hooman m. melamed, md...page 3 of 11 hooman m. melamed, m.d. orthopaedic spinal surgeon ph (310)...

Hooman M. Melamed, MD PATIENT DEMOGRAPHICS

Patient Name _____________________________________________________________ Date____/____/______

Home Address ________________________________________________________________________________

City_______________________________________ State __________________________ Zip_______________

Home Phone (_____) _____-________ Cell Phone (_____) _____-________ Work Phone (_____) _____-________

Email _______________________________________________________________________________________

Preferred Method of Contact: □ Home # □ Cell # □ Work # □ Email

SS# __________________________________ Date Of Birth ____/____/______ Gender___________________

Religious Preference ___________________________________________________________________________

Employer _____________________________________ Contact Person _________________________________

Employer Address _____________________________________________________________________________

State_______________________________ Zip______________ Employer Phone (_____) _____-_________

Occupation __________________________________________________________________________________

□ PPO / Private Inurances □ Work Comp □ Auto □ Personal Injury Other

INSURANCE CARRIER ___________________________________________________________________________

Address ______________________________________________________________________________

City____________________________________ State ______________________ Zip______________

Phone (_____) _____-________ Fax (_____) _____-________

ID # ____________________________Group#___________________ Effective _____/_____/______

Relationship to insured _______________________________________ SS# ______________________

DOB ____/____/______

Medicare #___________ Part A__________ Part B__________ Effective Date__________ Parts A&B_________

SECONDARY INSURANCE ________________________________________________________________________

Address ______________________________________________________________________________

City__________________________________ State _______________________ Zip_______________

Phone (_____) _____-________ Fax (_____) _____-________

Group/Claim # _______________________________________________ Effective ____/____/______

WORKERS COMPENSATION CARRIER ______________________________________________________________

Address ______________________________________________________________________________

City____________________________________ State _______________________ Zip______________

Phone (_____) _____-________ Fax (_____) _____-________

Claim # ______________________________________ Date Of Injury_______________________

Claims Adjuster ________________________________________________________________________

ATTORNEY ____________________________________________________________________________________

Address ______________________________________________________________________________

City_______________________________ State ____________________ Zip______________

Phone (_____) _____-________ Fax (_____) _____-________

Date Of Injury_______________________

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Patient Name _____________________________________________________ Date ____/____/______

Please provide the doctor with your physician’s information. Write down as much information as you can provide, (I.E. Name & City) so that we may keep them informed of your progress.

REFERRING PHYSICIAN

Name ________________________________________________________________________________

Specialty _____________________________________________________________________________

Address ______________________________________________________________________________

City_______________________________ State ____________________ Zip______________

Phone (_____) _____-________ Fax (_____) _____-________

INTERNIST/PRIMARY CARE PHYSICIAN /NAME SPECIALTY

Name ________________________________________________________________________________

Specialty _____________________________________________________________________________

Address ______________________________________________________________________________

City_______________________________ State ____________________ Zip______________

Phone (_____) _____-________ Fax (_____) _____-________

IF LEGAL CARE, PLEASE COMPLETE THE FOLLOWING INFORMATION

Attorney Name ________________________________________________________________________

Address ______________________________________________________________________________

City_______________________________ State ____________________ Zip______________

Phone (_____) _____-________ Fax (_____) _____-________

WORKERS COMPENSATION INFORMATION (IF APPLICABLE)

Insurance _____________________________________________________________________________

Address ______________________________________________________________________________

City_______________________________ State ____________________ Zip______________

Adjustor __________________________________________________ Phone (_____) _____-________

Claim# _______________________________________ Date of Injury ____/____/______

Please use the back of this form for any additional physician information.

Hooman M. Melamed, MD PHYSICIAN INFORMATION

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Hooman M. Melamed, M.D. Orthopaedic Spinal Surgeon ph (310) 574-0400 fax (310) 574-0422

□ 13160 Mindanao Way, Suite 300 □ 8750 Wilshire Blvd., Suite 350 Marina del Rey, CA 90292 Beverly Hills, CA 90211

All questions contained in this questionnaire are strictly confidential and will be part of your medical record.

NAME (Last, First, M.I.) DOB AGE

ADDRESS

PRIMARY PHYSICIAN Ph no. (_____) ______-_______

REFERRING PHYSICIAN Ph no. (_____) ______-_______

HOW DID YOU HEAR ABOUT DR. MELAMED? _______________________________________________________________________

_____________________________________________________________________________________________________________

HISTORY OF PRESNET ILLNESS

MY CHIEF COMPLAINT IS:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

HOW DID THIS INJURY OCCUR?

______________________________________________________________________________________________________________

WHEN DID SYMPTOMS FIRST START?_______________________________________________________________________________

_____________________________________________________________________________________________________________

Are they getting: Did the symptoms start: Does pain wake you up at night time?

□ Better

□ Suddenly

□ Yes

□ Worse

□Gradually

□No

□ Staying the Same

DESCRIBE QUALITY OF PAIN: □ Dull □ Sharp □ Throbbing □ Burning □ Stabbing □ Ache

PAIN DETAILS: Relieving or aggravating factors are: bending, lifting, sitting, standing, walking, lying , rest, ice, pain meds

(example: sitting 15 min relieves pain or standing 30 min aggrevated pain)

What makes it better? (Relieving factor) ____________________________________________________________________________

What makes it worse? (Aggravating factor) __________________________________________________________________________

I can walk: □ 0-1 blocks □1-3 blocks □3-5 blocks □ 5-7 blocks □>7 blocks

ASSOCIATED PROBLEMS: (Please check all that apply)

□ Do you have weakness? □ Arms □ Legs □ Both

□ Do you have difficulty controlling your bladder function?

□ Do you have difficulty controlling your bowel function?

□ Do you have difficulty with balance or coordination of arms and legs?

□ Do you have difficulty with fine finger movements?

□ Has your hand-writing gotten worse lately?

□ Do you suffer from migraines /headaches?

DATE ____/____/______

□ Private Insurance

□ Workers Comp

□ Auto/Personal Injury

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HISTORY OF PRESNET ILLNESS cont.

HAVE YOU HAD ANY OF THE FOLLOWING TREATMENTS: PLEASE CHECK ALL THAT APPLY □ NONE

Epidurals: □ Yes □ No If yes, then what levels? __________ How many times? I II >III Dates: ___________________

Are you: □ better □ same □ worse

Physical Therapy: How many sessions? ____________ Dates: From ____/____/______ to ____/____/______


Chiropractic Treatment: How many sessions? ______________ Dates: From ____/____/______ to ____/____/______


Acupuncture: How many sessions? ______________ Dates: From ____/____/______ to ____/____/______


DIAGNOSTIC STUDIES / TESTS FOR YOUR CONDITION □ NONE

MRI CT

X-Ray EMG/NCS (Nerve test)

□ Lumbar Spine

□ Lumbar Spine

□ Lumbar Spine

□ Arms

□ Thoracic Spine

□ Thoracic Spine

□ Thoracic Spine

□ Legs

□ Cervical Spine

□ Cervical Spine

□ Cervical Spine

□ Both

□ Dates: ____/____/______

□ Dates: ____/____/______

□ Dates: ____/____/______

□ Dates/Doctor _____________________

PAST MEDICAL HISTORY: HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLE □ NONE □ AIDS or HIV

□ High Blood Pressure

□ Diabetes

□ Venereal Disease

□ Measles

□ Lung Disease

□ Small Pox

□ Mitral Valve Prolapse

□ Bronchitis

□ Pneumonia

□ Infectious Mono

□ Stomach Ulcer

□ Sleep Apnea

□ Osteomalacia

□ Blood Transfusion

□ Stroke

□ Hepatitis

□ Other: (please list)

□ Tuberculosis

□ Polio

□ Epilepsy/Seizures

□ Bleeding Tendency

□ Osteoporosis

□ Hemorrhoids

□ Parkinsons

□ Aneurysm

□ Asthma

□ Thyroid Disease

□ Bladder Infections

□ Diphtheria

□ Low Blood Pressure

□ Heart Disease

□ Migraine Headaches

□ Anemia

□ Rheumatoid Arthritis

□ Kidney Disease

□ Whooping Couch

□ Heart Failure

□ High Choloesterol

□ Rheumatic Fever

□ Glaucoma

□ Heart Attack

PAST SURGICAL HISTORY □ NONE

Year Reason Hospital

OTHER HOSPITALIZATIONS □ NONE

Year Reason Hospital

LIST YOUR PRESCRIPTION AND OVER-THE-COUNTER DRUGS AND VITAMINS □ NONE

Name of Drug/ Vitamin Strength Frequency Taken

ALLERGIES □ NONE

Name of Drug Reaction you had

Hooman M. Melamed, MD | Orthopaedic Spinal Surgeon

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REVIEW OF SYSTEMS: PLEASE CHECK ALL THAT APPLY □ NONE

Musculoskeletal □ Joint pain

□ Back pain

□ Weakness of muscles or joints

□ Muscle pain or cramps

□ Joint stiffness or swelling

□ Cold Extremities

□ Difficulty in walking

General / Constitutional □ Fevers □ Chills □ Nausea Vomiting □ Loss of appetite

Hematologic / Lymphatic □ Lethargy □ Lumps under skin □ Slow to heal after cuts □ Easily bruising

Skin / Breast □ Rashes □ Eczema □ Slow to heal after cuts □ Easily bruising

Cardiovascular □ Heart Trouble □ Chest Pain □ Palpitation □ Shortness of breath while walking

Eyes / Ears / Nose / Throat □ Sore throat or voice change

□ Swollen glands in neck

□ Hearing loss or ringing

□ Ear ache

□ Chronic sinus problems

□ Nose bleeds

□ Bleeding gums

□ Wear glasses/contact lenses

□ Blurry or double vision

Respiratory □ Trouble breathing □ Frequent coughing □ Production of sputum □ Blood in sputum

Gastrointestinal □ Bloating □ Frequent diarrhea □ Constipation □ Rectal bleeding □ Abdominal pain

Genitourinary □ Frequent urination

□ Blood in urine

□ Burning or painful urination

□ Impotence

□ Incontinence or dribbling

Ob / GYN □ FEMALE: Number of Pregnancies ____________ □ Number of deliveries _______________

Endocrine □ Excessive thirst and urination □ Heat or cold intolerance □ Skin becoming dryer

Neurological □ Light headed or dizzy □ Numbness or tingling sensations □ Tremors □ Seizures

Psychological □ Memory loss or confusion

□ Nervousness

□ Depression

□ Insomnia

□ Problem controlling mood

□ Sleeping too much

LIST ANY MEDICAL PROBLEMS THAT RUN IN YOUR FAMILY □ NONE Age Significant Health Problem If Deceased, then cause of death

Father

Mother

Sibling □ M □ F

□ M □ F

□ M □ F

Grandmother (Maternal)

Grandfather (Maternal)

Grandmother (Paternal)

Grandfather (Paternal)

PERSONAL / SOCIAL HISTORY

Height: _________________ Weight: ___________lbs

CURRENT EMPLOYMENT STATUS: Are you currently employed? □ Yes □ No

If yes, then □ Full time □ Part Time – Hours per week _________

If no, then □ On disability □ On partial disability □ Unemployed

Job type □ Heavy labor □ Moderate activity □ Desk work

MARITAL STATUS: □ Single □ Partnered □ Married □ Divorced □ Widowed

Illicit / Recreational drug use □ No □ Yes If yes, how often? _______________________________

Alcohol Do you drink? □ Yes □ No If yes, # of years? _____________ How many drinks / week?__________

Tobacco Do you use tobacco? □ Yes □ No If yes, # of years______________ Or, year quit ______________

Cigarettes________#/day Chew ________#/day Pipe________#/day Cigars________#/day

DATE: ____/____/______ SIGNATURE: _________________________________________________________________________

Hooman M. Melamed, MD | Orthopaedic Spinal Surgeon

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PAIN DESCRIPTION

Where is your pain right now?

Mark the areas on the body below where you feel the described sensations, using the appropriate symbols. Mark the areas of radiation, including all affected areas.

How bad is your pain right now? (Indicate on the line below)

0----------1----------2----------3----------4----------5----------6----------7----------8----------9----------10 No Pain Intermediate Pain Worst Pain

I can tolerate my pain at a score of: __________ Please check the box that indicates the duration of your pain:

□ Continuous □ Positional □ Intermittent (on/off) □ Unable to rate

Patient Name _________________________________ Age ________ Date ____/____/______

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Hooman M Melamed, M.D. PATIENT CONSENT FORM

ph 310.574.0400 - fax 310.574.0422

13160 Mindanao Way, Suite 300 | Marina del Rey, CA 90292 8750 Wilshire Blvd., Suite 350 | Beverly Hills, CA 90211

Authorization for treatment and release of information: (Please initial ones that apply)

___ I consent for this provider to render the treatment set forth as ordered by my physician

___ I give authorization for treatment to be provided in areas not totally isolated from other patients and personnel

___ This authorization, or photocopy of same, authorizes the release of any medical information necessary for treatment and/or to process

claims for services rendered by this provider.

Alternate contact information: Dr. Melamed and/or his staff have my consent to (Please initial ones that apply)

___ Leave medical information on my home answering machine or email

___ Leave medical information on my cell phone

___ Contact me at my place of employment

___ Leave medical information on Family, Friends or Co-workers voicemail

___ Leave medical information on Family, Friend or Co-workers email

Signature of Patient/Guardian___________________________________ Date____/____/______

Guardian Name (please print) ____________________________Relationship _____________________

Assignment of Benefits

REIMBURSEMENT COVERAGE

I request and authorize my insurance and/or Medicare to make payment for benefits on my behalf to Hooman M. Melamed, M.D.


IF POLICY HOLDER IS OTHER THAN THE PATIENT, please complete the following. I, the policy holder, request and authorize my insurance

company and /or Medicare to make payments for benefits on behalf of this patient to Hooman M. Melamed, M.D.


Please Print Name _____________________________________________

PLEASE PROVIDE PROOF OF INSURANCE COVERAGE UPON COMPLETION OF THIS FORM

Assignment and Authorization: I hereby assign payment(s) directly to Hooman M. Melamed, M.D. for services and supplies provided to me of

the insurance benefits otherwise payable to me. I understand I am financially responsible to Hooman M. Melamed, M.D. for the charges not

covered by this authorization. I agree to forward any insurance payments made directly to me for services upon presentation of a bill from

Hooman M. Melamed, M.D..



A copy of this authorization shall be considered as valid as the original and valid for the duration of my care. I understand I am liable for all

charges incurred should my insurance not pay for these services (Except for Worker’s Compensation)



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Date ____/____/______

Patient’s Name __________________________________________

Insurance Plan __________________________________________

INSURANCE ACKNOWLEDGEMENT

Please be aware that D.I.S.C. (Diagnostic and Interventional Surgical Center) is not a contracted provider

with your insurance. We will submit a claim for services rendered to your insurance company. You will

be responsible for any balance unpaid by your insurance.

Please not that your referring provider’s contact affiliation will have no bearing on the processing of the

claims for X-rays. There is no affiliation with Mink Radiology. This notice is for X-rays taken at 13160

Mindanao Way, Marina del Rey, CA 90292.

Should you have any questions regarding the billing associated with your x-rays please contact Marina

Physician Services at 310.574.0442.

__________________________________________________

PATIENT SIGNATURE

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APPEAL AUTHORIZATION FORM

FOR A DESIGNATED REPRESENTATIVE

Date: _______________

Member Name: ____________________________

Member ID#: ____________________________

To: _____________________________ and/or __________________________________

Insurance Company Employer

I, ______________________________________ (patient name) hereby authorize Hooman

Melamed, M.D. (“healthcare provider”) and/or its designee, which shall include but not be limited to, a

law firm, an attorney or any other company or organization hired by healthcare provider, to appeal any

claim payment and/or benefit determination made by the insurance company, administrator and/or my

employer’s health and welfare benefit plan. I understand that by signing this Authorization, the law firm,

attorney or other company or organization will be hired and paid directly by healthcare provider and will

be representing my rights, which were previously assigned to healthcare provided pursuant to the

Assignment of Benefits.

By signing this Authorization, I understand and agree that either healthcare provider or the entity

that they hire will have direct communication with the insurance company, administrator of the health and

welfare benefit plan or my employer. I further instruct and authorize my insurance company,

administrator of my health and welfare benefit plan or employer to communicate directly with healthcare

provider or any designated entity that they hire to represent these interests. I understand that these

communications include ALL medical and financial information contained in my claim file.

This Authorization shall be valid for three (3) years from the date stated herein and a photocopy of

this Authorization shall be valid as an original. This Authorization shall remain valid until revoked in

writing by the Member and sent to both the healthcare provider and the insurance company /administrator

/employer health and welfare benefit plan.

______________________________________________

Signature of Member or Legal Guardian/Representative

Copyright property of Robert B. Silverman, all rights reserved. Any duplication is expressly prohibited

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ASSIGNMENT OF RIGHTS AND BENEFITS I hereby authorize and instruct my insurance company and/or the Administrator of my health and welfare benefit

plan and/or any other third party administer that is responsible for the issuance of reimbursements and/or payments

of healthcare expenses (collectively, the “INSURANCE COMPANY”) that I incur, to be paid directly to Hooman

Melamed, M.D. in their name or their designated associates or assignee(s) (collectively “PROVIDERS”) and shall

be mailed directly to 13160 Mindanao Way Suite 300, Marina Del Rey, CA 90292.

I hereby assign, whether signing as a patient or patient’s agent, all rights and benefits under my plan of insurance or

health and welfare benefit plan to any and all PROVIDERS. I give express right to PROVIDERS to obtain the plan

of insurance, the health and welfare benefit plan, the Summary Plan Description and/or any other relevant

information from INSURANCE COMPANY, Employer or any of their associates or agents. I also provide express

consent and give full rights to PROVIDERS to appeal, any adverse benefit decision affecting any rights that I am

entitled to under my plan of insurance or my health and welfare benefit plan. This assignment shall allow

PROVIDERS to file any necessary appeal(s) on my behalf to the INSURANCE COMPANY, Employer,

Administrative agency or any of their associates or agents.

This assignment further assigns PROVIDERS with the rights to obtain from INSURANCE COMPANY, Employer

or any of their agents or associates all information necessary for the determination of benefits allowed under the

plan of insurance or the health and welfare benefit plan and permits the direct disclosure to PROVIDERS of all

information including benefits provided including benefits and payments made on my behalf, limits and exclusions

of benefits and reasons for denial of benefits or reduction in charges for services rendered.

This assignment shall allow PROVIDERS to take any and all necessary legal action on my behalf, whether in

Federal or State Court, and shall include any and all legal rights under ERISA as well as any and all applicable

State Court causes of actions to obtain any and all financial and/or medical benefits or any other damages that I am

legally entitled to receive pursuant to the terms of the plan of insurance, health and welfare benefit plan, ERISA,

State Law or any other applicable Federal or State law. A photocopy of this assignment shall be considered as

effective and valid as the original.

I understand that this is an assignment of certain rights and that this does not affect my obligation to pay any

deductible, co-pay or co-insurance obligation. I also understand that my insurance may disallow certain diagnoses

or services as medically uncovered, medically unnecessary, cosmetic or simply that the services received are

excluded from coverage. I agree and understand that this Assignment does not alter my financial obligation to

PROVIDER in accordance with other documents that I may have signed.

In the event that my INSURANCE COMPANY disregards this Assignment and sends payments to me, I

understand that I will endorse and immediately deliver all funds to PROVIDER within 48 hours of receipt. I

understand that the intentional and knowing misappropriation of this payment may be a crime, that PROVIDER

will file a criminal complaint for such conduct and that I may be subject to criminal prosecution.

I further understand that this Assignment does not in any way affect or alter my plan of insurance or health and

welfare benefit plan which is an agreement between me and INSURANCE COMPANY. I understand that by

signing this Assignment, this will allow PROVIDER to assist me in the processing of my claim(s), filing of an

appeal, overturning any adverse decision, collect any payments issued, file complaints with the appropriate

authorities/agencies, filing of any necessary lawsuits and to hire any necessary third parties, such as independent

attorneys or billing and collection organizations to assist PROVIDER in the enforcement of the assigned rights.

This is a direct assignment of my rights and benefits under an insurance policy or health and welfare benefit plan,

including, but not limited to, any Plan that is subject to ERISA or PPACA. This Assignment shall be effective for

any and all prior medical services received by PROVIDER.

. .

Patient/Parent/Guardian/Representative - Signature Date


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HEALTH AND WELFARE BENEFIT PLAN REQUEST

Patient/Employee Name: __________________________________ Patient Date of Birth: ___________

Insurance Company: _______________________________ Patient ID: ____________________

Employer Name:___________________________________ Group ID: _____________________

Dear Plan Administrator/Employer:

I hereby authorize Hooman Melamed, M.D. (“healthcare provider”) and/or its designed agent to receive

on my behalf a copy of the Summary Plan Description pertaining to my health and welfare benefit plan (“SPD”)

and/or a copy of the entire health and welfare benefit plan. This request is made consistent with the Assignment

of Rights and Benefits that I have signed in favor of my healthcare provider. Please accept this letter as my formal

written request that you send my healthcare provider the SPD and/or the full health and welfare benefit plan

including all exclusions, limitations and ALL CHANGES made to the health and welfare benefit plan within the

last 5 years. In the event that you only send the SPD, my healthcare provider and/or their designed agent, shall

be entitled to request, at their discretion, a copy of the full health and welfare benefit plan.

In accordance with ERISA and other federal laws, the Employer and/or Plan Administrator is legally

obligated and required to provide the SPD and/or entire plan to me (a plan participant) immediately after my

request. (http://www.dol.gov./dol/topic/health-plans/planinformation.htm) I am aware that under Federal Law,

failure to provide the SPD and/or entire plan can result in financial penalties, currently set at $110.00 per day, in

addition to any attorneys’ fees incurred should legal action be necessary in order to compel compliance.

Please send the SPD and/or Plan electronically to:

[email protected]

or

Please mail a copy of the SBD and/or Plan to:

Hooman Melamed, MD

13160 Mindanao Way Suite 300

Marina Del Rey, CA 90292

____________________________________ ____________________________________

Patient/Employee/Legal Rep. Name (Print) Patient/Employee/ Legal Rep. (Signature)


http://www.dol.gov./dol/topic/health-plans/planinformation.htm

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