New Patient Paperwork

PATIENT INFORMATION

NOTICE:
These questions are included to comply with new federal health guidelines. We are required to ask all patients for this information.

PATIENT EMPLOYMENT INFORMATION

INSURANCE INFORMATION

(If you are insured through someone else, please list that person's information below)

I certify by my signature below that I understand and agree that I am ultimately responsible for payment. I further certify that this information is true and correct to the best of my knowledge.

AUTHORIZATION TO PAY PHYSICIAN

I hereby authorize Medicare/Insurance Company to pay directly to NORTH VALLEY G.I. CONSULTANTS for surgical/medical services furnished to me. I realize that this may not represent the full payment for this service rendered and I will be responsible for the balance due. I hereby authorize NORTH VALLEY G.I. CONSULTANTS to release any medical information needed by my insurance company.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PAST MEDICAL HISTORY

HABITS

FAMILY HISTORY

MEDICATION LIST

MEDICAL ALLERGIES

Robert B. Moghimi, M.D.
Diplomat American Board of Internal Medicine
Internal Medicine & Gastroenterology

AUTHORIZATION TO PAY BENEFITS

I hereby authorize MEDICARE and/or INSURANCE payment be made directly to North Valley G.I. Consultants for surgical and/or Medical services.

I realize that the Medicare/Insurance may not represent full payment for rendered services and I am responsible for the balance due.

I hereby authorize North Valley G.I. Consultants to release information concerning my illness to the insurance carrier.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

CANCELLATION POLICY / NO SHOW POLICY FOR DOCTOR SURGERY

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment,. Please remember that in order to accommodate another patient in your place we must notify the patient at least 5 days prior to the procedure to make arrangements and prepare for his/ her surgery.

1. Cancellation/No Show Policy For Surgery
   Due to the large block time needed for surgery, last-minute cancellation can cause problems and added expenses for the office and/or facility. If the surgery is not cancelled at least 5 days in advance you will be charged seventy-five dollars ($75.00) fee; This will not be covered by your Insurance.
2. Account Balances
   We will require that patients with self-pay balances pay their account balance to zero (0) prior to receiving further services by our practice. Patients who have questions about their bills or who would discuss payment plan options may call and ask to speak to our business office representative with whom they can review their account and concerns. Patients with a balance of over $100.00 must make payment arrangements prior to future appointments being made.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient refuses, or is unable, to acknowledge receipt of the Notice of Privacy Practice

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

NOTICE APPLIES TO

This Notice describes the practices of this office and those of:

• Any healthcare professionals authorized to enter information into your record
• All employees, staff and other office personnel; and
• Any volunteers, interns, or students we allow to work with you while you are a patient of this Medical Practice.

This Notice applies to all facilities and entities owned. Operated and/or managed by this practice. A complete listing of facilities and entities operating under this notice may be obtained by contacting the Privacy Officer at (818) 363-7120.

THE DUTIES OF THIS OFFICE/ORGANIZATION

This office/organization is required by law to maintain the privacy of your personal medical information and to provide you with notice of our legal duties and privacy practices with respect to that information. We are also required to abide by the terms of our current Notice of Privacy Practices

USE AND DISCLOSURE OF MEDICAL INFORMATION

The office/organization may use your medical information for treatment, payment, and healthcare operations purposes. The following are some examples:

• For treatment purposes, we may release your medical information to other physicians, dentists, or health care providers, such as nurses or technicians, to assist in treating you.
• In billing for your treatment, we may release your medical information to your insurance company in filing claims or in order to receive payments.
• We may also use your medical information for our healthcare operations. This includes activities involving the review of our treatment and services to help us evaluate the quality of care we are providing, and evaluation of the performance of our staff in caring for you.

APPOINTMENT REMINDERS, CALL BACKS, & TREATMENT ALTERNATIVES

We may use your information to contact you for appointment reminders, to call you with the results of diagnostic tests, or to check on your condition following a visit or procedure. We may also contact you to provide you with information about treatment alternatives or health-related benefits or services.

FUNDRAISING

We may use your information to contact you in effort to raise money for this organization and its operations.

OTHER DISCLOSURES

There are some disclosures of medical information that do not require your authorization. Those disclosures include any of the following:

• Those required by federal, state or local law;
• To report adverse events or defects associated with products or medications;
• For public health activities, such as the reporting of communicable diseases;
• About victims of abuse, neglect or domestic violence;
• To comply with government oversight activities, such as audits or investigations;
• For organ or tissue donation purposes, if you are an organ donor;
• For Judicial or administrative proceedings;
• For specialized government functions, such as intelligence, counter-intelligence, or other national security activities; and
• For worker’s compensation.
• For law enforcement purposes, such as in the course of criminal investigations or the location of a missing person;
• Other uses and disclosures of your medical information will be made only with your specific written authorization, which you may revoke any time by giving written notice.

YOUR RIGHTS

You have the following rights regarding the medical information we maintain about you:

• You have the right to request restrictions on the use and disclosure of your medical information, and you have the right to request a limit on the information we disclose about you to someone who is involved in your care or your payment for your care, such as a family member or friend. We are not required to agree to the restriction, but once we do agree, we are bound by that agreement, unless the information is needed to provide you with emergency treatment.
• You have the right to receive communication of your medical information. Requests must be made in writing and an appropriate charge may be assessed for each page copied.
• You have the right to inspect and obtain copies of your medical information. Requests must be made in writing and an appropriate charge may be assessed for each page copied.
• You have the right to request a change to your medical information if you believe there is an error. You must submit a request in writing; including the information you believe should be changed and we will change your record, if appropriate. We reserve the right to deny the request to change your record, if the change is not appropriate.
• You have the right to a list of disclosures we have made of your medical information, excepting disclosures made for the purpose of treatment, payment and healthcare operations. Requests must be made in writing. You may receive one listing per calendar year without charge; any additional listings may be subject to a reasonable fee.
• You have the right to receive a paper copy of this notice upon request.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have any questions about this Notice, please contact our Privacy Officer at (818) 363-7120

If you believe that we have violated your right to privacy, you may complain to the Privacy Officer at (818) 363-7120, or to the Secretary of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201. There will be no retaliation for filing a complaint

We reserve the Right to change our health information practices and the terms of our Notice of Privacy Practices, and to make the changes effective for all protected health information we maintain, including health information created or received before the effective date of the changes. In the event we change our health information practices, we will post and/or personally provide a revised Notice of Privacy Practices.

EFFECTIVE DATE

This Notice is effective as of April 14, 2003.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.