I understand that any deposit made for services incurred is merely a deposit, and that I will be financially responsible for all charges incurred.

In Medicare-assigned cases, Excel Spine Center agrees to accept the charge determination of the Medicare as the full charge, and I will be responsible only for the deductible, co-insurance, and non-covered services. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier.
In the event my account is referred to Collections, I agree to pay all court costs, collection fees and attorney fees associated with the collections of my account.

I agree to provide 24-hours advance notice for all canceled appointments. Should 24 hours advance notice not be provided, I understand that I may be charged a miss appointment fee.

NON-RESPONSIBILITY

I agree that Excel Spine Center and its physicians shall not be responsible for the errors or omission of the employees or contractors of other health care providers who provide services to me.

DISCLOSURE OF COMMON INTEREST

I acknowledge that my physician may have a financial interest in the hospitals, surgery centers, imaging centers, service providers, laboratories and/or implantable and non-implantable devices that he or she chooses to utilize.

As the patient, I understand that I have the right to choose another surgeon, device or request service at another facility. I understand that electing an alternative option will not impact the patient-physician relationship in any manner. If I choose another option, I agree to contact my insurance company to determine coverage and I understand Excel Spine Center does not guarantee that the other providers, devices, services or facilities are contracted with my insurance company.

THIS IS A LEGALLY BINDING DOCUMENT. PLEASE READ BEFORE SIGNING.

By signing below, I am agreeing to the above Consent for Medical Treatment, Release of Information, Eligibility and Assignment of Insurance Benefits, Financial Agreement, Non-Responsibility and Disclosure of Common Interest I understand and agree all of the provisions of this Agreement shall remain in full force and effect until revoked by me in writing.
Print Patient's Name:*
First and Last Name
Print Subscribers Name (If different than patient):
If signed by other than patient, indicate relationship to patient:
Signature*

Clear
Signature Date:*

MonthDayYear
Date
Witness (if applicable):

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES, NO SURPRISES ACT, OPEN PAYMENTS, AND MEDICAL RECORD RELEASE
I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices and No Surprises Act. I further acknowledge that a copy of the current notice will be posted in the reception area as well as the practice's website, and that I will be offered a copy of any amended notice at each appointment.

I also acknowledge that information regarding Open Payments is posted in the reception area and understand that 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

Excel Spine Center is committed to providing comprehensive care of your spine condition. Communication with your medical providers is an important part of providing you excellent care. By signing below, you will allow us to send and/or request for your medical records (clinic notes, operative reports, etc to/from these providers so we can optimize your treatment plan.

Ialso consent to the specific release of the following records: (if applicable) Drug/Alcohol/Substance Abuse, Tests for Antibodies to HIV, Psychiatric/Mental Health, and HIV Diagnosis/Treatment

I am requesting the correspondence concerning my private health information be communicated to me and any other healthcare providers by email. I understand that there is no guarantee of confidentiality with email.

This authorization shall be effective immediately and remain in effect until the doctor/patient relationship ends.
Print Name:*
Signature Date:*

MonthDayYear
Date
Signature:*

Clear
If not signed by the patient, please indicate relationship:

Parent or guardian of minor patientGuardian or conservator of an incompetent patientBeneficiary of personal representative of deceased patient
Name of Patient:

CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION
PURPOSE:

The purpose of this form is to obtain your consent for a telemedicine consultation with a healthcare provider.

NATURE OF TELEMEDICINE CONSULTATION:

Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken.

RISKS, BENEFITS AND ALTERNATIVES

The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.

MEDICAL INFORMATION AND RECORDS

All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.

CONFIDENTIALITY

All existing confidentiality protections under federal and California law apply to information used or disclosed during your telemedicine consultation.

RIGHTS

You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care of treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
My healthcare provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I have read and agreed to a telemedicine consultation.
Print Patient's Name:*
If signed by other than patient, indicate name and relationship to patient:
Signature:*

Clear
Signature Date:*

MonthDayYear
Date
Witness (if applicable):

Who is your Primary Care Doctor? *
First and Last Name
Where is their office located? (City/State)*
Do you see any other doctors on a regular basis? If so, please type their information below:
Name and specialty:
Office Location (City/State):
Name and specialty:
Office Location (City/State):
Name and specialty:
Office Location (City/State):
Please fill out the table below with ALL treatments you have received regarding your spine. Bring the reports/doctor's note for any injections listed below to your appointment.

TREATMENTS:

	WHO/WHERE	WHEN	HOW MANY?	DID IT HELP?
Physical Therapy
Chiropractor
Acupuncture
Injection(s)
Pain Management
Other
Other
Other
Other
Other
Other

Check this box only if you have had no previous treatment for your spine:

I have had no previous treatment for my spine.

THANK YOU! Please select the SUBMIT button below
Should be Empty:

	Medication Name	Strength	# of Pills per day
Medication #1
Medication #2
Medication #3
Medication #4

	Procedure Date	Procedure Name	Doctor
Procedure #1
Procedure #2
Procedure #3

ADDRESS : 6719 Alvarado Road, Suite 304, San Diego, CA 92120

PATIENT REGISTRATION

PATIENT INFORMATION:

HOW DID YOU FIND OUT ABOUT US?

EMERGENCY CONTACT INFORMATION:

INSURANCE INFORMATION:

CONDITIONS OF REGISTRATION AND AGREEMENT FOR PATIENTS OF EXCEL SPINE CENTER

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES, NO SURPRISES ACT, OPEN PAYMENTS, AND MEDICAL RECORD RELEASE

CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION

HISTORY OF CURRENT INJURY/ILLNESS

OTHER MEDICAL HISTORY

PAST SURGICAL HISTORY

SOCIAL HISTORY

SOCIAL HISTORY (CONTINUED)

LUMBAR SPINE: LOW BACK PAIN AND/OR LEG PAIN (OR ANY DISCOMFORT)

If you have low back pain/leg pain (or ANY DISCOMFORT), please answer the following questions by selecting the best answer. Please only select one answer for each question.

CERVICAL SPINE: NECK PAIN AND/OR ARM PAIN (OR ANY DISCOMFORT)

If you have neck/arm pain (or ANY DISCOMFORT), please answer the following questions by selecting the best answer. Please only select one answer for each question.

THANK YOU! Please select the SUBMIT button below