Pediatric Fees - Smart PDF

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

Consent for Anesthesia Services
The following is provided to inform patients and parents about having treatment under anesthesia. The information is not presented to make you more apprehensive, but rather to enable you to better understand the risks and benefits involved with anesthetic treatment.

I hereby authorize and request any Dentist Anesthesiologist represented with Bay Anesthesia Group to administer anesthesia as previously discussed with me. I understand and agree that procedures not talked about, but deemed necessary for myself/my child's well-being, may be performed to supplement the planned anesthesia. It has been explained to me that all types of anesthesia, although safe, involve some risks and no guarantees can be made concerning results. Serious complications are very rare. The following are complications that may be associated with the anesthetic treatment:

Common complications:
- Pain and/or bruising at the IV site
- Sore throat and/or hoarseness
- Muscle aches
- Nausea and/or vomiting
Uncommon complications:
- Headache
- Injuries to lips or teeth from airway instruments or devices
- Unexpected drug reaction
- Infection at intravenous site and veins nearby
- Bleeding/injury in the nose due to passage of a breathing tube
- Lung infection
- Eye injury or infection
- Weakness in breathing after awakening
- Nerve damage
Rare complications:
- Heart injury
- Brain damage or death
The administration and monitoring of general anesthesia may vary depending on the type of procedure, the type of practitioner, the age and health of the patient, and the setting in which anesthesia is provided. Risks may vary with each specific situation. You are encouraged to explore all the options available for your/your child's anesthesia for dental treatment, and consult with your dentist or physician as needed.
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com
Alternative options to deep sedation/general anesthesia have been discussed with me and may include the use of local anesthesia with nitrous oxide sedation or local anesthesia alone.

All sedation and anesthesia patients must be accompanied to and from the appointment by a responsible adult. The responsible adult should remain in the office during the appointment unless authorized by the practitioner. For the safety of the patient, the responsible adult must remain in the designated waiting area during treatment time. Office staff will escort the responsible adult back to the treatment area once the anesthesiologist deems it is safe, to be present for recovery. Upon release, the patient must be driven home by the responsible adult (public transportation or cabs are not acceptable).

I confirm that myself/the patient has not had anything to eat (other than indicated medications with water) for at least seven (7) hours prior to anesthesia, and only clear fluids were consumed up to two (2) hours prior to anesthesia.

I certify that to the best of my knowledge, myself/the patient is not pregnant or trying to become pregnant.

I have read and agreed to the Notice of Privacy Practices/HIPAA agreement posted on our website www.bayanesthesiagroup.com.

I consent to the anesthesia deemed appropriate by my Dentist Anesthesiologist. I acknowledge that I have read this form or had it read to me and that I understand the risks, alternatives and expected results of the anesthetic plan of care.
Patient Signature or Legal Guardian's Signature (If completed on behalf of the Patient)*

Clear
Date*

MonthDayYear
Legal Guardian's Name Printed (If completed on behalf of the Patient)*
Legal Guardian Relationship to Patient*
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com
Authorization for Release of Medical Information

Authorization
I hereby authorize the release of all health information pertaining to medical history, mental or physical condition and treatment received, to Bay Anesthesia Group. This information is imperative in order to be effectively screened by my anesthesiologist for dental treatment under General Anesthesia.

I also hereby authorize the release of any health information received by my anesthesiologist to be shared with the treating provider of my dental services, should it pertain to my safety and well being while under General Anesthesia.

My Rights

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
Patient Name*
Legal Guardian's Name Printed (If completed on behalf of the Patient)*
Date*

MonthDayYear
Patient Signature or Legal Guardian's Signature (if completed on behlf of the patient)*

Clear
Legal Guardian's Relationship to Patient*
160 W. Foothill Pkwy Ste 105 #244 Corona, CA 92882

Designation of Financial Responsibility

Bay Anesthesia is a private "Fee-for-Service" company and payment is due in full at the time services are rendered. We are a completely separate entity from your dentist and all related fees, operative times and/or orders are separately charged and billed. Although separate entities, your dental office is authorized to provide personal information to us as it pertains to your anesthesia account with Bay Anesthesia, and vice versa.

Bay Anesthesia Group does NOT accept insurance as payment for services. Upon request, we can provide you with an itemized receipt and a copy of the anesthesia record, from the day of treatment (after your balance has been paid in full) that you may submit directly to your insurance company for potential out-of-network reimbursement. We do not guarantee that you will receive reimbursement from your insurance company. Please contact your carrier directly with any questions regarding your coverage, their payment policies, and reimbursement procedures.

Once your deposit has been paid, your appointment will be confirmed with our office. The remaining balance is due in full on the day of the procedure, and will be automatically charged to the card on file on or after treatment is completed, until the balance is paid in full.

I certify that I have read, understood, and acknowledged the above information. By completing the below information, I also understand and acknowledge my financial responsibility for the anesthesia services provided by Bay Anesthesia Group.
Patient Name:
DOB:

MonthDayYear
Financially Responsible Party #1

Financially Responsible Party #2 (Optional)
Name:*
Name:
DOB:*

MonthDayYear
DOB:

MonthDayYear
Social Security Number:*
Social Security Number:
Driver's License:*
Driver's License:
Expiration Date:*

MonthDayYear
Expiration Date:

MonthDayYear
Home Address:*
Home Address:
Employer:*
Employer:
Employer Phone:*
Employer Phone:
Financially Responsible Party # 1:
Signature:*

Clear
Date

MonthDayYear
Financially Responsible Party # 2:
Signature

Clear
Date

MonthDayYear
160 W. Foothill Pkwy Ste 105 #244 Corona, CA 92882

Financial Policy

Welcome to Bay Anesthesia Group! We are honored that you have entrusted us to provide your child's anesthesia treatment. Bay Anesthesia's group of Anesthesiologists specialize in providing hospital quality advanced anesthesia services from the comfort of your own dental office. Please read the information below which outlines your financial obligation for the day of your child's procedure. Should you have any questions, please contact our office directly at 650-282-4171. We look forward to speaking with you!

Payment for Services:
Insurance:
I certify that I have read, understood, and acknowledged receipt of a copy of the above Financial Policy. I also understand and acknowledge my financial responsibility for the anesthesia services provided by Bay Anesthesia Group.
Patient Name:
Date of Service:

MonthDayYear
Patient/Guardian Signature:

Clear
Date:

MonthDayYear
Credit Card Payment Authorization
Cardholder Name:
Card Number:
Expiration Date:
CVV:
Driver's License:
Exp:

MonthDayYear
Address & Zip Code:*
Cardholder Signature:*

Clear
Date

MonthDayYear
160 W. Foothill Pkwy Ste 105 #244 Corona, CA 92882

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

Instructions and Guidelines for Pediatric Patients
Please read the following instructions regarding your anesthesia care. Careful adherence to these instructions will allow us to provide the safest care possible.

Required Steps
1. Fill out the Health History Questionnaire. This information allows us to develop a plan that is most appropriate for your child's needs. Even if you still have questions regarding anesthesia, we will be able to better answer your questions with this information completed. You should receive an email invitation from OnPatient to fill out the forms. (Please remember to register with your CHILD's Name & DOB.) Alternatively, the forms can be found under the 'Payments and Forms' tab on our website. They can be returned to your dental office or directly to our office by one of the following ways: email: info@bayanesthesiagroup.com, fax: (650) 282-4187 or clear photos texted to (650) 282-4171.
2. Review the Consent for Treatment. This will be signed electronically via OnPatient, or you may choose to sign on the day of treatment.
3. Complete the Check-In Process. After you have completed the required Health Forms & Deposit, our office will review your child's health history and clear them for anesthesia. We will then reach out to you by text with all pre-op instructions and eating and drinking guidelines for the day of their procedure. It is IMPERATIVE that you read these messages thoroughly and respond as requested. You will then have an option to receive a phone call from our care team to answer any remaining questions or discuss the anesthesia process in further detail, if you wish. Your check-in process should be completed a minimum of 7 days prior to the day of treatment to ensure your child's safety. If you have not received a text or call from our office within two business days of setting up your child's appointment at your dental office, please contact us directly at (650) 282-4171.
Financial information

A non-refundable $300 deposit is due at the time of scheduling. This will secure your child's scheduled appointment. Your deposit may be completed on our website at: https://bayanesthesiagroup.com. Anesthesia fees are due IN FULL on the day of the procedure, and will be automatically charged to this same card, unless prior arrangements are made. By signing this document, you authorize Bay Anesthesia to submit payment to your credit card for any remaining balance due on or after the date of service, until the balance is paid in full. Please contact our office if you wish for an estimate of anesthesia fees.
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com
- Bay Anesthesia Group is a PRIVATE, FEE FOR SERVICE practice and does NOT accept insurance. Upon request, we can provide you with an itemized receipt and a copy of the anesthesia record, from the day of treatment, that you may submit directly to your insurance company for potential Out of Network reimbursement. We do not guarantee that you will receive reimbursement from your insurance company. Please contact your carrier directly, for any questions regarding your coverage, their payment policies, and reimbursement procedures.
- I attest that I am not a TriCare patient or TriCare beneficiary.
- I attest I am not currently enrolled in a MediCal program.
- Generally, the anesthesiologist will require up to an additional 15 minutes before the dentist can begin treatment and up to an additional 15-20 minutes after the dentist completes treatment. When estimating your anesthesia cost, be sure to account for this anesthesia time in conjunction with the dental time. Anesthesia rates will be reviewed during your pre-operative call or you may request a breakdown of the rates by email.
Other important information

Please read the attached Pre-Anesthesia Instruction form and follow the instructions explicitly. Violation of any of these instructions or other specific instructions from your anesthesiologist may result in the cancellation of your appointment and forfeiture of your deposit.

Please arrive promptly the day of your child's procedure. We will be conducting a thorough physical examination and it is important we have enough time to complete this preanesthetic examination. Late arrivals are subject to rescheduling of the procedure, and may result in the forfeiture of your deposit.

Additional payment policies can be found on our website at https://www.bayanesthesiagroup.com/.
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

PRE-ANESTHESIA INSTRUCTIONS FOR PEDIATRIC PATIENTS
We are here to provide a comfortable experience before, during and after your child's treatment. These instructions are designed with your child's safety and wellbeing in mind. Neglecting any of the following may lead to your case being postponed or canceled without a refund or transfer of your deposit. Please do not hesitate to contact us with any questions or concerns you may have.

9 or More Hours Before the Procedure

Your last meal must be completed at LEAST 9 hours prior to your appointment. For most patients, this meal is dinner. Any dinner foods you would normally enjoy are permitted. Examples would be: meat, eggs, bread and pasta.

7 or More Hours Before Procedure:

A Light Meal is permitted but may ONLY include the following: Fruits, vegetables, apple sauce, yogurt, milk, oatmeal, cereal, toast, clear broth, plain rice and baby formula.

2 or More Hours Before Procedure:

CLEAR FLUIDS and Approved Medications are permitted. ONLY the following fluids are permitted: Water, black coffee (NO creamer or sugar), apple juice, 7up/Sprite, Ginger Ale, Gatorade or Pedialyte. NO MILK. Light Colored Jell-O and Otter Pops are also permitted (*Nothing RED in color please).

**If Your Child's appointment is scheduled in the Afternoon or Early Evening: We highly encourage your child to hydrate with Clear Fluids or Jell-O up to 2 hours before their procedure time!

** PLEASE REFER TO THE EATING & DRINKING GUIDELINES BEFORE ANESTHESIA FOR DETAILED INFORMATION**

Escort: All sedation and anesthesia patients must be accompanied to and from the appointment by a responsible adult. The responsible adult should remain in the office during the appointment unless authorized by the practitioner. For the safety of the patient, the responsible adult must remain in the designated waiting area during treatment time. Office staff will escort the responsible adult back to the treatment area once the anesthesiologist deems it is safe, to be present for recovery. Upon release, the patient must be driven home by the responsible adult (public transportation or cabs are not acceptable).

Clothing and makeup: Casual and comfortable clothing, with short sleeves, and in two pieces, is recommended for easier and more effective placement of monitors. Contact lenses must be removed before the appointment. Facial piercings should also be removed prior to the surgery. Do not wear fingernail polish or use moisturizer on your trunk and arms on the day of the appointment. For children, a change of clothes is recommended.

Change in health: A change in your health, especially the development of a cold or fever, is very important. For your safety, you may be rescheduled for another day. Please inform the doctor of any change in your health prior to your appointment.

School & Day Care: Patients should be kept home from School or Day Care on the day of their procedure in order to ensure they have abided by the strict food & drink guidelines for their procedure. This is imperative to their safety under anesthesia.

After surgery and anesthesia, please be prepared to have a responsible adult caregiver for the remainder of the day. Rest at home and avoid driving, hazardous tasks, making any important decisions, and working for at least 24 hours.
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

POST-OPERATIVE INSTRUCTIONS FOR PEDIATRIC PATIENTS UNDERGOING GENERAL ANESTHESIA
Your child has undergone general anesthesia in addition to dental procedures today. Please read and follow the instructions listed below for the remainder of the day to maximize safety for your child.
1. Do not leave your child unattended for the next 6 to 8 hours. The medication your child has received today may continue to have lasting effects THAT MAY VARY for this time period. Although your child has met adequate discharge criteria before leaving the dental office, occasionally factors such as food intake, changes in environmental stimulation, resolution of pain and other factors may cause your child to be somewhat sleepy or uncoordinated. Check on your child periodically if he/she falls asleep. It is normal for a child to want to rest for the remainder of the day, however, it is important to be extra attentive that your child's head position facilitates ease of breathing. This means your child's chin should not be dropped down to the chest, as this may obstruct the airway.
2. Do not allow your child to participate in physically demanding activities (sports, etc). Although your child may appear to be fully awake and alert and requesting to participate in such activities, coordination and the ability to react and respond during physical activity may continue to be impaired and lead to unintended injuries.
3. It is recommended that clear liquids are given or offered as soon as possible as your child requests and tolerates it. Other liquids and food should be advanced as the child tolerates it. Sometimes, your child may vomit or become nauseous as food and liquid are given. If this occurs, rest, and resume with clear liquids. Encourage as much fluid intake as possible throughout the day as this will help your child recover from the medications he or she has received. IT IS IMPORTANT THAT YOUR CHILD NOT BECOME DEHYDRATED. The lasting effects of the medications combined with a state of dehydration is a dangerous situation.
4. Pain control strategies will have been discussed prior to discharge. It is important to follow these instructions carefully. Typically, over the counter acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) are okay to consume as directed by the manufacturers recommendations as needed for pain.
5. As long as your child's mouth is still numb from the local anesthetic you should not give hot beverages or hard food. Similarly, watch for lip/cheek/tongue biting or picking around the mouth. The patient may not feel that s/he is traumatizing the tissues of the mouth and an ulcer could develop. The numbness generally lasts 3-4 hours.
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Your anesthesiologist's direct phone number is listed below. If they cannot be reached, you can call our 24-hour line and follow the prompts to connect with our on-call doctor. Please call if any of the following are observed:
1. Your child still appears sleepy and lethargic and 'not normal self' after 6 hours
2. Persistent nausea or vomiting (vomiting once or twice is normal, but extended bouts of vomiting is not normal)
3. Your child begins to behave strangely
4. There is persistent, excessive bleeding
5. Your child develops a high fever (above 100 degrees F) or rash
6. Your child continues to experience pain that is not relieved by over-the-counter medication
CALL 911 IMMEDIATELY if you observe the following:
1. Your child is unresponsive - unable to be awakened or will not follow commands
2. Your child has difficulty breathing
3. Your child has a seizure
4. IF YOU ARE CONCERNED ABOUT THE IMMINENT SAFETY OF YOUR CHILD
Bay Area/Northern California:
Dr. Philip Yen (408) 823-0944
Dr. Andrew Young (909) 538-9101
Dr. Ryan Cheung (415) 812-0503
Dr. Janice Huang (909) 851-2927
Dr. Arielle Freed (626) 696-9973
Dr. MC Ho (412) 927-7937
Dr. Goutam Krish (805) 791-1454
Dr. Vivien Lee (702) 996-7521

Los Angeles/Southern California:
Dr. Michael Alanes (323) 553-0055
Dr. Taylor Chock-wong (805) 807-9243
Dr. Philip Yen (408) 823-0944
Dr. Andrew Young (909) 538-9101
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

Confirmation of Receipt of Pre-Operative Instructions and Guidelines
I have thoroughly read the above pre-operative instructions, including the food and drink guidelines that must be adhered to in order for my child to be seen on our scheduled day of treatment. I understand that these guidelines are imperative to my child's safety, and should they not be followed explicitly, Bay Anesthesia reserves the right to refuse anesthesia treatment and withhold my paid deposit. I further understand that arriving after our scheduled procedure time may result in the cancellation or rescheduling of the appointment, and may result in the forfeiture of my paid deposit.

Lastly, I understand anesthesia fees are DUE IN FULL on the day of the procedure, and will be automatically charged to the same card used for my deposit, unless prior arrangements are made.I authorize Bay Anesthesia to submit payment to my credit card for any remaining balance due, on or after the date of service, until the balance is paid in full. An estimate of anesthesia fees is available upon my request.

Should I have any additional questions regarding these policies, I will contact Bay Anesthesia Group directly at (650) 282-4171.
Patient Signature or Legal Guardian's Signature (If completed on behalf of the Patient)*

Clear
Date*

MonthDayYear
Legal Guardian's Name Printed (If completed on behalf of the Patient)*
Patient Name:*

Eating and Drinking Guidelines Before Anesthesia

Please follow the guidelines outlined below before your child's/your procedure to ensure an empty stomach at the time of anesthesia. If the stomach is not empty at the time of anesthesia, stomach contents can enter the airway, make their way to the lungs (called aspiration) and can cause serious health complications and lung scarring.

**No gum, candy or mints on the day of your appointment

For any questions about the Eating and Drinking Guidelines, please contact us by phone or text at 650-282-4171. We are happy to provide you with detailed instructions based on your appointment time, provided by your dental provider. You may also use our online calculator to help determine what time you will need to begin fasting.
https://bayanesthesiagroup.com/food-and-drink-calculator/

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; physical examination, medical consultations, rendering of anesthesia services, referring you to another doctor or clinic for other health care or services or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney) "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we will ask you for special written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
- When a state or federal law mandates that certain health information be reported for a specific purpose;
- For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
- Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicaid; or for investigation of possible violations of health care laws;
- Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
- Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime to provide information about a crime at our office; or to report a crime that happened somewhere else;
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com
- Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- Uses or disclosures for health related research;
- Uses and disclosures to prevent a serious threat to health and safety;
- Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes, or for the evaluation and health of members of the foreign service;
- Disclosures of de-identified information;
- Disclosures relating to worker's compensation programs;
- Disclosures of a "limited data set" for research, public health or health care operations;
- Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
- Disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information.
Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental anesthesia care.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a postcard and/or email you and/or leave you a reminder voicemail on the phone number provided or with someone who answers your phone.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes we may initiate the authorization process if the use or disclosure is our idea. Sometimes you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make use of the disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information You can:
- Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restrictions, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
- Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address or by using email to your personal email address. We will accommodate these requests if they are reasonable and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
- Ask to see or get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or 60 days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
- Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 day from when you ask us. We will send the corrected information to persons who we know got the wrong information and others that you specify. If we do not agree, you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to considera request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or email shown at the beginning of this notice.
Patient Name:*

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com
- Get a list of the disclosures that we have made of your health information within the past six years (or shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations, disclosures with your authorization, incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice.
- Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got the one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or email shown at the beginning of this notice
OUR NOTICE OF PRIVACY PRACTICES

By law we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice on our website and have copies available upon request.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or email shown at the beginning of this notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this notice.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of Bay Anesthesia Group's Notice of Privacy Practices.
Patient Signature or Legal Guardian's Signature (If completed on behalf of the Patient)*

Clear
Date*

MonthDayYear
Legal Guardian's Name Printed (If completed on behalf of the Patient)*
Patient Name:*
Should be Empty:

Medical History for Pediatric Patients

Condition

Yes

No

If Yes, Please Provide Further Details

Condition

Yes

No

If Yes, Please Provide Further Details

Consent for Anesthesia Services

Authorization for Release of Medical Information

Designation of Financial Responsibility

Financial Policy

Credit Card Payment Authorization

Instructions and Guidelines for Pediatric Patients

PRE-ANESTHESIA INSTRUCTIONS FOR PEDIATRIC PATIENTS

POST-OPERATIVE INSTRUCTIONS FOR PEDIATRIC PATIENTS UNDERGOING GENERAL ANESTHESIA

Confirmation of Receipt of Pre-Operative Instructions and Guidelines

Eating and Drinking Guidelines Before Anesthesia

NOTICE OF PRIVACY PRACTICES