West Medical - New Patient Package: Bariatrics (English)

The information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected under the federal law. Refusal to sign this authorization will not affect the patient's ability to obtain health care service or reimbursement for services unless authorization is required to bill the patient's insurance company.

2. Person or Agency to Receive Information. West Medical Center, Inc. Dr. Shahram Salimitari. Dr. Hooman Shabatian. Address: 17609 Ventura Blvd. Suite #106. Encino, CA 91316. Phone: (818) 342-2696 Fax: (818) 342-3478

The following items must be initialed to be released

I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance upon this authorization. If I revoke my authorization, the information described above may no longer be used or disclosed for the purpose described in this authorization. Unless revoked earlier, this authorization will expire on the earlier of 1 year from the date of signing.

A multidisciplinary team approach is the optimal approach for the surgical treatment of obesity. The team should involve: (a) a physician with a special interest in obesity; (b) a surgeon with extensive experience in bariatric procedures; (c) a dietitian or nutritionist; and (d) a psychologist, psychiatrist or licensed mental health care provider interested in behavior modification and eating disorders. West Medical has most of this multidisciplinary team on staff. However, West Medical does not work directly with any psychologist, psychiatrist, or licensed mental health care provider. Therefore, in order to provide optimal care, we require you to obtain a mental health evaluation from an outside mental health care provider prior to determining whether bariatric surgery is appropriate care. YOU ARE NOT REQUIRED TO FILL OUT THESE DOCUMENTS. If you complete these documents, we will forward them to the psychologist for review. PLEASE NOTE, SHE IS NOT A PART OF WEST MEDICAL AND SHE WILL BILL YOUR INSURANCE SEPARATELY FOR THIS SERVICE.

RE: Psychological Evaluation. Dear Patient: Prior to surgery every patient must have a psychological evaluation. This is a normal part of the pre-operative procedures. Your surgeon requires it, as does your insurance company in order to get approval for the surgery. Enclosed are some pencil and paper tests that you are required to complete for your psychological evaluation. It is very important that you complete these forms yourself and by yourself. This service is billed to your insurance but there is a discount for cash paying patients. Please note that I am completely separate from your surgeon and the facility. Sincerely,

Please complete the following. Our psychologist will review this along with all of your other pre-operative information and will be contacting you.

Please note having a psychiatric history does not exclude you from surgery.

Below is a list of problems that a lot of people have. Read each one carefully and rate how much that problem has distressed you over the last 7 days. Please rate them as follows: 0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit, 4 = extremely.

agree to allow licensed clinical psychologist, Dr. Melissa Bailey (PSY17402, 3796), and/or her psychological assistants to perform the following services: Psychological testing, assessment, screening and/or evaluation; Report writing; Consultation with other providers outside of the surgeon if needed (with additional release of information); Others: (Please specify below).

I understand that these services may include direct, face-to-face contact, record reviewing, phone contact, interviewing, and/or testing and scoring. There is a fee for these services and it will be billed to your insurance. There is a discount for patients paying cash. I also understand that the results of the evaluation will be given to my physician to assist in making medical decisions. Once the report is completed it will become part of my permanent medical record with the surgeon. I understand that Dr. Bailey is completely separate from the surgeon and the facility. I understand that this evaluation is to be done for the sole purpose of psychological screening prior to bariatric surgery. Tests will be chosen that are suitable for the purposes described above and will be given and scored according to the instructions in the test manuals. Tests and test results will be kept in a safe place. I agree to help as much as I can by supplying full answers and making an honest effort. I also agree that if the psychologist gives me any forms to fill out while not in the presence of the psychologist (i.e. at home) that I will be the one filling out the form without the help of anyone else. I also agree to this screening taking place on the phone, if necessary, and that I am in one of the four states that Dr. Bailey is licensed in: Arizona, California, Florida and Nevada. In order to submit a claim for payment for services covered under your policy, we must have your authorization to release medical information to your insurance carrier. MEDICARE & MEDI-CAL: I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. ALL OTHER INSURANCE: I hereby authorize Dr. M. Bailey, Psy.D. to submit a claim to my insurance carrier for all covered services and authorize and direct my insurance carrier to issue payment directly to the provider for the next 12-month period. I have been given a copy of privacy policies. PAYMENT DEFAULT: In the event of payment default, I agree to be responsible for any and all collection fees.

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. West Medical Center Inc. and its employees are dedicated to maintaining the privacy of your personal health information (PHI), as required by applicable federal and state laws. These laws require us to provide you with this Notice of Privacy Practices and to inform you of your rights and our obligations concerning Protected Health Information (PHI), which is information that identifies you and that relates to your physical or mental health condition. We are required to follow the privacy practices described below while this Notice is in effect. A. Permitted Disclosures of PHI. We may disclose your PHI for the following reasons: Treatment - to a physician or other health care provider providing treatment to you. Payment - to bill and collect payment for services we provide to you, including to insurance companies and our business associates such as billing and claims processing companies. Health Care Operations - quality assessment, reviewing competence or qualifications of health care professionals, evaluating provider performance, and other business operations, including to accountants, attorneys, and consultants. Emergency Treatment - if you require emergency treatment or are unable to communicate with us. Family and Friends - to a family member, friend or other person you identify as involved with your care or payment for care unless you object. Required by Law - for law enforcement purposes and as required by state or federal law, including reporting abuse, neglect or domestic violence, certain injuries such as gunshot wounds, and to comply with an order in a legal or administrative proceeding. Serious Threat to Health or Safety. Public Health - to authorities charged with preventing or controlling disease, injury or disability. Health Oversight Activities - audits, investigations, inspections, licensure or disciplinary actions. Research - with protections and protocols in place. Workers' Compensation. Specialized Government Activities - military command authorities and national security. Organ Donation. Coroners, Medical Examiners, Funeral Directors. Disaster Relief - unless you object. Direct Contact with You - appointment reminders and information about treatment alternatives or health-related benefits and services.

B. Disclosures Requiring Written Authorization. Not Otherwise Permitted - in any other situation not described in Section A above, we may not disclose your PHI without your written authorization. Psychotherapy Notes - we must receive your written authorization to disclose psychotherapy notes, except for certain treatment, payment or health care operations activities. Marketing and Sale of PHI - we must receive your written authorization for any disclosure which is a sale of PHI.

C. Your Rights. Right to Receive a Paper Copy of This Notice. Right to Access PHI - to inspect and copy your PHI for as long as we maintain your medical record (a reasonable fee may apply). Right to Request Restrictions on use or disclosure for treatment, payment or health care operations (we are not legally required to agree). Right to Restrict Disclosure for Services Paid by You in Full. Right to Request Amendment if you believe your PHI is incorrect or incomplete. Right to an Accounting of Disclosures during the 6 years prior to your request. Right to Confidential Communication by certain means or at certain locations. Right to Notice of Breach of your unsecured PHI.

D. Changes to this Notice. We reserve the right to change this Notice at any time in accordance with applicable law. E. Acknowledgment of Receipt of Notice. We will ask you to sign an acknowledgment that you received this Notice. F. Questions and Complaints. If you are concerned that we may have violated your privacy rights, you may complain to us by contacting the Privacy Officer, or submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.

Please direct any of your questions or complaints to: Privacy Officer: Brian Olson, West Medical Center Inc., 17609 Ventura Blvd., Suite #106, Encino, CA 91316, (818) 342-2696.

By signing this form, you hereby acknowledge receipt of the Notice of Privacy Practices from West Medical Center Inc. This Notice of Privacy Practices tells you how we may disclose and use your protected health information. We encourage you to read it in full.

As a patient in our facility, you have certain responsibilities, which include: To work with your health care team and to follow all safety rules. To show respect and consideration to our staff and to other patients and visitors. To respect the privacy of other patients. To give your health care team complete and correct information about your health. To tell your doctor about any changes in your health after you leave our facility. To keep, or cancel in a timely manner, your scheduled appointments for your health care. To follow the directions given by your health care team after you have agreed to treatment in our facility. To tell your health care team if you wish to change any of your decisions. To ask for clarification if you do not understand any information or instructions given to you by your health care team. This facility does not honor Advance Directives.

IF YOU HAVE ANY CONCERNS: If you have any questions or concerns about your responsibilities, you can contact our administrator or Medical Director. If you wish to file a complaint about your care in our facility, you may contact the Medical Board of California at (800) 633-2322, Central Complaint Unit, 2005 Evergreen St., Ste. 1200, Sacramento, CA 95815. You may also contact the office of the Medicare Beneficiary Ombudsman at www.medicare.gov/Ombudsman/resource.asp. I did read and understand all of the above information:

(Please bring this form and give it to the receptionist on the day of your appointment. We will make a copy of this for you to keep in your records.)

I wish to be contacted in the following manner (Please check all that apply):

West Medical Center will not communicate any information (such as pathology results or appointment times) to anyone (including family members) unless his or her name are specified below:

PLEASE NOTE: There is some level of risk sending an unencrypted email and that the information could be read by a third party. Further, e-mail can be circulated and forwarded electronically, and e-mail senders can easily misaddress an email. We recommend that a secure option is used. Please keep in mind that employers and online services have the right to archive and inspect email transmitted through their systems.

PLEASE NOTE: Please let us know if your phone is lost, stolen, or you have changed your number. While text messages will be sent securely, the text message may not be received in a secured manner. Messages displayed on your phone may be read by others with access to your phone, and text messages you receive are stored on your phone.

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means. The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for, PHI to the minimum necessary to accomplish the intended purpose.

Thank you for choosing West Medical Center, Inc. as your healthcare provider. We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important. If a parent, spouse or domestic partner is financially responsible for your services or is the subscriber on your insurance plan, please share this policy with them. By signing below you acknowledge and agree (please initial each item):

1. I am informed that West Medical Center, Inc. (WMC) is an out of network provider for my insurance carrier. I understand that my insurance carrier will process claims in accordance with my out-of-network benefits and subject to co-insurance, deductible and in some instances co-pay.

2. I, the patient (or the financially responsible party for the patient) acknowledge, understand and agree that payment is due from me at the time services are rendered. I further understand that WMC is providing medical services to me in consideration of expected provider reimbursement.

3. I understand that my insurance company may send provider reimbursement checks directly to the subscriber and that the subscriber may be a family member other than me (e.g., spouse, ex-spouse, parent). I agree to inform and share this financial policy with the subscriber of my insurance policy.

4. I understand and agree that it is my responsibility to ensure that the subscriber endorses the back of the check and to see that the check and accompanying explanation of benefits is remitted to WMC within 5 business days of receipt to: 17609 Ventura Blvd. Suite #106 Encino, CA 91316.

5. I understand that should the subscriber deposit the insurance check, I remain responsible for remittance of the provider reimbursement to WMC within 5 days of deposit, via cashier's check, credit card payment, check or money order. Furthermore, unless I am a minor, I am responsible for all charges assessed by WMC.

6. Insurance Benefits: I understand that my insurance policy is a contract between myself and my insurance company. WMC will verify your insurance benefits and submit your claim as a courtesy to you. I understand that I am directly responsible to WMC for all bills submitted for services rendered to me, including any coinsurance, deductible, and co-payments as determined by my insurance carrier.

7. Payment options: WMC is committed to working with you to ensure the lowest possible out of pocket costs. We offer several payment options including prompt pay discounts, discounts based on financial hardship and mutually agreeable payment plans. To qualify for discounts and payment plans, I must keep my account in solid financial standing by remitting all provider reimbursements paid directly to the subscriber in accordance with this policy.

8. Fees Assessed by WMC: Returned Checks: the charge for a returned check is $35. Missed Appointment: to avoid a possible $35 no-show fee, WMC requests 48-hour prior notice for cancellations; please call 800-561-9000. Completion of Forms (e.g. Disability, FMLA): $25. Medical Records: no charge for records sent to another provider; personal copies charged $10 clerical fee plus $0.25 per page for 6 pages and above. Refunds are not given for services already provided or for medical equipment/supplies purchased and opened.

9. Non-Payment on Account: failure to remit payment in full to WMC within 5 days of receipt of any insurance checks may result in delinquent account status. Should collection proceedings become necessary, I am responsible for all costs of collection which may include a 25% collection fee, court costs and fees, reasonable attorney fees, and interest added at the legal rate.

10. Minor Patients: the parent/guardian of a minor is responsible for payment of the minor's account balance. Responsibility for payment of treatment of minor children whose parents are divorced rests with both parents. WMC is not to be included in any court-ordered responsibility determinations.

I certify that by initialing above and signing below I acknowledge that I have read and fully understand the above information, I am aware of my out of network benefits, and agree to all terms contained herein.

What was your approximate weight at these ages?

EPWORTH SLEEPINESS: How likely are you to doze off or fall asleep in the following situations? Rate each description according to your normal way of life in recent times. Even if you have not been in some of these situations recently, try to determine how sleepy you would have been. 0 = would never doze, 1 = slight chance of dozing, 2 = moderate chance of dozing, 3 = high chance of dozing.

List your current medications here:

This assignment is in addition to any prior assignment(s) of rights that I may have made to the medical providers, health care facilities, and other providers, or their designated associates, affiliates or assignee(s) (collectively PROVIDERS) relating to the medical care that I received or will receive from the PROVIDERS, which include, but are not limited to West Medical Center, Inc.; Mount Sinai Surgery Center, LLC; Los Angeles Sleep Study Institute, LLC; their affiliates, assigns, and successors. To the extent I have not already done so, I hereby expressly transfer, assign, and convey all rights, causes of action, claims, titles, interests and demands of whatsoever nature relating to medical services I received from the PROVIDERS, including but not limited to: all claims for benefits under my insurance and health plan(s) for medical services; all my statutory rights; ERISA rights, statutory and otherwise; and to pursue relief of any kind including those against my insurer and health plan(s). Release of Information: to the extent necessary to determine liability for payment and to obtain reimbursement, the providers may disclose portions of the patient's record, including medical records, to any person or corporation that is or may be liable for all or any portion of the provider's charges, including insurance companies, health care service plans, or workers' compensation carriers. Financial Agreement: the undersigned agrees, whether signing as agent or as a patient, that in consideration of the services to be rendered to the patient, he or she individually obligates himself or herself to pay the account of the providers in accordance with the regular rates and terms of the providers. Should the account be referred to an attorney for collection, the undersigned will pay reasonable attorneys' fees and all collection expenses. All delinquent accounts bear interest at the legal rate. It is the policy of the providers not to give refunds for medical services already provided, except for extraordinary circumstances at the providers' election. Assignment of Insurance Benefits: the undersigned authorizes direct payment to the providers of any insurance benefits otherwise payable to the undersigned for the medical services at a rate not to exceed the provider's regular charges. Payment to the providers by an insurance company discharges the insurance company of its obligations to the extent of that payment. The undersigned is financially responsible for charges not covered by this assignment. Assignment of Claims and Right to Sue: the express rights assigned include the right to initiate any legal proceeding or complaint including against my insurance company and/or health plan(s); to make any request for disclosure of governing plan documents; to seek penalties including those under ERISA; to pursue all claims and causes of action under federal or state laws including antitrust laws and class action relief; to pursue or sue for breaches of fiduciary duty; to pursue any form of equitable relief including equitable estoppel, equitable surcharge, and reformation; and to pursue and collect attorney's fees. In asserting these rights, the PROVIDERS shall stand in my shoes such that my transfer of rights is complete and I retain no interest in them. In the event any right is deemed not transferable or assignable under applicable law, I authorize PROVIDERS to assert such matters as my representatives and collection agents in my name or their own name as they deem appropriate.

Weight History (2021-2025)

1. Consider how severe the problem is when you experience it and how frequently it happens, please rate each item below on how bad it is by selecting the number that corresponds with how you feel. 0 = no problem, 1 = very mild problem, 2 = mild or slight problem, 3 = moderate problem, 4 = severe problem, 5 = problem as bad as it can be

IN ACCORDANCE WITH HEALTH AND SAFETY CODES, THE WEST MEDICAL CENTER AND MEDICAL STAFF HAVE ADOPTED THE FOLLOWING LIST OF PATIENT RIGHTS: Patient rights will be exercised without regard to sex or culture, economic, educational or religious background or the source of payment for his or her care. 1. Considerate and respectful care. 2. Knowledge of the name of the physician who has primary responsibility for coordinating his or her care and the names and professional relationships of the other physicians who will see the patient. 3. Receive information from his or her physician about his or her illness, his or her course of treatment and his or her prospects for recovery in easily understood terminology. 4. Receive as much information about any proposed treatment or procedure as he or she may need in order to give informed consent or to refuse the course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved and knowledge of the person who will carry out the procedure or treatment. 5. Participate actively in decisions regarding his or her medical care, to the extent permitted by law, including the right to refuse treatment. 6. Full consideration of privacy concerning his or her medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. The patient has the right to know the reason for the presence of any individual. 7. Confidential treatment of all communications and records pertaining to his or her care and his or her stay in the WEST MEDICAL CENTER INC. His or her written permission shall be obtained before his or her medical records can be made available to anyone not directly concerned with his or her care. 8. Reasonable responses to reasonable requests he or she may make for services. 9. He or she may leave the WEST MEDICAL CENTER INC., even against the advice of his or her physicians. 10. Reasonable continuity of care and advance knowledge of the time and location of appointment, as well as knowledge of the physician providing the care. 11. Be advised if WEST MEDICAL CENTER INC. /personal physician purposes to engage in or perform human experimentation affecting his or her care or treatment. The patient has the right to refuse to participate in any research projects. 12. Be informed by his or her physician, or a delegate of his or her physician, of his or her continuing health care requirements following his or her discharge from the Surgery Center. 13. May choose a different physician than was assigned to that patient. 14. Notified of the ASC's policy on Advance Directives, as required by state or federal regulations. WEST MEDICAL CENTER INC. does not honor Advance Directives. 15. Refuse to participate in experimental research or research studies. 16. Know the facility fees for services. 17. Be informed of procedures for grievances and complaints. 18. Receive a privacy notice to inform the patient about how his or her protected information will be used or disclosed, request that uses and disclosures of protected information be restricted, inspect, copy and amend their medical records, get an accounting of the disclosure of their protected information for the past six years; and file a complaint. For complaints or comments about your medical care, you may contact our Administrator or Medical Director, Dr. Shabatian at (818) 342-2696. You may also contact the Medical Board of California at (800) 633-2322, Central Complaint Unit, 2005 Evergreen St., Ste. 1200, Sacramento, CA 95815. You may also contact the office of Medicare Beneficiary Ombudsman: www.cms.hhs.gov/center/ombudsman.asp.

West Medical Center is committed to meeting or exceeding our patients', families' and visitors' expectations of care and services. Effective resolution of complaints/grievances and concerns are key factors in achieving patient satisfaction. Patient's complaints/grievances are opportunities for improvement and should receive respectful, prompt, and efficient attention. Patient satisfaction is everyone's responsibility, and patient's complaints/grievances and concerns may require different resolution processes. However, prompt and effective resolution is the goal for resolving patient issues, regardless of whether it's a minor concern or a serious complaint. All patients are encouraged to report any complaints/grievances or concerns to any West Medical Center employee for resolution, as each teammate is empowered to resolve issues and complaint/grievances within his/her authority or professional expertise. If you feel they are not the appropriate personnel to resolve the matter at hand, please use the below contact information and send a written statement to our West Medical Center General Manager. A customer may file a concern or complaint/grievance for any reason. The process to do that is as follows: - Notify any staff member that you have a complaint/grievance or concern. - All efforts will be made to resolve complaints/grievances or concerns on the same day notified. - Complaints/grievances or concerns that cannot be immediately resolved to the patient's satisfaction will result in the review and investigation of the complaint/grievance within a reasonable time frame initiated by the center administrator. - The general manager or designee will provide the customer with a verbal progress report within 3 business days of receipt of the complaint/grievance and maintain ongoing communication until the point of resolution, not to exceed 30 days. - Once the investigation is completed, the General Manager will communicate in writing to the patient or legal representative, when necessary, the findings and determination regarding the complaint/grievance in understandable terms, including written notice of its decision, name of center's contact person, steps taken on behalf of the patient to investigate the complaint/grievance, the results of the complaint/grievance process and date of completion, and information on how to contact the State Agency for any issues the patient feels is unresolved. Patients may contact the State Agency directly regardless of whether he/she has first initiated the center's complaint/grievance process. You may contact the following entities to express any concerns, complaints or grievances you may have: Contact: Hooman Shabatian MD Main Phone Number: (818) 342-2696 Fax: (818) 698-8366 West Medical Center Inc. 17609 Ventura Blvd, Ste 106 Encino CA, 91316 State Agency: For complaints and incidents Contact: Medical Board of California 2005 Evergreen St., Ste. 1200 Sacramento, CA 95815 Toll Free: (800) 633-2322 Fax: (916) 263-2435 Medicare: Office of the Medicare Beneficiary Ombudsman www.cms.hhs.gov/center/ombudsman.asp