New Patient Registration Form

Please select any of the following that apply to you

Refractive/Lasik/RK/PRK - Which eye?    Please Select Left Right Surgeon:   
Date(s):   Date 

Cataract - Which eye?  Please Select Left Right Surgeon:      
Date(s):   Date 
  
Eye lid - Which eye? Please Select Left Right Surgeon:   
Date(s):   Date   

Pterygium - Which eye? Please Select Left Right Surgeon:     
Date(s):   Date 
  
- Which eye?  Please Select Left Right  Surgeon:
Date(s):Date 
  
Other please specify - Which eye?  Please Select Left Right Surgeon:  
Date(s):   Date

Injections - Which eye?     Please Select Left Right Doctor Name:    
Last Injection:   Date              

Copy of Medical Records, Disability, DMV, or Any Other Medical Forms / Paperwork
If you require copies of medical records, please send a written request to authorize the release of such records. There is a $25 upfront charge for copies of medical records or any medical paperwork/form. Please allow 1-2 weeks from the date of your request. Patients may also obtain their medical records from their patient portal at no charge. Please allow 1-2 weeks after your appointment, for your medical records to become available through the patient portal. 
I have read and understand the policy above.                        
I Agree      *(initials)

Missed/Cancelled Appointments
We may charge a $50 late cancellation/missed appointment fee unless we are notified 48 hours in advance. We may charge a $100 late cancellation/missed appointment fee for a scheduled in-office procedure. The cancellation fee is entirely patient responsibility and will not be covered by your insurance company.
I have read and understand the policy above.                        
I Agree      *(initials)

Late to Appointments
If you are more than 15 minutes late for your appointment, out of respect for our other patients, we may ask you to reschedule.
I have read and understand the policy above.                        
I Agree      *(initials)

Refraction Policy
The refraction is a service which measures your best corrected vision. A refraction is used to write a prescription for eyeglasses.
After your first appointment, to obtain your best vision, a refraction may be recommended for you. Please be aware that a refraction is NOT a covered benefit by Medicare or most medical insurance plans. Medical insurance plans consider refraction a "vision" service. It may be covered under VSP insurance, but the Orange County Eye Institute is not a contracted VSP provider. 
You may choose to schedule a refraction with our office or you may choose to schedule with your own optometrist/optical shop. If you choose to receive a refraction in our office, the fee for the refraction will be collected at the time of service. Any copayment, co-insurance, or deductible may apply.
I have read and understand the refraction policy above.        
I Agree      *(initials)

Precautions following Dilation
It may be necessary to dilate your eyes during your eye examination or treatment. Dilation results in light sensitivity and an inability to see clearly for a few hours. We provide free disposable sunglasses. Patients should wear sunglasses outdoors and be cautious when walking and going up or down stairs. We recommend that you not drive or operate dangerous machinery after dilation until your eyes are back to normal. We also recommend that someone accompany you to your appointment to drive you home, or that you wait until your eyes return to normal so that you can drive safely.
I have read and understand the dilation precaution above.     
I Agree      *(initials)

Consent to Audio and Video Recording
For quality assurance purposes, the Orange County Eye Institute has audio and video surveillance in its office spaces, whereby it records all conversations in its office common areas. We do not record in the restrooms or patient exam rooms. While I am on the Orange County Eye Institute’s premises, I understand and consent to the video and audio recording of my conversations. I also acknowledge that I have no expectation of privacy in my communications while I am on its premises.
I understand there is audio and video recording.                      
I Agree      *(initials)

NOTICE AND ACKNOWLEDGEMENT OF RECEIPT AND UNDERSTANDING

George M. Salib, M.D. and Dr. Satvinder Gujral, M.D. are licensed and regulated by the Medical Board of California.  To checkup on a license or file a complaint go to www.mbc.ca.gov,  email: licensecheck@mbc.ca.gov or call (800) 633-2322. 

Insurance Coverage Terms
Your insurance plan is an agreement between you and your insurance company. It’s your responsibility and not that of the Orange County Eye Institute to know your insurance plan terms and conditions. As a courtesy, we try to verify your eligibility/benefits. However, insurance coverage is known only after all the claims are processed by your insurance company. Be aware that some medical insurance policies do not cover routine exams or refractions.
I have read and understand the insurance coverage terms above.         
I Agree    *(initials)

Prior Authorization
If your insurance company requires prior authorization from your Primary Care Provider, it is your responsibility to obtain the relevant authorization prior to your first visit. Without a valid authorization, the full cost of your visit will be your responsibility.
I have read and understand the prior authorization policy above.             
I Agree   *(initials)

HMO, PPO and MEDI-CARE ADVANTAGE Insurances: In-Network/Out-of-Network Status
Any or all of the providers/doctors at this office, and this office itself, may or may not be in network with the patient’s insurance, and this may vary according to which location the patient is seen. The Orange County Eye Institute will not be responsible for informing the patient whether our providers/doctors and/or the office itself (“we”) are IN-NETWORK or OUT-OF-NETWORK with the patient’s insurance. It is solely the patient's responsibility to verify if we are IN-NETWORK or OUT-OF-NETWORK with their insurance plan prior to their first visit and prior to all subsequent visits. The patient is fully responsible for all payments due to the Orange County Eye Institute regardless of whether we are IN-NETWORK or OUT-OF-NETWORK. Additionally, IF we are OUT-OF-NETWORK, the patient will be fully responsible for ALL charges (including additional OUT-OF-NETWORK costs) due to the Orange County Eye Institute that were not paid by the insurance whether or not they were informed of our in or out of network status prior to any appointments or procedures/surgeries.
I have read and understand the policy above.                                          
I Agree      *(initials)

Insurance Claims Processing
If contracted with your insurance, the Orange County Eye Institute will file an insurance claim on your behalf. If we are not contracted with your insurance, it is the patient’s responsibility to file all insurance claims.
I have read and understand the insurance claims policy above.                    
I Agree   *(initials)

Insurance Claim Disputes
The negotiation of payments due to our office and the settling of any claim disputes is entirely the responsibility of the patient.
I have read and understand the insurance claims/disputes policy above.   
I Agree   *(initials)

Copays and Outstanding Balances
All account balances and copays are due at the time of service. We require all account balances to be paid in full prior to your next office visit. Should you require, we will work with you on a convenient payment plan.
I have read and understand the copay and outstanding balance policy above.   
I Agree *(initials)

If your Account is Sent to Collections
Unpaid debt to George M. Salib M.D., Inc./Orange County Eye Institute or OCEI is handled by a third-party collection company. You are responsible for settling any attorney fees, interest, or penalties applicable by law.
I have read and understand the collections policy above.                  
I Agree   *(initials)

Patient Responsibility to Provide Accurate Insurance Information
Insurance companies provide a limited time to submit claims. I acknowledge and agree to be responsible for the full cost of my visit and testing if my insurance information is not provided, inaccurate, ineligible or inactive at the time of my visit.
I have read and understand the policy above.                                        
 I Agree   *(initials)

Medicare Accept Assignment Policy
Orange County Eye Institute will accept the fee approved by Medicare for any “covered services”. The patient will be responsible for any amount approved but not paid by Medicare, for example, the annual deductible and the 20% co-insurance. The patient is also responsible for the full amount of any services not-covered by Medicare. Most diagnostic eye examinations and tests are covered by Medicare. However, refractions and the fitting and supply of glasses or contact lenses are non-covered services.
I agree to assume financial responsibility for co-insurance and deductibles as specified by Medicare. I also agree to assume financial responsibility for charges of any non-covered services that I choose to have performed.
I have read and understand the medicare assignment policy above.          
I Agree   *(initials)

Insurance and Billing Policy Acknowledgement and Consent

I have read and consent to the above insurance and billing policies.

I understand that all charges for professional services not covered by my insurance are my responsibility.

I authorize payments of medical benefits to George M. Salib, M.D. Inc.

Additional Information
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You may ask to receive a copy.

Patient Signature:   Signature   
Date:   Date   
 
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination-notice.
 
According to the Paperwork Reduction Act of 1955, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this Information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
 
Article 2: All Claims Must be Arbitrated: It is the Intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.
 
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician or patient to collect or contest any medical fee shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any malpractice claim, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.
 
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.
 
Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
 
The parties’ consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
 
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05; however, depositions may be taken without prior approval of the neutral arbitrator.
 
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
 
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.
 
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:
 
Effective as of the date of first medical services.  I Agree*(Patient’s or Patient Representative’s initials)
 
If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
 
I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

By: 
Physician’s or Authorized Representative Signature    Date   

By:
Patient’s or Patient Representative’s Signature      Date