New Patient Form

PRIMARY INSURANCE

ADDITIONAL/SECONDARY INSURANCE:

PHARMACY

OFFICE FINANCIAL POLICY

FINANCIAL TERM AGREEMENT: I hereby authorize David B. Lalezari and or it's designates to verify my health plan/insurance coverage and policy limits. Your insurance carrier will be billed on your behalf and your provider will be paid directly. You (the patient), will be responsible for any applicable deductibles and co-payments. If insurance is not in effect when services are rendered, you are responsible for payment. Co-payments are due at the time services are rendered. If you are without health insurance coverage, payment arrangements should be made prior to the appointment. A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit report agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.

CANCELLATIONS/ MISSED APPOINTMENTS: If an appointment is missed or cancelled within 24 hour notice you will be billed accordingly to the scheduled procedural fee and/or to the rules of your health plan. Frequent cancellations may result in termination of your treatment; your compliance in keeping appointments and being on time is vital to active participation in your treatment process.

CONSENT FOR TREATMENT: I authorize and request that my physician render medical examinations, treatments and/or diagnosis during the course of my treatment. I understand that treatment information will be explained to me. All courses of treatment are designed to be helpful and beneficial to me.

ASSIGNMENT OF BENEFITS: I hereby authorize the release of necessary information to Medicare, MediCAL, and all other health insurance plans for claims, certification/case management/quality improvements and any other benefits related to my health plan.

INSURANCE COVERAGE: It is your responsibility to understand your insurance benefits and limitations. Contact your insurance provider with any questions about coverage.

NON-COVERED SERVICES: If your insurance denies coverage for a service, you are responsible for the full charge. Payment is due upon receipt of your statement.

OUT-OF-NETWORK PATIENTS: If we are not contracted with your insurance, payment is due upon receipt of your statement. We will submit claims on your behalf, but reimbursement will go directly to you.

CO-PAYS AND DEPOSITS: All copays and deductibles must be paid before services are rendered.

• NEW PATIENTS: $200
• ESTABLISHED PATIENTS: $150
• MISSED APPT FEE: $50

(THESE WILL BE APPLIED TO YOUR CHARGES)

BALANCES: Balances after insurance must be paid within 30 days unless prior arrangements are made.

PRE-CERTIFICATION AND PRIOR AUTHORIZATION: Some services require pre-approval from insurance. We will assist in the process and if there are any delays with the insurance or approval process we will contact you in a timely manner.

ANCILLARY SERVICES: You may receive separate bills for labs, imaging, anesthesia, and or other services performed outside our office.

MEDICAL RECORDS AND FORMS:

Only necessary labs will be ordered based on a patients medical history, family, history, and symptoms. A patient may not be able to ask for a specific labs that are not deemed necessary.

We are unable to order labs, imaging or other tests prior to appointment and examination

All sleep studies require a follow up phone or visit in person

We reserve the right to refuse to prescribe controlled substances. We may instead refer you to a specialist, such as a Pain Management or Psychiatry.

We will communicate imaging and lab results through CS link messaging

• MEDICAL RECORDS: Contact CEDAR SINAI MEDICAL RECORDS DEPARTMENT (310) 423-2259
• FORMS (E.G., DISABILITY, FMLA): $75 per form, due at drop off. Please allow 5 business days.
• MISSED APPOINTMENTS: Fees apply for missed appointments without 1 business day notice.
• TELEHEALTH/ PHONE APPOINTMENTS: Please note: You may be billed directly if your insurance does not cover telehealth visits or phone consultations.
• POLICY UPDATES: Policies and fees are subject to change, we will notify you of any updates.
• BILLING QUESTIONS: For billing inquiries contact our billing department at (310) 402-2222
• MEDICAL DEBT AND DISCLOSURE (SB-1061): A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable.

• For Treatment: Sharing with other healthcare providers for care coordination.
• For Payment: To obtain reimbursement from insurance or other payers.
• For Healthcare Operations: For quality improvement, training, audits, etc.

• No use/disclosure for marketing or selling your information without explicit consent.
• Any other use outside the scope of treatment, payment, and operations requires written authorization.

1. Request Special Privacy Protections Ask for restrictions on certain uses or disclosures.

2. Request Confidential Communications Request contact in specific ways (e.g., by mail, phone).

3. Inspect and Copy Records You may review and request copies of your health records.

4. Amend Records You can request corrections if you believe your records are incomplete or incorrect.

5. Accounting of Disclosures Get a list of instances where your information was shared (excluding treatment, payment, and operations).

6. Right to a Paper Copy You may request a printed version of this Notice at any time.

• The practice may revise this policy and must post the updated notice and make it available.

NOTICE TO PATIENTS OF MEDICAL BOARD LICENSE DISPLAY: Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to WWW.MBC.CA.GOV

EMAIL: LICENSECHECK@MBC.CA.GOV OR CALL (800) 633-2322

"FOR INFORMATIONAL PURPOSES ONLY, A LINK TO THE FEDERAL CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) OPEN PAYMENTS WEB PAGE IS PROVIDED HERE. THE FEDERAL PHYSICIAN PAYMENTS SUNSHINE ACT REQUIRES THAT DETAILED INFORMATION ABOUT PAYMENT AND OTHER PAYMENTS OF VALUE WORTH OVER TEN DOLLARS (10$) FROM MANUFACTURERS OF DRUGS, MEDICAL DEVICES, AND BIOLOGICS TO PHYSICIANS AND TEACHING HOSPITALS BE MADE AVAILABLE TO THE PUBLIC."

The Open Payments database is a federal tool used to search payments made by drug and device companies for physicians and teaching hospitals. It can be found at

If you believe your privacy rights have been violated, you may file a complaint with the practice or the Department of Health and Human Services. You will not be retaliated against for filing a complaint.

I hereby acknowledge that I received a copy of this medical practice Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment. We may use and disclose this information to review and improve the quality of care we provide by digitally recording and transcribing your visit with the Doctor (or other Healthcare Provider) into your electronic medical record today. I would like to receive a copy of any amended Notice of Privacy Practices by email at:

PATIENT HEALTH QUESTIONNAIRE -9 (PHQ-9)

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.