New Patient Registration Forms

Full Name *

First Name Middle Name Last Name

Date of Birth *

Month Day Year

Marital Status *

Single Divorced Separated Widowed Married

Gender Assigned At Birth *

Gender Identity *

Social Security #: xxx-xx-xxxx

Race *

Ethnicity *

Cell Phone *

Phone Number

Home Phone

Phone Number

Email *

example@example.com

Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Is your physical address different from your mailing address? *

Yes No

Physical Address (If Different From Mailing Address) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Are you being seen today due to a Worker's Compensation Injury? *

Yes (If you marked yes, then do NOT complete this section.) No

Are you being seen today on a lien-basis due to personal injury? *

Yes (If you marked yes, then do NOT complete this section.) No

Primary Care Physician: First Name* Last Name*
Referring Physician: First Name* Last Name*

Primary Insurance Company: Insurance Name* Employer: Employer*

Subscriber's Information (if not self)
Relationship to Patient:Relationship SSN or Insurance ID: SSN or Insurance ID First Name Last Name Date of Birth

Secondary Insurance Company:Insurance Name Employer: Employer

Subscriber's Information (if not self)
Relationship to Patient:Relationship SSN or Insurance ID: SSN or Insurance ID First Name Last Name Date of Birth

Please attach a copy of a valid ID and your insurance card, front and back.

Browse Files

Do you have Medi-Cal? *

Yes No

Effective Medi-Cal Date *

Month Day Year

Medi-Cal ID# *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Signature

Clear

Date *

Month Day Year

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.

Signature *

Clear

Date *

Month Day Year

Name of Pharmacy: Name of Pharmacy*

Pharmacy Address *

Street Address

Street Address 2

City State / Province

Postal / Zip Code

Pharmacy Phone Number *

Area Code Phone Number

Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

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.

Signature *

Clear

Date *

Month Day Year

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.

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.

Signature *

Clear

Date

Month Day Year

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.

I acknowledge that I have read the Patient Portal Privacy Policy And Terms of Use. *

I agree to opt into the patient portal. I opt out of the patient portal.

Signature *

Clear

Date *

Month Day Year

INSTRUCTIONS: Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by checking the box in the corresponding space in the column next to each symptom. *

	Not at all	Mildly but it didn't bother me much	Moderately it wasn't pleasant at times	Severely it bothered me a lot
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding/racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Shaky/unsteady
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Faint/lightheaded
Face flushed
Hot/cold sweats

Beck's Anxiety Score

Question 1 *

0 I do not feel sad. 1 I feel sad. 2 I am sad all the time and I can't snap out of it. 3 I am so so and unhappy that I can't stand it.

Question 2 *

0 I am not particularly discouraged about the future. 1 I feel discouraged about the future. 2 I feel I have nothing to look forward to. 3 I feel the future is hopeless and that things cannot improve.

Question 3 *

0 I do not feel like a failure. 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failures. 3 I feel I am a complete failure as a person.

Question 4 *

0 I get as much satisfaction out of things as I used to. 1 I don't enjoy things the way I used to. 2 I don't get real satisfaction out of anything anymore. 3 I am dissatisfied or bored with everything.

Question 5 *

0 I don't feel particularly guilty. 1 I feel guilty a good part of the time. 2 I feel quite guilty most of the time. 3 I feel guilty all of the time.

Question 6 *

0 I don't feel I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished.

Question 7 *

0 I don't feel disappointed in myself. 1 I am disappointed in myself. 2 I am disgusted with myself. 3 I hate myself.

Question 8 *

0 I don't feel I am any worse than anybody else. 1 I am critical of myself for my weaknesses or mistakes. 2 I blame myself all the time for my faults. 3 I blame myself for everything bad that happens.

Question 9 *

0 I don't have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance.

Question 10 *

0 I don't cry any more than usual. 1 I cry more now than I used to. 2 I cry all the time now. 3 I used to be able to cry, but now I can't cry even though I want to.

Question 11 *

0 I am no more irritated by things than I ever was. 1 I am slightly more irritated now than usual. 2 I am quite annoyed or irritated a good deal of the time. 3 I feel irritated all the time.

Question 12 *

0 I have not lost interest in other people. 1 I am less interested in other people than I used to be. 2 I have lost most of my interest in other people. 3 I have lost all of my interest in other people.

Question 13 *

0 I make decisions about as well as I ever could. 1 I put off making decisions more than I used to. 2 I have greater difficulty in making decisions more than I used to. 3 I can't make decisions at all anymore.

Question 14 *

0 I don't feel that I look any worse than I used to. 1 I am worried that I am looking old or unattractive. 2 I feel there are permanent changes in my appearance that make me look unattractive. 3 I believe that I look ugly.

Question 15 *

0 I can work about as well as before. 1 It takes an extra effort to get started at doing something. 2 I have to push myself very hard to do anything. 3 I can't do any work at all.

Question 16 *

0 I can sleep as well as usual. 1 I don't sleep as well as I used to. 2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 3 I wake up several hours earlier than I sued to and cannot get back to sleep.

Question 17 *

0 I don't get more tired than usual. 1 I get tired more easily than I used to. 2 I get tired from doing almost anything. 3 I am too tired to do anything.

Question 18 *

0 My appetite is no worse than usual. 1 My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 I have no appetite at all anymore.

Question 19 *

0 I haven't lost more than five pounds. 1 I have lost more than five pounds. 2 I have lost more than ten pounds. 3 I have lost more than fifteen pounds.

Question 20 *

0 I am no more worried about my health than usual. 1 I am worried about physical problems like aches, pains, upset stomach, or constipation. 2 I am very worried about physical problems and it's hard to think of much else. 3 I am so worried about my physical problems that I cannot think of anything else.

Question 21 *

0 I have not noticed any recent change in my interest in sex. 1 I am less interested in sex than I used to be.. 2 I have almost no interest in sex. 3 I have lost interest in sex completely.

Beck's Depression Score

Date *

Month Day Year

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.

On average, what is your pain level from zero to ten? *

1. PAIN INTENSITY *

0 I can tolerate the pain I have without having to use pain killers. 1 The pain is bad but I manage without taking pain killers. 2 Pain killers give complete relief from pain. 3 Pain killers give moderate relief from pain. 4 Pain killers give very little relief from pain. 5 Pain killers have no effect on the pain and I do not use them.

2. PERSONAL CARE (e.g. Washing, Dressing) *

0 I can look after myself normally without causing extra pain. 1 I can look after myself normally, but it causes extra pain. 2 It is painful to look after myself and I am slow and careful. 3 I need some help but manage most of my personal care. 4 I need help every day in most aspects of self-care. 5 I don't get dressed, I was with difficulty and stay in bed.

3. LIFTING *

0 I can lift heavy weights without extra pain. 1 I can lift heavy weights, but it gives extra pain. 2 Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table. 3 Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. 4 I can lift very light weights. 5 I cannot lift or carry anything at all.

4. WALKING *

0 Pain does not prevent me from walking any distance. 1 Pain prevents me from walking more than one mile. 2 Pain prevents me from walking more than 1/2 mile. 3 Pain prevents me from walking more than 1/4 mile. 4 I can only walk using a stick or crutches. 5 I am in bed most of the time and have to crawl to the toilet.

5. SITTING *

0 I can sit in any chair as long as I like. 1 I can only sit in my favorite chair as long as I like. 2 Pain prevents me from sitting more than one hour. 3 Pain prevents me from sitting more than 1/2 hour. 4 Pain prevents me from sitting more than 10 minutes 5 Pain prevents me from sitting at all.

6. STANDING *

0 I can stand as long as I want without extra pain. 1 I can stand as long as I want but it gives me extra pain. 2 Pain prevents me from standing for more than one hour. 3 Pain prevents me from standing for more than 30 minutes. 4 Pain prevents me from standing for more than 10 minutes. 5 Pain prevents me from standing at all.

7. SLEEPING *

0 Pain does not prevent me from sleeping well. 1 I can sleep well only by using medication. 2 Even when I take medication, I have less than 6 hours sleep. 3 Even when I take medication, I have less than 4 hours sleep. 4 Even when I take medication, I have less than 2 hours sleep. 5 Pain prevents me from sleeping at all.

8. SOCIAL LIFE *

0 My social life is normal and gives me no extra pain. 1 My social life is normal but increases the degree of pain. 2 Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. dancing, etc. 3 Pain has restricted my social life and I do not go out as often. 4 Pain has restricted my social life to my home. 5 I have no social life because of pain.

9. TRAVELING *

0 I can travel anywhere without extra pain. 1 I can travel anywhere but it gives me extra pain. 2 Pain is bad, but I manage journeys over 2 hours. 3 Pain restricts me to journeys of less than 1 hour. 4 Pain restricts me to short necessary journeys under 30 minutes. 5 Pain prevents me from traveling except to the doctor or hospital.

10. EMPLOYMENT/HOMEMAKING *

0 My normal homemaking/job activities do not cause pain. 1 My normal homemaking/job activities increase my pain, but I can still perform all that is required of me. 2 I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming) 3 Pain prevents me from doing anything but light duties. 4 Pain prevents me from doing even light duties. 5 Pain prevents me from performing any job or homemaking chores.

VAS Score

OSWESTRY Score

Date *

Month Day Year

Please answer the questions below using the following scale. *

	Never 0	Seldom 1	Sometimes 2	Often 3	Very Often 4
1. How often do you have mood swings?
2. How often do you smoke a cigarette within an hour after you wake up?
3. How often have you taken medication other than the way that it was prescribed?
4. How often have you used illegal drugs (marijuana, cocaine, etc) in the past five years?
5. How often, in your lifetime, have you had legal problems or been arrested?

Opioid Risk Score

Date *

Month Day Year

How do you describe your pain? Please check the following: *

Intensity of Pain *

Mild Moderate Severe

Frequency of Pain *

Occasional 25% Intermittent 50% Frequent 75% Constant 100%

Please circle the area(s) that you experience pain

Please check all that apply

RESPIRATORY

ASTHMA PNEUMONIA CHRONIC COUGH SMOKER EMPHYSEMA WHEEZING VALLEY FEVER COPD

CARDIOVASCULAR

METABOLIC/ENDOCRINE

DIABETES THYROID DISORDER KIDNEY PROBLEMS

IMMUNE SYSTEM

RECENT STEROIDS CANCER LEUKEMIA CHEMOTHERAPY RADIATION THERAPY UNEXPLAINED WEIGHT LOSS NIGHT SWETS LYMPHOMA

HEMA/HEPTIC/GI

FREQUENT HEART BURN BLEEDING DISORDER HEPATITIS/JAUNDICE DIFFICULTY SWALLOWING COLON PROBLEM STOMACH PROBLEMS ANEMIA HIATAL HERNIA

MUSCULOSKELETAL/NEURO

HEADACHE/MIGRAINE BLACKOUTS/FAINTING LIMITED JOINT MOVEMENT NERVE/MUSCLE PROBLEMS BACK INJURY PAIN SEIZURE NUMBNESS STROKE MENTAL HEALTH

Is your pain a result of an injury? If yes, enter DATE OF INJURY.

Month Day Year

ANESTHESIA/SURGERY HISTORY enter history

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, name of patient* 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.

Signature *

If signed by someone other than the patient, state your legal relationship to the patient and provide the appropriate documentation. Clear

Date *

Month Day Year Hour Minutes AM/PM Option

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

PATIENT INFORMATION

INSURANCE INFORMATION

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

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.

ASSIGNMENT OF BENEFITS

PHARMACY INFORMATION

EMERGENCY CONTACT INFORMATION

HIPAA NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT

PRIVACY POLICY AND TERMS OF USE

Beck's Anxiety Inventory

Beck's Depression Inventory

OSWESTRY DISABILITY QUESTIONNAIRE

OPIOID RISK TOOL (ORT)

Review of Medical History

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION