• New Patient Intake — Bay Area Orthobiologics | The Osteopathic Way

    Thank you for your interest in becoming a new patient. Please complete this form so we can focus on your care, not paperwork.

  • Patient Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred Method of Contact*
  • Occasionally we may have imaging or lab work results, if you are not reachable is it okay to Leave a Detailed Voicemail containing those results?*
  • Format: (000) 000-0000.

  • What You'd Like Treated

  • Which area is affected?*
  • Have you had any imaging of this area?
  • Do you have a physical copy of the imaging listed above?

  • Please bring your records to your first visit. Imaging discs or reports, lab work, notes from previous doctors, and a list of anything you have already tried for this problem. Your first visit is scheduled with extra time specifically so your physician can review your history properly. Walking in with your records in hand is the single biggest thing you can do to speed up the process of getting to a treatment plan. If you cannot find something not to worry — we will work with what you have.

  • Financial Policy and Insurance

  • Please read carefully — each item requires your acknowledgment.
  • Bay Area Orthobiologics and The Osteopathic Way are a cash-pay practice. We are direct-pay by design: our recommendations are driven by what is best for you clinically, not by what an insurance code will approve. Here is exactly what that means for your visit.

  • Visit fees. Your initial visit is $382.00. Follow-up visits are $265. Payment is due at the time of service. Orthobiologic procedures, imaging, Therapeutic Laser and other services are priced separately. These procedures and pricing for these procedures will be discussed with you prior to them being performed. The additional procedures if agreed upon may increase the initial and follow up visits.  

  • Insurance. We are out of network with all insurance plans, with one exception: we are in network with TRICARE. If you have any other commercial or private insurance, we do not bill your plan. On request we can provide you with an itemized superbill that you may submit to your insurer yourself.

  • Attention Medicare beneficiaries:

    The Osteopathic Way and Bay Area Orthobiologics are Non participating providers of medicare. This means that the examination and any procedural fees are due at the time of service paid directly to The Osteopathic Way or Bay Area Orthobiologics. We will then submit claims on your behalf to medicare.

     

    At this time it is not possible for us to predict medicares reimbursement as reimbursement is determined by medicare and the secondary insursance programs which you have chosen. At this time, reimbursement averages 4-6 weeks for each of our patients. Time to reimbursement does vary by insurance plan. 

  • Bay Area Orthobiologics and The Osteopathic Way cannot predict, promise, or guarantee any amount of reimbursement, and your financial responsibility to this practice does not change based on what your plan decides to pay you.
  • Yes, I understand the Medicare payment and claim submission process described above.*
  • Yes, I understand that reimbursement varies by plan and is not guaranteed.*

  • Cancellations and missed appointments. Your appointment time is held for you and not offered to anyone else, so we ask for at least 3 business days notice if you need to cancel or reschedule. A first missed appointment without that notice is charged $75. A second is charged $175. A third ends the relationship — we will discharge you from the practice and help you find care elsewhere.

    This is not about being rigid. Missed appoinments equal lost revenue to our small practice as we still have to pay for overhead and staffing even if you do not show to your appointment.

    In addition, giving us advanced notice allows us to give the appointment to another patient who is in need. If something comes up, call or text us. We would much rather move your appointment than charge you for it.

  • Do you have TRICARE?
  • Do you have Medicare?
  • Expiration Date on medicare or Insurance card:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Photo, Video, and Recording Consent

  • The items below are optional. Your answers here have no effect on your care, and you can change your mind at any time by telling us in writing.
  • Part A — Clinical Images
  • During your care we may take photographs, video, or ultrasound images of the area being treated. These become part of your medical record and are used to document your condition, guide treatment, and track your progress over time.
  • I consent to clinical photographs, video, and ultrasound imaging as part of my medical record.
  • Part B — Teaching and Education
  • We sometimes use de-identified images — no face, no name, no identifying features — to teach other clinicians or explain a condition to future patients.
  • I consent to the use of de-identified images of my case for teaching and patient education.
  • Part C — Marketing and Public Use

  • Separately, we would need your written authorization to use images or video in which you are identifiable for marketing purposes  our website, social media, or educational content produced by Bay Area Orthobiologics, The Osteopathic Way. This authorization covers photographs, video, and ultrasound images taken during your care. It has no expiration date unless you set one below. You may revoke it at any time by writing to our office, and revocation will apply going forward but not to anything already published or distributed. Bay Area Orthobiologics and The Osteopathic Way will not condition your treatment on whether you sign this. Once information is disclosed publicly it may no longer be protected by federal privacy law.

  • I authorize the use of identifiable photographs, video, and ultrasound images of me for the marketing and educational purposes described above.
  • Part D — AI Documentation Assistant

  • To spend more of your visit looking at you instead of a screen, we are introducing an AI documentation assistant. With your permission, the conversation during your visit is recorded and automatically transcribed into a clinical note. Three things worth knowing. The vendor handling that recording is bound by a business associate agreement and is required to protect your information under the same federal privacy rules we follow. Dr. Fischer or Dr. Knight personally reviews, corrects, and approves every note before it enters your record — the AI drafts, it does not decide. And you can decline this, or ask us to stop recording at any point during a visit, without giving a reason and without any effect on your care.

  • I consent to the use of an AI documentation assistant to record and transcribe my future visits.

  • 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.
  • The Osteopathic Way, P.C. dba Bay Area Orthobiologics — Carmel, CA and Soquel, CA. Effective Date: August 25, 2026. This Notice replaces any Notice of Privacy Practices previously issued by this practice.

  • Our Commitment to Your Privacy

  • The Osteopathic Way, P.C. dba Bay Area Orthobiologics is committed to protecting the privacy of health information. We are required by law to maintain the privacy of your protected health information (PHI), provide you with this Notice of Privacy Practices (Notice) of our legal duties and privacy practices regarding your PHI, and follow the terms of the Notice currently in effect. This Notice tells you about the ways in which we may use and disclose health information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your health information. The privacy practices described in this Notice will be followed by all members of the workforce at The Osteopathic Way, P.C. dba Bay Area Orthobiologics, including health care professionals, employees, trainees, students, and volunteers. Additionally, third parties (business associates) that provide services on our behalf will be required to comply with all applicable provisions.

  • How We May Use and Disclose Health Information About You

  • The following sections describe different ways we may use and disclose your health information. We abide by all applicable laws related to the protection of this information. Not every use or disclosure is listed. All of the ways we are permitted to use and disclose health information, however, will fall within one of the following categories. Treatment. We may use and disclose your health information to provide, coordinate, or manage your healthcare and related services. This includes consultation with other healthcare providers regarding your treatment and referral to another provider. For example, your primary care physician may share your health information with a specialist to coordinate your care. Payment. We may use and disclose your health information to obtain payment for services we provide. This includes billing activities, claims management, and collection activities. For example, we may send claims to your health insurance company containing certain health information to obtain payment for services we provided. Healthcare Operations. We may use and disclose your health information for our healthcare operations, which include internal administration and planning and various activities that improve the quality and cost-effectiveness of care. For example, we may use health information to evaluate the performance of our staff, assess the quality of care, or conduct training programs.

  • Other Uses and Disclosures We May Make Without Your Authorization

  • As Required by Law. We may disclose health information when required by federal, state, or local law. Law Enforcement. We may disclose health information to law enforcement officials for law enforcement purposes as permitted by law. Coroners, Medical Examiners, and Funeral Directors. We may disclose health information to coroners, medical examiners, and funeral directors to carry out their duties. Organ and Tissue Donation. We may disclose health information to organizations involved in the procurement, banking, or transplantation of organs, eyes, or tissue. Research. We may use or disclose health information for research purposes when an institutional review board or privacy board has reviewed the research proposal and established protocols to ensure the privacy of your information. To Avert a Serious Threat to Health or Safety. We may use or disclose health information when necessary to prevent a serious threat to the health or safety of you, another person, or the public. Specialized Government Functions. We may disclose health information for military, national security, protective services, or correctional institution purposes as authorized by law. Workers' Compensation. We may disclose health information as authorized by workers' compensation laws. Others Involved in Your Care. Unless you tell us not to, we may disclose health information to anyone involved in your care or payment for your care, such as a friend, family member, or any individual you identify.

  • Substance Use Disorder Treatment Records

  • We are required to protect the privacy and security of your substance use disorder patient records in accordance with 42 U.S.C. 290dd-2 and 42 C.F.R. Part 2, the Confidentiality of Substance Use Disorder Patient Records (Part 2), in addition to HIPAA and applicable state law. In a civil, criminal, administrative, or legislative proceeding against an individual, we will not use or share information about your SUD treatment records unless a court order requires us to do so (after notice and an opportunity to be heard is provided to you, as provided in 42 C.F.R. Part 2) or you give us your written permission. You may report suspected violations to the U.S. Attorney for the judicial district in which the violation occurs. Our offices in Carmel (Monterey County) and Soquel (Santa Cruz County) are located within the Northern District of California, served by the San Jose Branch Office: United States Attorney's Office, Northern District of California, Federal Courthouse, 450 Golden Gate Avenue, P.O. Box 36055, San Francisco, CA 94102. San Francisco: (415) 436-7200 · TTY: (415) 436-7221. San Jose Branch Office: (408) 535-5061. www.justice.gov/usao-ndca. Suspected violations by an opioid treatment program may be reported to the Substance Abuse and Mental Health Services Administration (SAMHSA), Division of Pharmacologic Therapies, by phone at 240-276-2700 or by email at DPT@samhsa.hhs.gov.

  • Uses and Disclosures That Require Your Written Authorization

  • We will obtain your written authorization before using or disclosing your health information for purposes other than those described above. Specifically, we will obtain your authorization before using or disclosing psychotherapy notes (with limited exceptions), health information for marketing purposes, and health information in a manner that constitutes a sale of PHI. Additionally, with certain limited exceptions, we are not allowed to sell or receive anything of value in exchange for your health information without your written authorization. If you provide us with authorization to use or disclose your health information, you may revoke your authorization, in writing, at any time. However, uses and disclosures made before the revocation of your authorization are not affected by your action, and we cannot take back any disclosures we may have already made with your authorization or that may have been made in reliance on your authorization.

  • Use of Unsecure Electronic Communications

  • If you choose to communicate with us via unsecure electronic communications, such as regular email or text message, we may respond to you in the same manner in which the communication was received and to the same email address or account from which you sent your original communication. In addition, if you provide your email address or cell phone number to a health care provider, we may send you emails or text messages related to appointment reminders, surveys, or other general informational communications. For your convenience, these messages may be sent unencrypted. Before using or agreeing to use any unsecure electronic communication to communicate with us, note that there are certain risks, such as interception by others, misaddressed or misdirected messages, shared accounts, messages forwarded to others, or messages stored on unsecured, portable electronic devices. By choosing to correspond with us via unsecure electronic communication, you are acknowledging and agreeing to accept these risks. Additionally, you should understand that the use of email or other electronic communications is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

  • Your Rights Regarding Your Health Information

  • Right to Inspect and Copy. You have the right to inspect and obtain a copy of your health information that may be used to make decisions about your care, including medical and billing records. To inspect or copy your health information, submit a written request to our Privacy Officer. We may charge a reasonable fee for copying and mailing costs. Right to Amend. If you believe that information in your record is incorrect or incomplete, you may request that we amend it. To request an amendment, submit a written request to our Privacy Officer that includes the reason for your request. We may deny your request in certain circumstances, and if we do, we will provide you with a written explanation. Right to an Accounting of Disclosures. You have the right to receive a list of certain disclosures we have made of your health information. To request an accounting, submit a written request to our Privacy Officer specifying the time period for which you want the accounting (not to exceed six years). The first accounting in a 12-month period will be provided free of charge; subsequent requests may incur a reasonable fee. Right to Request Restrictions. You have the right to request restrictions on how we use or disclose your health information for treatment, payment, or healthcare operations, or to restrict disclosures to family members or others involved in your care. We are not required to agree to your request except in one situation: if you pay for a service or item out of pocket in full, you can ask us not to share information about that service or item with your health insurer for payment or healthcare operations purposes, and we will honor that request. Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. To request confidential communications, submit a written request to our Privacy Officer specifying how or where you wish to be contacted. We will accommodate reasonable requests. Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice of Privacy Practices at any time. You may request one at either office or by contacting our Privacy Officer at the address provided below. Right to Be Notified of a Breach. You have the right to be notified in the event that we discover a breach of your unsecured health information.

  • Changes to the Terms of This Notice

  • We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request, in our facility, and on our website.

  • Complaints

  • If you have any questions about this Notice or our privacy practices, or if you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at the address and phone number below. You will not be retaliated against for filing a complaint. Privacy Officer: Joshua Fischer, DO The Osteopathic Way, P.C. dba Bay Area Orthobiologics 26350 Carmel Rancho Lane, Suite 200, Carmel, CA 93923 2425 Porter Street, Suite 17, Soquel, CA 95073 Phone: (831) 920-3838 Email: drfischer@theosteopathicway.com To file a complaint with HHS: Office for Civil Rights, U.S. Department of Health and Human Services 200 Independence Avenue, S.W., Washington, D.C. 20201 Phone: 1-877-696-6775 · Toll-free: 1-800-368-1019 · TDD: 1-800-537-7697 Email: OCRComplaint@hhs.gov Website: www.hhs.gov/ocr/privacy/hipaa/complaints/ California residents may also contact the OCR regional office serving this state: Office for Civil Rights, Region IX U.S. Department of Health and Human Services 90 7th Street, Suite 4-100, San Francisco, CA 94103 Customer Response Center: (800) 368-1019 · TDD: (800) 537-7697
  • You may request a paper copy of this Notice at any time, at either office or by contacting our Privacy Officer.

  • Consent To Treatment

  • Consent to Treatment This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, treatment and electronic reconciliation of your medical prescriptions and prescription history. By signing below, you are indicating that: 1. You consent to treatment at this office (or any other satellite office under common ownership). 2. You intend this consent to remain effective after a specific diagnosis has been made and treatment recommended. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your physician, including the purpose, potential risks, and benefits of any test, treatment, or recommended course of action. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions. Patient statement of consent: 'I voluntarily request the health care provider(s) at The Osteopathic Way, P.C. dba Bay Area Orthobiologics to perform reasonable and necessary medical examination, testing, treatment and electronic reconciliation of my medical prescriptions and prescription history for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive, or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). I certify that I have read and understand the above statements and consent fully and voluntarily to them.'

  • Patient Signature to above information:

  • By signing below, I confirm that this single signature applies to this entire form and is legally binding. 

    I also agree that: The information I have provided is true and complete to the best of my knowledge.

    I have read and understand the financial policy, including the $382.00 initial visit fee and $265 follow-up visit fee, that this practice is out of network with all insurance except TRICARE, how Medicare claims are handled, that reimbursement varies by plan and is never guaranteed, and the cancellation and missed appointment policy.

    I have read the Consent to Treatment above and consent fully and voluntarily to evaluation and treatment as described.

    I have received and had the opportunity to read the Notice of Privacy Practices included in this form.

    Where this form offered me optional choices — including photography and video, teaching use, marketing use, an AI documentation assistant, and educational emails — my selections above reflect my own decision. I understand these were optional, that I was free to decline any of them, and that my decision does not affect my care.

    I understand that signing this form electronically has the same legal effect as signing it by hand.

     

  • Date*
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    2 digit month, 2 digit day, 4 digit year
  • As part of our intake process, we provide our patients with a free informational webinar about Osteopathic Medicine and Regenerative medicine. Would you like to receive this webinar as well as occasional educational emails about treatment options at Bay Area Orthobiologics and The Osteopathic Way?
  • Optional. This has no effect on your care, and you can unsubscribe at any time.
  • Should be Empty: