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  • Please fill out the form below and submit online Or print out the form by clicking on the button below and bring it to your appointment

    If you are unable to fill the form in advance, plan to arrive 40 MINUTES BEFORE your scheduled appointment time to fill out paperwork.
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  • PATIENT INFORMATION

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  • Social Security #:

  • INSURANCE INFORMATION

  • Primary Care Physician: *   *   
    Referring Physician:  *   *   

  • Primary Insurance Company: * Employer: *

  • Subscriber's Information (if not self)
    Relationship to Patient: SSN or Insurance ID:             Pick a Date  

  • Secondary Insurance Company: Employer:

  • Subscriber's Information (if not self)
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  • We are not contracted with Medi-Cal. If Medi-Cal is your secondary insurance, then Medi-Cal eligibility will be verified to determine your financial responsibility for: co-pays, share of cost, deductibles, and/or accepting assignment from your primary insurance.

  • MEDI-CAL AUTHORIZATION RELEASE

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  • The above information is true to the best of my knowledge. I authorize MEDI-CAL to release my eligibility status directly to the office of Robert G. Salazar, M.D. Inc. for verification of eligibility and financial responsibility.

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  • ASSIGNMENT OF BENEFITS

  • The above information is true to the best of my knowledge. I hereby authorize my insurance benefits to be paid directly to Robert G. Salazar, M.D. Inc. for services rendered. I understand that I am financially responsible for all medical services rendered and that your office may bill my insurance plan directly as a convenience to me but that I am personally responsible for such charges until they are paid in full. I also authorize Robert G. Salazar, M.D. Inc. to release any information required to process my claim(s) and/or to provide medical treatment.

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  • PHARMACY INFORMATION

  • Name of Pharmacy: *

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  • EMERGENCY CONTACT INFORMATION

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  • PATIENT FINANCIAL RESPONSIBILITIES 

    Co-Payment and Deductible

    You are responsible for your deductible and co-payment. If your deductible has been satisfied, we will bill your health plan. If your deductible has not been satisfied, payment is required at the time of service. Your co-payment is also due at the time of service.

     

    Assignment

    We accept assignment of the approved amount as full payment for covered services through insurances we are In-network with. You may be responsible for your deductibles, co-pay and/or co-insurance.  Out-of- network insurances reviewed on a case by case basis.

     

    Non-Covered Services

    We will verify coverage of services before providing them to you however if your health plan determines not to cover those services once the claim is reviewed you may be responsible for payment in full for those services.

     

    Appointment Cancellation Charge

    By way of this notice you are hereby notified you may be charged $25 for appointments canceled without a minimum of twenty-four hours’ notification (missed appointment fee). This fee is your responsibility and cannot be billed to your health plan.

    If your visit is related to a worker’s compensation case, we will notify your workers compensation carrier if your appointment is canceled without a minimum of twenty-four hours’ notification and/or for no-shows/missed appointment.

    Excessive missed appointments may be cause for being discharged from the practice. The purpose of this policy is to have the option to offer the appointment time to another patient.

     

    Payment Arrangements

    Payments may be made in by; Visa, MasterCard, Discover Network, JCB International and American Express

    Payments by check are payable to: Robert G. Salazar, M.D. Inc and we also accept cash payments.

     

    Collections

    If it is necessary to assign your account to a collection agency and/or attorney, you may be responsible for all of our collection agency and attorney fees and costs.

    We are happy to discuss with you any questions relating to the information above. We thank you for your consideration of these matters and choosing California Advanced Pain & Spine Specialists for your health care needs.

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  • HIPAA NOTICE OF PRIVACY PRACTICES

  • THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION:

    Understanding what is in your health record and how your health information is used will help you to ensure its accuracy, allow you to better understand who, what, when, where and why others may access your health information, and assist you in making more informed decisions when authorizing disclosure to others. When you visit us, we keep a record of your symptoms, examinations, test results, diagnoses, treatment plan, and other medical information. We also may obtain health records from other providers. In using and disclosing this protected health information (“PHI”), it is our objective to follow the Privacy Standards of the federal Health Insurance Portability and Accountability Act, 45 CFR Part 464. The law allows us to use and disclose PHI without your specific authorization for treatment, payment, operations and other specific purposes explained on the next page. This includes the sharing of information, when necessary and appropriate, with other physician’s, as necessary for your continued care. It also includes contacting you for appointment reminders and follow-up care. All other uses and disclosures require your specific authorization.

    YOUR HEALTH INFORMATION RIGHTS ALLOWS YOU TO:

    • Request a restriction on the uses and disclosures of PHI as described in this notice, although we are not required to agree to the restriction you request. If you have paid for services out-of-pocket, in full, and request that we not disclose your PHI, related solely to those services, we shall accommodate your request except where the disclosure is required by law. You should address your request in writing to the Privacy Officer. We will notify you within thirty (30) days if we cannot agree to the restriction.
    • Obtain a paper copy of this Notice and upon written request, inspect and obtain a copy of your health record for a fee of $.25 per page and the actual cost of postage per the U.S. Postal Service, except that you are not entitled to access, or to obtain a copy of, psychotherapy notes and information compiled for legal proceedings. We may deny your request to inspect and/or copy your health record in certain limited circumstances. If you are denied access to your health information, you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review.
    • Amend your health record by submitting a written request with the reasons supporting the request to the
    Privacy Officer. To request an amendment, complete and submit a Medical Record Amendment/Correction Form to the Privacy Officer. We will respond to your request within sixty (60) days of receipt of your written request, unless additional time is needed to respond, at which time we may extend our response deadline for up to an additional thirty (30) days and provide you with an explanation as to the reason for the delay. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) we did not create, unless the person or entity that created the information is no longer available to make the amendment; (2) is
    not part of the health information that we keep; (3) you would not be permitted to inspect and copy; or (4) is inaccurate and incomplete.
    • Obtain an accounting of disclosures of your health information, except that we are not required to account for disclosures for treatment, payment, operations, or pursuant to authorization, among other exceptions. To obtain this “accounting of disclosures,” you must submit your request in writing to the Privacy Officer. Your request must state a time period, which may not be longer than six (6) years prior to the date on which the accounting is requested. Your request should indicate in what form you want the list (for example, on paper or electronically). The first accounting in any twelve (12) month period is free of charge. Additional requests for accounting of disclosures may result in charges to you for the costs of providing such accounting. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. We will respond to your request for an accounting of disclosures within sixty
    (60) days of receipt of your written request, unless additional time is needed to respond, at which time we may extend our response deadline for up to an additional thirty (30) days and provide you with an explanation as to the reason for the delay.
    • Request in writing to the Privacy Officer that we communicate with you by a specific method and at a specific location. We will typically communicate with you in person; or by letter, e-mail, fax, and/or telephone.
    • Revoke an authorization to use or disclose PHI at any time except where action has already been taken.

    OUR RESPONSIBILITIES AS REQUIRED BY LAW:

    • Maintain the privacy of PHI and provide you with notice of our legal duties and privacy practices with respect to PHI.
    • Abide by terms of the notice currently in effect. We have the right to change our notice of privacy practices and we will apply the change to your entire PHI, including information obtained prior to the change.
    • Post notice of any changes to our Privacy Policy in the lobby, or on our practice website (if any), and make a copy available to you upon request.
    • Notify affected individuals following a breach of unsecured PHI.
    • Use or disclose your PHI only with your authorization except as described in this notice.
    • Follow the more stringent law in any circumstance where other state or federal law may further restrict the disclosure of your PHI.

    FOR MORE INFORMATION OR TO REPORT A PROBLEM, CONTACT THE PRIVACY OFFICER AT:


    California Advanced Pain & Spine Specialists
    7152 North Sharon #102
    Fresno, California 93720
    Telephone: 559.432.6807

    If you feel your rights have been violated, you may file a complaint in writing with the Privacy Officer. If you are not satisfied with the resolution of the complaint, you may also file a complaint with the Office of Civil Rights either writing to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/ Filing a complaint will not result in retaliation.

    We may use or disclose your PHI for treatment, payment and operations, and for purposes described below:

    TREATMENT

    We will use and exchange information obtained by a physician, nurse practitioner, nurse or other medical professionals, staff, trainees and volunteers in our office to determine your best course of treatment. The information
    obtained from you or from other providers will become part of your medical records. We may also disclose your PHI to other outside treating medical professionals and staff as deemed necessary for your care. For example, we may disclose your PHI to an outside physician for referral. We will also provide your health care providers with copies of various reports to assist them in your treatment. If you are an athlete, and wish to have your trainer or coach notified, we may disclose PHI to athletic trainers and coaches pertaining to medical conditions that may restrict your ability to compete.

    PAYMENT

    We may use and disclose protected health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may send a bill to you or to your insurance carrier. The information on or accompanying the bill may include information that identifies you, as well as that portion of your PHI necessary to obtain payment.

    HEALTH CARE OPERATIONS

    Members of the medical staff, trainees, medical students, a Risk or Quality Improvement team, or similar personnel may use your information to assess the care and outcomes of your care in an effort to improve the quality of the healthcare and service we provide or for educational purposes. For example, an internal review team may review your medical records to determine the appropriateness of care. There may also be times in which our accountants, auditors, health information specialists or attorneys may review your PHI to meet their responsibilities.

    OTHER USES AND DISCLOSURES NOT REQUIRING AUTHORIZATION

    • Business Associates: There are some services provided to our organization through contracts with business associates, such as laboratory and radiology services. We may disclose your health information to our business associates so that they can perform these services. We require the business associates to safeguard your information to our standards.
    • Notification: We may disclose limited health information to friends or family members identified by you as being involved in your care or assisting you in payment. We may also notify a family member, or another person responsible for your care, about your location and general condition.
    • Legally Required Disclosures & Public Health: We may disclose PHI as required by law, or in a variety of circumstances authorized by federal or state law. For example, we may disclose PHI to government officials to avert a serious threat to health or safety or for public health purposes, such as to prevent or control communicable disease (which may include notifying individuals that may have been exposed to the disease, although in such circumstances you will not be personally identified), federal or state health oversight agencies, child abuse or neglect, domestic violence, to an employer to evaluate work related injuries, and to public officials to report births and deaths.
    • Law Enforcement & Subpoenas: We may disclose PHI to law enforcement such as limited information for identification and locations purposes, or information regarding suspected victims of crime, including crimes committed on our premises. We may also disclose PHI to others as required by court or administrative order, or in response to a valid summons or subpoena.
    • Information Regarding Decendents: We may disclose health information regarding a deceased person to:
    1) coroners and medical examiners to identify cause of death or other duties 2) funeral directors for their required duties and 3) to procurement organizations for purposes of organ and tissue donation.
    • Research: We may also disclose PHI where the disclosure is solely for the purpose of designing a study, or where the disclosure concerns decedents, or an institutional review board or privacy board has determined that obtaining authorization is not feasible and protocols are in place to ensure the privacy of your health information. In all other situations, we may only disclose PHI for research purposes with your authorization.

    • Marketing & Funding Raising: We may contact you with information about treatment alternatives or other health related benefits and services that may be of interest to you. We may also contact you as part of a fund raising effort, unless you instruct us not to.
    • Directory Information: We may disclose limited information regarding your name and location for directory purposes to those persons who ask for you by name or to members of the clergy. You may request that we not include your name in the directory.

    DISCLOSURES REQUIRING AUTHORIZATION

    The release of health information, other than those identified above, will be made with written authorization from the patient, which you have the right to revoke at any time, except to the extent we have already relied upon the authorization or in the event of an emergency.

  • ACKNOWLEDGEMENT OF RECEIPT

  • Federal law requires that we seek your acknowledgment of receipt of this Notice of Privacy Practices. Please sign below.

  • I , {name} acknowledge that I have read the Notice of Privacy Practices with an effective date of {date224} and I understand that if I have any questions regarding this Notices, I may contact California Advanced Pain & Spine Specialists. Additionally, I will be offered a copy of the notice upon checking in for my consultation.

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  • PRIVACY POLICY AND TERMS OF USE

  • Please review our Privacy Policy and Terms of Use to understand our practices and the terms and conditions under which you are granted the right to access and use this Patient Portal site.

    ELECTRONIC COMMUNICATIONS

    When you visit the California Advanced Pain & Spine Specialists Patient Portal or send e-mails to us, you are communicating with us electronically. You consent to receive communications from us electronically. We will communicate with you where we deem appropriate by e-mail or by posting notices on this site. You agree that all agreements, notices, disclosures and other communications that we provide you electronically satisfy any legal requirements that such communications be in writing.

    THE PATIENT PORTAL IS NOT INTENDED TO PROVIDE MEDICAL ADVICE

    SITE CONTENT IS NOT INTENDED IN ANY WAY TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE FROM YOUR HEALTH CARE TEAM. ALL CONTENT PROVIDED BY DR. SALAZAR ON THIS PATIENT PORTAL IS GENERAL IN NATURE, IS PRESENTED IN SUMMARY FORM, AND IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY TO IMPROVE YOUR COLLABORATION WITH YOUR HEALTH CARE TEAM. THIS WEBSITE IS NOT INTENDED FOR USE IN THE DIAGNOSIS OF DISEASE OR OTHER CONDITIONS, OR IN THE CURE, MITIGATION, TREATMENT, OR PREVENTION OF DISEASE. ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTHCARE PROFESSIONAL FOR YOUR QUESTIONS CONCERNING A MEDICAL OR CLINICAL CONDITION, DECISIONS, GUIDELINES, MANAGEMENT OR TREATMENT. DO NOT RELY ON CONTENT, GUIDELINES, PRODUCTS OR ANY OTHER SERVICE OFFERED BY OR THROUGH THE PATIENT PORTAL OR THE SITE FOR MEDICAL OR CLINICAL DECISIONS, DIAGNOSIS, MANAGEMENT OR TREATMENT. NEVER DISREGARD MEDICAL ADVICE OR DELAY IN SEEKING IT BECAUSE OF SOMETHING YOU HAVE READ ON THIS SITE.  DO NOT USE THIS PATIENT PORTAL TO COMMUNICATE WITH DR. SALAZAR REGARDING ANY URGENT MEDICAL ISSUE OR FOR A MEDICAL EMERGENCY. IF YOU HAVE A MEDICAL EMERGENCY OR AN URGENT MEDICAL MATTER CALL OUR OFFICE DURING NORMAL BUSINESS HOURS AND AFTER HOURS SEEK TREATMENT AT AN URGENT CARE OR EMERGENCY ROOM OR CONTACT 911. 

    YOUR PERSONAL INFORMATION

    Your privacy is important to us. You will need to provide a User ID and password to access and use this service. When you download your personal information from your data source (including, for example, medical information from visits to healthcare providers) the Portal will store your personal information.

    YOUR ACCOUNT

    If you use this site, you are responsible for maintaining the confidentiality of your account and password and for restricting access to your computer, and you agree to accept responsibility for all activities that occur under your account or password. We reserve the right to refuse service, terminate accounts, remove or edit content, or cancel orders in their sole discretion.

    In addition, we may automatically gather general statistical information about our Web site and users, such as IP addresses, browsers, pages viewed and number of visitors, but in doing so we do not reference you by individual name, e-mail address, home address, or telephone number. We use this data in the aggregate to determine how much our customers use parts of our site so we can improve our site. We may provide this statistical information to third parties, but if and when we would do so we will not provide any personally identifying information without your prior permission. We do not sell or rent or share personally identifying information collected during your use of our Web site without your permission. We collect and store your profile in order for you to manage your health.

    As part of our service, we may use cookies to store and sometimes track information about you. A cookie is a small amount of data that is sent to your browser from a Web server and stored on your computer's hard drive. Generally, we use cookies to: (i) remind us who you are and enable us to access your account information so you do not have to reenter it; (ii) gather statistical information about usage by registered or unregistered users and (iii) research visiting patterns. In addition, we may, in the future, use cookies to: (i) help target advertisements based on user interests; (ii) assist our partners to track visits and process orders; and (iii) track progress and participation in promotions. In some instances, our partners and advertisers appearing at our site may use their own cookies. Preference and options configurations in your browser determine if and how a cookie will be accepted. You can change those configurations on your computer if you desire. By changing your preferences, you can accept all cookies, you can be notified when a cookie is set, or you can reject all cookies. If you do so and cookies are disabled, you may be required to reenter your information more often and certain features of our site may be unavailable.

    SECURITY

    We employ reasonable and current security methods to prevent unauthorized access, maintain data accuracy, and ensure correct use of information your account information and profile are password-protected. We recommend that you do not divulge your password to anyone. Our personnel will never ask you for your password in an unsolicited phone call or in an unsolicited e-mail. Remember to sign out of your account and close your browser window when you have finished your session. This is to help ensure that others cannot access your personal information and correspondence if you share a computer with someone else or are using a computer in a public place where others may have access to it. Remember that certain portions of the website that you may visit may be public places, whether solely for users within a practice or for any users of our portal. Whenever you voluntarily disclose personal information online - for example on message boards, through e-mail or in chat areas - that information can be collected and used by others. No data transmission over the Internet or any wireless network can be guaranteed to be perfectly secure. As a result, while we try to protect your personal information, we cannot ensure or guarantee the security of any information you transmit to us, and you do so at your own risk. We have taken the steps required of us under the Health Information Technology for Economic and Clinical Health ("HITECH") and HIPAA to protect the security and privacy of any patient information housed on our website.

    MINOR POLICY

    We have no way of monitoring or distinguishing the age of individuals who access this site and so we carry out the same Privacy Policy for individuals of all ages. If a minor has provided us with personally identifying information without parental or guardian consent, the parent or guardian should contact the practice to restrict access and remove the information. You represent that you are of sufficient legal age to use this site and to create binding legal obligations for any liability you may incur as a result of the use of this site. You understand that you are financially responsible for all uses of this site by you and those using your login information.

    HOW YOU CAN OPT-OUT

    You must notify us to disengage from the Patient Portal.  Please contact us if you wish to opt out or terminate use of this Patient Portal.

    LICENSE AND SITE ACCESS

    We grant you a limited license to access and make personal use of this site and not to download (other than page caching) or modify it, or any portion of it, except with tools provided by us or with the express written consent of California Advanced Pain & Spine Specialists.  This license does not include any resale or commercial use of this site or its contents; the right to make or establish a derivative use of this site or its contents; any downloading or copying of account information for the benefit of another party - except as might otherwise be allowed under the site (e.g. parent/guardian/minor relationship); or any use of data mining, robots, or similar data gathering and extraction tools. This site or any portion of this site may not be reproduced, duplicated, copied, sold, resold, visited, or otherwise exploited for any commercial purpose without express written consent of California Advanced Pain & Spine Specialists. You may not frame or utilize framing techniques to enclose any trademark, logo, or other proprietary information (including images, text, page layout, or form) of California Advanced Pain & Spine Specialists or third party providers without express written consent. You may not use any meta tags or any other "hidden text" utilizing California Advanced Pain & Spine Specialists's name or trademarks without the express written consent of California Advanced Pain & Spine Specialists. Any unauthorized use terminates the permission or license granted by California Advanced Pain & Spine Specialists. You are granted a limited, revocable, and nonexclusive right to create a hyperlink solely to the home page of Dr. Salazar so long as the link does not portray Dr. Salazar or their products or services in a false, misleading, derogatory, or otherwise offensive matter. You may not use any California Advanced Pain & Spine Specialists logo or other proprietary graphic or trademark as part of the link without express written permission.  This patient portal and the associated software are licensed by California Advanced Pain & Spine Specialists from General Electric Company and is subject to further restrictions and limitations on use imposed by General Electric Company

    DISCLAIMER OF WARRANTIES AND LIMITATION OF LIABILITY

    THIS SITE IS PROVIDED ON AN "AS IS" AND "AS AVAILABLE" BASIS. DR. SALAZAR MAKE NO REPRESENTATIONS OR WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, AS TO THE OPERATION OF THIS SITE OR THE INFORMATION, CONTENT, MATERIALS, OR PRODUCTS INCLUDED ON THIS SITE. YOU EXPRESSLY AGREE THAT YOUR USE OF THIS SITE IS AT YOUR SOLE RISK. TO THE FULL EXTENT PERMISSIBLE BY APPLICABLE LAW, WE DISCLAIM ALL WARRANTIES, EXPRESS OR IMPLIED, INCLUDING, BUT NOT LIMITED TO, IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. WE DO NOT WARRANT THAT THIS SITE, ITS SERVERS, OR E-MAIL SENT FROM US ARE FREE OF VIRUSES OR OTHER HARMFUL COMPONENTS. WE WILL NOT BE LIABLE FOR ANY DAMAGES OF ANY KIND ARISING FROM THE USE OF THIS SITE, INCLUDING, BUT NOT LIMITED TO DIRECT, INDIRECT, INCIDENTAL, PUNITIVE, AND CONSEQUENTIAL DAMAGES.

    RELEASE

    Because we do not use the Patient Portal in the rendering of medical advice, in the event that you have a dispute with any individual and/or entity that arises out of your use of the Patient Portal, you release Dr. Salazar (and our officers, directors, agents, subsidiaries and employees) from claims, demands and damages (actual and consequential) of every kind and nature, known and unknown, suspected and unsuspected, disclosed and undisclosed, arising out of or in any way connected with such disputes. You further waive California Civil Code §1542, which says: "A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor."

    NO RESPONSIBILITY FOR LINKS TO OR FROM OTHER SITES

    This Patient Portal may contain lines to other websites and other websites may link to this portal.  These links are provided for your convenience only.  Dr. Salazar does not control these other sites and assume no liability or responsibility for them, including any content or services provided to you by such sites. You should not consider any link to or from another site as an endorsement of that site by Dr. Salazar. 

    REVIEWS, COMMENTS, COMMUNICATIONS, FORUMS, AND OTHER CONTENT

    Visitors may post reviews, comments, and other content; send communications; engage in chat rooms and submit suggestions, ideas, comments, questions, or other information, so long as the content is not illegal, obscene, threatening, defamatory, invasive of privacy, infringing of intellectual property rights, or otherwise injurious to third parties or objectionable and does not consist of or contain software viruses, political campaigning, commercial solicitation, chain letters, mass mailings, or any form of "spam." You may not use a false e-mail address, impersonate any person or entity, or otherwise mislead as to the origin of any content. You agree that you will not upload or transmit any communications that infringe any patent, trademark, trade secret, service mark, copyright or other proprietary rights of any party. California Advanced Pain & Spine Specialists reserves the right (but not the obligation) to remove or edit such content, but does not regularly review posted content. Please remember that any information (including personal and medical information) that you reveal in a Patient Portal public forum (such as a bulletin board, posting, chat room/event) is not protected by this Privacy Policy. Third parties not related to Patient Portal may see such postings. If you do post content or submit material, and unless we indicate otherwise, you grant California Advanced Pain & Spine Specialists a nonexclusive, royalty-free, perpetual, irrevocable, and fully sub-licensable right to use, reproduce, modify, adapt, publish, translate, create derivative works from, distribute, and display such content throughout the world in any media. You also grant California Advanced Pain & Spine Specialists and sub-licensees the right to use the name that you submit in connection with such content, if they choose. You represent and warrant that you own or otherwise control all of the rights to the content that you post; that the content is accurate; that use of the content you supply does not violate this Privacy Policy and will not cause injury to any person or entity; and that you will indemnify Dr. Salazar for all claims resulting from content you supply. You warrant that your communications comply with federal, local and international laws respecting trademark, trade secret, service mark, copyright or other proprietary rights of any party. Dr. Salazar takes no responsibility and assumes no liability for any content posted by you or any third party.

    INFORMATION CONTROL

    We do not control the information provided by other users that is made available through our system. You may find other user's information to be offensive, harmful, inaccurate, or deceptive. Please use caution, common sense, and practice safe trading when using our site. Please note that there are also risks of dealing with underage persons or people acting under false pretense.

    MODIFICATION, AND SEVERABILITY

    We reserve the right to make changes to our site, policies, and these Conditions of Use at any time. Any changes to our policies will be communicated through our web site at least in advance of its effective date. Information collected before changes are made will be secured according to the previous policies. If any of these conditions shall be deemed invalid, void, or for any reason unenforceable, that condition shall be deemed severable and shall not affect the validity and enforceability of any remaining condition.

    GENERAL

    This Agreement shall be governed in all respects by the laws of the State of California as such laws are applied to agreements entered into and to be performed entirely within California between California residents. We do not guarantee continuous, uninterrupted or secure access to our services, and operation of our site may be interfered with by numerous factors outside of our control. If any provision of this Agreement is held to be invalid or unenforceable, such provision shall be struck and the remaining provisions shall be enforced. You agree that this Agreement and all incorporated agreements may be automatically assigned by Dr. Salazar, in our sole discretion, to a third party in the event of a merger or acquisition. Headings are for reference purposes only and in no way define, limit, construe or describe the scope or extent of such section. Our failure to act with respect to a breach by you or others does not waive our right to act with respect to subsequent or similar breaches. This Agreement sets forth the entire understanding and agreement between us with respect to the subject matter hereof.

    If you have any questions regarding this website, your enrollment or any other question, please contact us.

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  • Beck's Anxiety Inventory

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  • Beck's Depression Inventory

    Please choose one selection for each question listed below.
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  • OSWESTRY DISABILITY QUESTIONNAIRE

  • Instructions: this questionnaire has been designed to give us information as to how your pain has affected your ability to manage everyday life. Please answer every section and mark in each section only the ONE box which applies to you at this time.

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  • OPIOID RISK TOOL (ORT)

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  • Review of Medical History

  • Please check all that apply

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  • ANESTHESIA/SURGERY HISTORY

  • AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

  • Completion of this document authorizes the disclosure and/or use of health information about you. Failure to provide all information requested my invalidate this authorization.

  •  I, * hereby authorize Surescripts to release to: Robert G. Salazar M.D. Inc DBA California Advanced Pain & Spine Specialists; 7152 N. Sharon Avenue, Suite 102, Fresno, California 93720. The following information: current medication history, including both my prior medication history, discontinued medications and any future medication which may be prescribed until this consent is revoked. Purpose of requested use or disclosure: To verify medications and drug interactions. Limitations if any: None

  • EXPIRATION

    This authorization expires three years after the date of the signature.

    MY RIGHTS

    I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits. I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of. I may revoke this authorization at any time, but I must do so in writing and submit it to the following address: 7152 N. Sharon Avenue, Suite 102, Fresno, California 93720. My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization. I have a right to receive a copy of this authorization. Information disclosed pursuant to this authorization could be redisclosed by the recipient. Such re-disclosure is in some cases not prohibited by California law and may no longer be protected by federal confidentiality law (HIPPA). However, California law prohibits the person receiving my health information from making further disclosure of it unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.

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