Adult Fees - Smart PDF

I hereby certify that the information provided above is complete and accurate to the best of my knowledge. I acknowledge that any incomplete or inaccurate information may adversely affect my child's treatment and its outcomes. Additionally, I authorize Bay Anesthesia Group to communicate patient information using the contact details provided.
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:*

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:*

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.

I 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:*
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'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 toyour 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 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 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 Adult 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 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. 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 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 your 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 safety. If you have not received a text or call from our office within two business days of setting up your appointment at your dental office, please contact us directly at (650) 282-4171.
Financial information

A non-refundable $500 deposit is due at the time of scheduling. This will secure your 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 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 ADULT PATIENTS
We are here to provide a comfortable experience before, during and after your treatment. These instructions are designed with your 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 and plain rice.

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 appointment is scheduled in the Afternoon or Early Evening: We highly encourage you to hydrate with Clear Fluids or Jell-O up to 2 hours before their procedure time!

** PLEASE ALSO 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.

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 re-appointed for another day. Please inform the doctor of any change in your health prior to your appointment.

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 ADULT PATIENTS UNDERGOING GENERAL ANESTHESIA

You have just undergone IV sedation/general anesthesia in addition to dental procedures today. Please read and follow these instructions to ease your recovery following dental treatment.
1. A responsible adult should drive you home and remain with you, under direct supervision, until you are fully alert.
2. It is normal to feel tired, forgetful, and groggy after anesthesia. Your judgment and mental acuity will be impaired. It is imperative that you do not drive a car or operate machinery while recovering from anesthesia, nor should you attempt to perform any strenuous work or activity. Relax for the remainder of the day.
3. After surgery, you may experience minor discomfort throughout the day. You may have bruising and tenderness at the site of the IV, or a scratchy throat. This is short-lived and should not cause alarm.
4. The local anesthesia (numbing medication) administered during your surgery normally lasts for 4-6 hours, and it is important to take measures to control the discomfort before it wears off.
5. Nausea and vomiting are common after surgery. To minimize symptoms, lie down, avoid dairy products, take narcotic medications (if prescribed) with small amounts of food, and drink clear liquids until resolution occurs.
6. Your diet should include clear liquids only for the first several hours after surgery (water, apple juice, ginger ale, Gatorade, etc). Fluids are important to prevent dehydration. Your first meal should include soft foods (soup, Jell-o, mashed potatoes, etc). in moderate quantities. Once this is tolerated, you may gradually advance your diet to solid foods. If you are diabetic, maintain your normal diet as much as possible, and follow your doctor's instructions regarding your insulin schedule.
7. Do not drink any alcoholic beverages for the remainder of the day.
Please call our office immediately at (650) 282-4171 if you develop any unexpected reactions. Call your anesthesiologistif your IV site becomes red and tender, if vomiting persists beyond 4 hours, if you develop a fever beyond 24 hours, or if any other matter related to your anesthesia causes concern.

Your doctor's 24 hour number is listed below. Do not hesitate to call if you have any questions regarding the 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 to be seen on my scheduled day of treatment. I understand that these guidelines are imperative to my safety, and should they not be followed explicitly, Bay Anesthesia reserves the right to refuse anesthesia treatment and with hold my paid deposit. I further understand that arriving after my 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 fromthe 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 oradministrative 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:*

- Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors toaid 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 withyour 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 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 consider a 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:*

- 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 Adult 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 Adult Patients

PRE-ANESTHESIA INSTRUCTIONS FOR ADULT PATIENTS

POST OPERATIVE INSTRUCTIONS FOR ADULT PATIENTS UNDERGOING GENERAL ANESTHESIA

Confirmation of Receipt of Pre-Operative Instructions and Guidelines

Eating and Drinking Guidelines Before Anesthesia

NOTICE OF PRIVACY PRACTICES