• COASTAL MEDICAL GROUP

  • PATIENT INFORMATION:

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  • EMPLOYMENT INFORMATION

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  • Brief description of incident:

  • SLIP AND FALL ONLY

  • DOG BITE ONLY

  • CURRENT MEDICATIONS:

  • HABITS

  • SURGICAL HISTORY

  • MEDICAL HISTORY

  • I hereby irrevocably assign and transfer all payments of benefits for the services rendered to be made directly to Coastal Medical Group regardless of my insurance benefits, if any, and agree to allow a photocopy of my signature to be used to file insurance. I understand that each patient (Or responsible party) is financially responsible for services rendered. I acknowledge that the Medical Authorization & Lien is incorporated by reference to this document. In the instance of dispute with my insurance company regarding payment, I authorize Coastal Medical Group to act on my behalf. While the business Office is pleased to assist in the preparation and submission of insurance forms, the obligation for payment remains the patient's or the responsible party. In the case of an accepted Worker's Compensation injury, it is understood that the patient is not financially responsible. I also authorize Coastal Medical Group to render medical Treatment.

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  • Authorization to Release Medical Records

  • I,     ,by this release, authorize and request you to release to Coastal Medical Group any and all information and/or records in your possession, or to which you have access, including medical records, reports, files, charts, memoranda, correspondence, raw data, test results, emergency mom records, pharmaceutical records, problem lists, medication lists, visit notes, specialty consultative reports, hospital admitting and discharge reports, laboratory test results, x-ray and all other diagnostic tests, any and all records related to the diagnosis and/or treatment, any and all records, reports, data, memoranda, correspondence, charts, or other records related to psychiatric and/or psychological treatment or services given, and all other documents relating in any way to the medical and mental health history pertaining to      .


    I understand that the information in these medical records may include information relating to sexually  transmitted diseases such as acquired immunodeficiency syndrome ("AIDS") and human immunodeficiency virus ("HIV"). It may include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I expressly authorize you to disclose to and/or discuss with the physicians and/or staff associated with Coastal Medical Group. all such information. I further authorize you to disclose any information in your possession that was received from, provided to and/or exchanged with past or present medical doctors,  psychiatrists, psychologists, counselors, or any other individuals.


    I am aware that I can revoke this authorization by writing Coastal Medical Group and/or individual physicians and staff, and indicating that I desire to revoke it. I understand that information disclosed pursuant to this authorization may be re-disclosed to individuals or organizations not subject to HIPAA. I hereby release you in your individual and professional capacity from any and all liability arising from the disclosure of otherwise confidential information.


    A photocopy, facsimile transmission or by electronics means of this authorization shall be as valid as the original. This authorization is valid for three years from the date noted below. I understand that I am entitled to a copy of this release.

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  • THE FOLLOWING NOTICE IS REQUIRED BY CALIFORNIA LAW

  • During the course of your treatment, you may require additional imaging studies. You may be referred to SMI Imaging Center for these tests. Please be aware that some of the doctors that will provide treatment to you have a financial interest of or provides services to the aforementioned facility. Feel free to inquire our staff about the individuals' names.

    There are other facilities available in our medical community where the same procedure(s) can be performed, and you have the option and are free to use any of these alternate facilities. Some of these facilities are listed below.

    The following address is provided for the filing of any complaints relevant to this notice or the services provided: Medical Board of Califomia, 2005 Evergreen Street, Suite 1200, Sacramento, CA 95815.

    I hereby acknowledge receipt of this notice.

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  • Alternative Facilities:

    Imaging Healthcare, MAX MRI, Expert MRI, Valley Radiology 

  • Medical Authorization & Lien

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  • I authorize Coastal Medical Group to furnish my attorney with a full report of my examination, diagnosis, treatment, prognosis, and billing statement of myself regarding the injury sustained as a result of the incident. I authorize my attorney to furnish Coastal Medical Group and individual physicians with documents pertaining to my case, including, but not limited to, attorney's fee agreement, settlement agreement, and judgement or verdict. All prior authorizations are revoked. This authorization shall remain in effect until the sooner of the completion of my case or until revoked by me.

    I further give a lien on my case to Coastal Medical Group and individual physicians against all proceeds of the settlement, judgment or verdict which may be paid to me or to my attorney as a result of the injuries sustained as a result of the incident and treated by Coastal Medical Group and individual physicians. I hereby authorize and direct my attorney to pay directly to Coastal Medical Group such sums as may be due and owed to them for medical services rendered. I understand and agree that payment is not contingent on any insurance company's determination as to appropriateness of services rendered and/or fees charged. I understand that if I miss a scheduled neuropsych test without prior notice, I will be responsible to pay for the full amount of the charges. I understand and accept that Coastal Medical Group and individual physicians do not accept any medical insurance.

    This lien does not replace/supersede my own responsibility for outstanding medical bills, but is given as protection for the physician and in consideration for the physician's willingness to wait for delayed payment. I understand that payment of all outstanding fees to Coastal Medical Group and individual physicians are payable upon demand and are not contingent on the receipt of an award through settlement, judgment or verdict.

    I agree to promptly notify Coastal Medical Group and individual physicians of any change or addition of attorney(s) used by me in connection with this incident and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted or added attorney(s).

    In the event legal action is required to enforce any provision of this Lien Agreement, the prevailing party in such action shall be entitled to reasonable attorney's fees and costs, including but not limited to collection costs, enforcement of judgment, wage garnishment, etc.

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  • As the attorney of record for the above patient, I agree to observe the terms of this agreement, and to withhold from my award, settlement, judgment or verdict without demand in this case such sums as are required to adequately protect and fully compensate Coastal Medical Group and individual physicians with payment of outstanding bills/costs owed to Coastal Medical Group and individual physicians by      . In the event a dispute regarding this lien occurs, attorney agrees to hold the full amount of outstanding balance in attorney's client trust account until full resolution is obtained. I further agree to inform Coastal Medical Group and individual physicians in a timely matter any change in representation of       such as addition of new attorney or substitution of an attorney, withdrawal from the case, decision of not pursuing the case, etc.

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  • Coastal Medical Group Telemedicine Consent

  • I      agree to receive health care services via telehealth. I understand that:

    1.  California law defines telehealth as the “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers." See Business and Professions Code 2290.5
    2. All providers must comply with relevant laws, regulations, ethical standards, and policies to ensure the confidentiality of clients.
    3. I have the right to access Coastal Medical Group services through an in-person, face-to-face visit or through telehealth.
    4. The use of telehealth is voluntary, and I may withdraw my consent to, or stop receiving services through telehealth at any time without affecting my ability to access medical services through Coastal Medical Group in the future.
    5. I acknowledge there may be limitations or risks related to receiving services through telehealth as compared to an in-person visit. For example, it may prove difficult to assess an ankle injury without actual physical examination of the ankle to determine exactly where the pain may be originating, or showing range of motion of a shoulder injury.
    6. Acceptable technologies. A provider who wants to use audio or video communication technology to provide services via telehealth can use any “non-public facing remote communication product” that is available to communicate with patients. Specifically, they may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, or Zoom.

    I have read this document carefully, understand the potential limitations and risks of receiving medical services via telehealth and have had my questions answered to my satisfaction.

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