Please hand-carry ALL new or old radiology images and reports (X-rays, MRI, CT scan etc.) to your appointment. We prefer a CD of the images. We need to view the actual images to develop your treatment plan.

HOW TO OBTAIN IMAGES ON CD: If you do not already have the images in your possession, please contact the facility where your studies were performed. Tell them the following:

“Please burn a CD of all my spine imaging studies and please print reports. I will pick it up prior to my appointment with the spine doctor.”

*As your images may not reach our office in time for appointment*

Thank you for your help in this matter!

Welcome to the Spine Institute of San Diego! Thank you for choosing us for your spinal care needs.

Our team is committed to providing you with the highest level of care and compassion. Our team consists of many staff members striving to make your experience the best possible.

Our mission is to be readily available to answer any questions or address any concerns you may have. Also, our administrator, Josephine Turner, is always available to help in any way possible. Email is the preferred method of communication; however, you can contact us by phone should that be your method of communication.

To Our Valued Patients:

Thank you for choosing the Spine Institute of San Diego for your spinal care needs. In our efforts to provide you the very highest level of care, we ask that you take time to fill out the enclosed forms. We strive to provide our patients with outstanding care and service. Please do not hesitate to call us with any questions prior to your appointment.

Please arrive fifteen minutes prior to your appointment time with the forms COMPLETED in BLACK INK to avoid delay of your appointment.

REMINDER: IT IS VERY IMPORTANT TO BRING YOUR ACTUAL X-RAYS/MRI/CT IMAGES TO YOUR OFFICE VISIT (NOT JUST THE RADIOLOGY REPORT).

CONDITIONS OF REGISTRATION AND AGREEMENT FOR PATIENTS OF SPINE INSTITUTE OF SAN DIEGO, INC.
If the patient is a minor, the parent, legal guardian or authorized person (in writing) must sign.

MEDICAL CONSENT
The undersigned consents to any and all service that do not require informed written consent.

RELEASE OF INFORMATION
The undersigned acknowledges receiving Spine Institute of San Diego's Notice of Privacy Practices. Additional copies are available upon request.

FINANCIAL AGREEMENT
The undersigned agrees, whether he/she signs as an agent or as a patient that in consideration of the services to be rendered to the patient, he/she hereby individually obligates him/herself to pay all monies due in accordance with the regular rates and terms of Spine Institute of San Diego. In addition, the undersigned understands that any deposit made for services incurred is merely a deposit, and that he/she will be flnancially responsible for all charges incurred.

Co-payments, co-insurance, payments for non-covered services and/or deductibles are due at the time of visit. Monies not collected at the time of visit will be the patient's responsibility.

All patient accounts are due and payable upon receipt of a billing statement. If it is necessary to employ professional collection agency and/or attorney to enforce this Agreement or to collect a judgment based on this Agreement, the patient or the person responsible for payment of fees related to the account that is the subject of this Agreement promises to pay all applicable Interest, court costs and attorney fees.

The undersigned herby agrees to provide 24 hours advance notice for all canceled appointments. Should 24 hours advance notice not be provided, he/she understands that they may be charged a missed appointment fee.

The undersigned hereby authorizes Spine Institute of San Diego to check and/or verify all references and financial information about him/her that is pertinent to his/her acc,ount, including but not limited to credit reports.

ELIGIBILITY GUARANTEE
The undersigned agrees that he/she must be eligible with their health insurance plan at the time of visit. The undersigned understands and agrees that Spine Institute of San Diego will not take responsibility for the refusal of an insurance company to pay for testing or treatment due to lack of insurance benefits. If he/she is unable to provide insurance coverage at time of visit, he/she has 30 calendar days to provide this information. If he/she is unable to provide eligible coverage within 30 calendar days, he/she will assume full financial responsibility for all charges incurred. In addition. should eligibility status of the patient's insurance terminate retroactively. he/she will be financially responsible for any services provided.

ASSIGNMENT OF MEDICARE BENEFITS
The undersigned requests that payment of authorized Medicare benefits be made on the patient's behalf to Spine Institute of San Diego for any services furn ished to the patient by the physician. The undersigned authorizes any holder or medical information about him/her to be released to the Centers for Medicare and Its agents, as well as any information necessary to pay the claim. If other health insurance coverage is indicated on Item 9 of the CMS-IS00 claim form or elsewhere on other
approved claim forms or electronically submitted claims, the undersigned signature authorizes release of the information to the insurer or agency. In Medicare-assigned cases, the physician agrees to accept the charge determination of the Medicare as the full charge, and the patient is responsible only for the deductible, co-insurance, and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier.

NON-RESPONSIBILITY
The undersigned agrees that Spine Institute of San Diego and its physicians shall not be responsible for the errors or omission of the employees or contractors of other health care providers who provide services to the undersigned in the course of their treatment by Spine Institute of San Diego. The undersigned certifies that he/she has read the foregoing, received a copy thereof and is the patient, the patient's legal representative o r is fully authorized by the patient as the patient's general agent to execute this Agreement and accept its terms.

COMMON INTEREST
The undersigned acknowledges that your physician may have a financial interest in the hospitals, surgery centers, imaging centers, service providers, laboratories and/or implantable and non-implantable devices that he or she chooses to utilize. As the patient you have the right to choose another surgeon, device or request services at another facility.

I acknowledge that I received a copy of this document.

Use the key below to indicate where you are having the following sensations

On a scale from 0 to 10, mark your level of pain discomfort with 0 being none and 10 being unbearable. (CHOOSE ONE)

NECK/ARM PAIN

LOWER BACK/LEG PAIN

SOCIAL HISTORY

FAMILY HISTORY (DO YOU HAVE A FAMILY HISTORY OF THE FOLLOWING?)

1. Authorization: authorize disclosure of medical information and health records as described below:

8. Additional Copy
I further understand that I have a right to receive a copy of this authorization upon my request.

9. Re-disclosure
A statement that protected health information used or disclosed pursuant to the authorization may or may not be subject to re-disclosure by the recipient and thus no longer protected by the Privacy Rule.

10. Revocation
This authorization is also subject to written revocation by the undersigned at any time between now and the disclosure of information by the disclosing party. Written revocation will be effective upon receipt, but will not be effective to the extent that the Requester is specifically required or permitted by law.

11. Explanation
I understand that my treatment is no way conditioned on whether or not I sign the authorization and that I may refuse to sign it.

12. Patient Billing: I understand I will be charged $15 plus $0.25 per page for personal requests.

I hereby acknowledge that I received a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.

If not signed by patient, please indicate: