Medical History Form October 2024

PATIENT INTAKE FORM

Medical Questionnaire
Stryker Interventional Specialists
StrykerMD
Jeanne N. Stryker MD DABR

www.strykermd.net

Phone: 858-480-1977 Fax: 888-625-8230

Mailing Address Only:

153 S Sierra Ave #990

Solana Beach, CA 92075

Physical Surgical Addresses:

SS Vascular Surgery Center Phone:

1045 E Pennsylvania Avenue

Escondido, CA 92025

Phone: 760-884-4500 Fax: 619-567-7775

WELCOME!

To Our Patients:

Thank you for choosing the office of Dr. Jeanne N. Stryker, MD to assist you in determining the best course of action and treatment plan with minimally invasive image guided surgery and immunotherapy for cancer and non cancer treatment. We pledge to provide you with a caring, healing and professional environment dedicated to meeting all your treatment options. Dr. Stryker strives to provide you with all treatment options including surgery, chemotherapy, radiation oncology and interventional radiology oncology regarding your diagnosis so you can make a well informed decision regarding what treatment options meet your unique individual needs.

Our goal is to educate you and keep you safe. We do not make suggestions to meet Dr. Stryker's needs regarding her specialty but options which meet your needs depending on your personality, emotional, mental, spiritual and medical condition.

Your visit to our medical facility will involve a thorough review of your medical history, radiology imaging and prior treatments in order to evaluate the best treatment for your known diagnosis. This questionnaire will assist the physician in determining the appropriate testing, imaging and next step to assess all your treatment options for a known malignant and non malignant condition.

The paperwork is essential to your visit. To maximize your time with the physician, please initial that you understand this entire packet needs to be completed prior to your appointment time. All recent radiology imaging CD's, prior medical reports including pathology, copy of driver's license, front and back of your insurance card need to be received prior to confirming an appointment with Dr. Stryker. Dr. Stryker does not accept insurance. We collect the insurance information for the facility where your procedure will be performed.

The intake form must be completed in it's entirety before a confirmed appointment can be made. You are not considered a patient of Dr. Stryker's until the completion of the initial appointment. Please do not try to make an appointment until all criteria is met with the office policy and procedure.

Policy and procedure requires completing medical intake form and submitting to office. A valid copy of a government ID, front and back of your insurance card and hard copy CD of recent imaging or a valid code so Dr. Stryker can evaluate your anatomy and location of tumor in order to create a unique treatment plan for you.

Please List MRI, CT, Ultrasound, Mammograms, and Pet/CT scans below.
Please include the date it was completed, and the facility name and contact information for each scan.
We will need copies of these diagnostic images on a disc, thumb drive in DICOM format or access to a portal to review your images.

Please mail the disc or thumb drive to:

StrykerMD

153 South Sierra Avenue, Suite 990

Solana Beach, CA 92075

Today's Date*
Full Name*

First NameLast Name
Occupation:*
Gender*

MaleFemale
Race*
Ethnicity*
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Scans*

PET CTMRICTUltrasoundOther
Date of Scans*
Facility Name*
Facility Telephone Number*
Facility where your biopsy was performed ?*
Date biopsy was performed:*
Facility location:*
Facility Telephone:*
Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature*

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Terms of Agreement

Dr. Stryker does not accept insurance and is not in network with any insurance company. We ask for a copy of your insurance card to submit to the facility in order to schedule a procedure.

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay DR. JEANNE N. STRYKER M.D., as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided.

I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, procedures and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under.

I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same.

I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action to obtain (or protect) benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan.

This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature*

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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION:

I authorize Dr. Stryker to release medical information about me requested by insurance companies with whom I have coverage or any public agency and its agent to determine benefits for services provided or benefits for related services.
I agree to pay all costs of collections, including reasonable attorney’s fees and I further hereby waive all rights of exemption as to personal property under the Constitution and Laws of the State of Arizona and California.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature of Responsible Party*

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Effective: October 1, 2024

Jeanne N. Stryker, MD understands that unanticipated events happen occasionally. However, appointments that are missed and not cancelled prevent other patients access to our providers.

In order to provide health care service available to as many patients as possible, we require the following notice of any cancellation for established and new patients. This will allow us the opportunity to offer your cancelled/rescheduled appointment to patients on our waiting list or needing to get in.

Cancellation policy for both new patients and follow up appointments is as follows and by signing, patient agrees to the following:

I understand that I will be charged a cancellation fee of $880.00 (new consultation) and $400 (second opinion imaging or follow up appointment) scheduled if the appointment is not cancelled or rescheduled at least 48 business hours in advance. These fees are non-refundable. Appointments scheduled for Tuesdays must be cancelled by appointment time Friday. All consultations whether in person or via phone consultation is a non-refundable fee.

New Consultation: 880.00

Follow Up Consultation:

30 Minutes: 440.00 - 620.00

60 Minutes: 620.00 - 800.00

Estimated Rates for Procedures are based on a range depending on the complexity of the case. Each patient's condition is personal and specific for the type of procedure which will be performed.

Cryoablation: 17,700.00-19,000.00

Prostate Cryoablation: $22,600.00

Complicated Cryoablation: $22,600.00

Embolization: 19,700.00-20,600.00

Immunotherapy/Chemotherapy No additional charge for intratumoral placement of the medication for the professional fee.

Patient is responsible for payment of the drug if insurance does not cover. There is a fee for Intravenous Immunotherapy if patient follows up in office for intravenous therapy at 620.00. This does not cover the cost of the drug.

There are two fee structures. The facility in which you have your procedure will bill/charge separately which is called the technical fee.

The professional fee is charged separately which is Dr. Stryker's fee for performing the procedure.
Sometimes in a hospital setting you may also have a separate bill from the laboratory, pathology, anesthesia and other ancillary services.

In the event that my appointment is not cancelled within the above mentioned time frame.This fee must be paid in full prior to future services including prescription refills, office visits, etc. This is non-refundable. All completed consultations with Dr. Stryker are non refundable. All procedures performed by Dr. Stryker are non-refundable. We cannot guarantee any outcome or success of a procedure. All procedures are billed/charged accordingly as above. All procedures performed by Dr. Stryker are non-refundable.

I authorize Stryker Interventional Specialists to charge my credit card account indicated above for the cost for cancelled procedures if the procedure is not cancelled within 48 business hours and 100 % cost of the procedure if cancelled the day of the scheduled procedure for administrative fees, the cost of medical devices and clinical staff. This is a non-refundable fee. This payment is for a cancellation fee in accordance with the Cancellation Policy provided to me by Stryker Interventional Specialists (StrykerMD).
Name*

First NameLast Name
Date*

MonthDayYear
Signature *

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Authorization for Disclosure of Health Information

I authorize the use or disclosure of the named individual’s health information as described below.

The following individual or organization is authorized to make the disclosure:

Telemedicine

Mailing Address Only

Jeanne N. Stryker MD
153 South Sierra Avenue, Suite 990
Solana Beach, CA 92075

Physical Surgical Addresses

SS Vascular Surgery Center

1045 E Pennsylvania Avenue

Escondido, CA 92025

Phone: 760-884-4500 Fax: 619-567-7775

I understand that the information in my health record may include information relating to sexually transmitted disease, Hepatitis C, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact: Stryker Interventional Specialists.

PLEASE NOTE: This information has been disclosed to you from confidential records protected from disclosure by state and federal law. No further disclosure of this information should be done without specific, written and informed release of the individual to whom it pertains or as permitted by state law (ORC – 3701.243) and federal law 42 CFR, part II.
Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature*

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Certain Waivers under HIPAA.

(a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician.

(b) By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following:

E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI;
Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications.
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature*

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Patient acknowledges and agrees that Physician and Group, along with their assigns, will be entitled to use any data, discoveries, results, improvements or other information resulting from the Services for any lawful purpose whatsoever, including, but not limited to, internal research, academic or other publications or commercial purposes. All data will be kept on a Cloud Based system that is password protected, and accessible to Stryker Interventional Specialists staff.
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature*

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Authorization Form Policy

Effective date of policy: July 1, 2024

Protected health information (PHI) will only be released from our practice with a properly executed authorization from the patient or his/her personal representative, except for treatment, payment, or health care operations (TPO) and as otherwise required by law.

Examples of some instances in which we are required to disclose your PHI include: Public health activities; information regarding victims of abuse, neglect, or domestic violence; health oversight activities; judicial and administrative proceedings; law enforcement purposes; organ donations purposes; research purposes under certain circumstances; national security and intelligence; correctional institutions; and Worker’s Compensation.
Dr Jeanne N. Stryker MD will only use or disclose PHI, except as noted above, consistent with the terms of the authorization.

A patient may revoke his/her authorization to use or disclose PHI at any time but actions taken prior to the revocation are excluded. If authorization is a condition of obtaining insurance coverage, and the authorization is revoked, the insurer may contest a claim under the policy.

Authorizations must be properly executed by the patient or his personal representative. It should include, the date signed, specific PHI to be released or used, to whom this use or release relates, and an expiration date for the authorization.
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature*

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Authorization to Request Medical Records
I give my express permission to StrykerMD and Dr. Jeanne N. Stryker, MD, to obtain and access to all of my medical records. I understand that my personal and medical information may be stored on a password protected secure cloud service.
Today's Date*

MonthDayYear
Patient Name*

First NameLast Name
Signature

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Emergency Contact Name*

First NameLast Name
Relationship*
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Email
example@example.com
Type a question*

MarriedSingleDivorceWidow
Spouse/Partner/ Significant Other Name*

First NameLast Name

Insurance:*

YesNo
Insurance Name:*
Name of Insurance
Policy Number*
Policy Number
Group ID:*
Group ID
Eligibility Date*
Insurance Date
Insurance Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number*

Area CodePhone Number
Patient/Partner Employer:*
Patient Work Phone:

Area CodePhone Number

Are They the Insured Party?*

YesNo
Name of Insured:*
Insured Party DOB:*

MonthDayYear
Pharmacy Name and Phone Number:
Name of Person Referring Patient:*
What are your symptoms? Right or Left side Cancer*
What type of cancer for example; right or left breast cancer
Please list your 5 major health concerns in order of importance:*
Concerns

Jeanne N. Stryker MD

Telemedicine

Mailing Address

153 South Sierra Avenue Suite 990

Solana Beach, CA 92075

p: (858) 480-1977

f: (888) 625-8230
www.strykermd.net

Credit Card Authorization Form

For all Payments and CANCELLATIONS

Please sign and complete this form to authorize Stryker Interventional Specialistscharge your debit or credit card listed below. By signing this form you give permission to debit your account for the amount indicated in agreement with our cancellation policy. All consultations are to be paid in full. The fee is non-refundable.

I authorize Stryker Interventional Specialists to charge my credit card account 50 % for the cost for specific appointments and $890.00 for new patient appointments, $350.00 for second opinion imaging, $350.00 for 30 minute follow up appointment, $440.00 for ultrasound appointment. This payment is for a cancellation fee in accordance with the Cancellation Policy provided to me by Stryker Interventional Specialists (StrykerMD).

I authorize Stryker Interventional Specialists to charge my credit card account indicated below for 50% of the cost for cancelled procedures if the procedure is not cancelled within 48 business hours and 100% cost of the procedure if cancelled the day of the scheduled procedure for administrative fees, the cost of medical devices and clinical staff. This fee is non-refundable. This payment is for a cancellation fee in accordance with the Cancellation Policy provided to me by Stryker Interventional Specialists (StrykerMD).
I authorize the above named business to charge the credit card indicated in the authorization form according to the terms outlined above. This payment authorization is for the amount indicated above only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company. All fees are non-refundable. At the time of completing the medical intake form; you are not charged for submission of the medical intake form. You will only be charged when an appointment is scheduled. We never charge your credit card without your verbal authorization via telephone.
Today's Date*

MonthDayYear
Name*

First NameLast Name
Signature*

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OFFICE PROTOCOL and ETIQUETTE

As a major in the army serving in Operation Iraqi Freedom war I understand order is imperative when dealing with the enemy. Order defines the difference between life and death. Today we are in the battlefied with cancer (the enemy). I strive to have order in my office and the facilities where I perform my procedures. Please follow my office policy and procedure so we can assure the best possible options and outcomes for you. Please be courteous, patient, provide all the information we request in order for you to have a successful outcome. Scheduling your procedure may take time depending on the availability of the facility. Dr. Stryker is not the only physician who performs procedures. There is a facility fee which is separate from the professional and technical fees.
Signature*

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Should be Empty:

PATIENT INTAKE FORM

WELCOME!

Terms of Agreement

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION:

Authorization for Disclosure of Health Information

Certain Waivers under HIPAA.

Authorization Form Policy

Authorization to Request Medical Records

OFFICE PROTOCOL and ETIQUETTE