MRI Review Packet v2

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 MRI review. If you choose to treat with our office, 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.
For your MRI review, we need the following items

This completed MRI ReviewPacketAny CD’s of your imaging studies (MRI, x-rays, CT scan, etc.) uploaded to our portal (instructions attached)
Please email your MRI Review Packet and MRI report to Courtney@ExcelSpine.com You may also have any records faxed to our office at (619) 333-6029.

If you’re unable to upload your MRI images, you may mail the CD to our office at:

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

The enclosed paperwork is mandatory for your MRI review to take place. Without receipt of this, your MRI review will not proceed.

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 MRI Review, please contact Courtney, our New Patient Coordinator, by phone at (619) 229-5346 or by email at Courtney@excelspine.com. We look forward to hearing from you!

Dr. Choll Kim graduated cum laude from Harvard Medical School and completed his fellowship training in complex spine surgery at the Mayo Clinic. In addition, he is double board certified by the American Board of Orthopedic Surgeons and the American Board of Spine Surgery.

Dr. Kim is an internationally recognized expert in the field of computer-assisted minimally invasive spine surgery. He has trained and continues to train specialists throughout the country on the safe and effective application of state-of-the-art techniques using image guidance and navigation technologies.

Dr. Kim utilizes a broad range of minimally invasive treatments to effectively treat all aspects of complex spinal disorders, including herniated disks, spinal stenosis, adult scoliosis, spondylolisthesis, traumatic injuries, tumors, and infections throughout the entire spine from the neck to the low back. He is one of only a handful of surgeons in the world to master laser endoscopic spine surgery (LESS), a state-of-the-art minimally invasive procedure that effectively treats herniated disks, radiculopathy and sciatica. The LESS procedure can be performed under local anesthesia, in a same day setting and with a small stab incision that is covered with a band aid.

A leader in his field, Dr. Kim is the founder and past-president of the Society for Minimally Invasive Spine Surgery (SMISS), the founder of Minimally Invasive Spine Centers of Excellence (MIS-COE), the chair of the MIS Committee for the International Society for the Advancement of Spine Surgery (ISASS), the director of the Advanced Spine & Joint Institute at Alvarado Hospital and an associate clinical professor at the University of California, San Diego.

Furthermore, Dr. Kim is a Qualified Medical Evaluator and a past voting member of the FDA Orthopedic Devices Panel, which reviews all new spinal technologies. He has designed minimally invasive instrumentation used by surgeons around the world. Dr. Kim is an active member of the North American Spine Society (NASS) and the American Academy of Orthopedic Surgeons (AAOS), and a fellow of the Scoliosis Research Society. Dr. Kim has over 200 publications and presentations.

PATIENT REGISTRATION
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CONDITIONS OF REGISTRATION AND AGREEMENT FOR PATIENTS OF EXCEL SPINE CENTER
CONSENT FOR MRI REIVEW
I hereby consent to the review of my MRI images and any associated diagnostic procedures, including medical history deemed appropriate and necessary by the reviewing physician. I understand that this review is for informational purposes only and does not constitute medical treatment or the establishment of a patient-doctor relationship for treatment purposes. I understand that I will be informed of any potential considerations based on the review, and it is my responsibility to seek further medical advice or treatment as needed.
RELEASE OF INFORMATION
I acknowledge reviewing Excel Spine Center’s Notice of Privacy Practices located at https://excelspine.com/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.
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.

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

By signing below, I am agreeing to the above Consent for MRI Review, Release of Information, and Non-Responsibility. I understand and agree all of the provisions of this Agreement shall remain in full force and effect until revoked by me in writing.
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PATIENT REGISTRATION

CONDITIONS OF REGISTRATION AND AGREEMENT FOR PATIENTS OF EXCEL SPINE CENTER

CONSENT FOR MRI REIVEW

RELEASE OF INFORMATION

NON-RESPONSIBILITY

Signature:

History of Current Injury/Illness

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

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